Mobile phone technology: a new paradigm for the prevention, treatment, and research of the non-sheltered "street" homeless?

Adapting mHealth Interventions (PrEPmate and DOT Diary) to Support PrEP Retention in Care and Adherence Among English and Spanish-Speaking Men Who Have Sex With Men and Transgender Women in the United States: Formative Work and Pilot Randomized Trial

BACKGROUND

A growing number of mobile health (mHealth) technologies are being developed to support HIV preexposure prophylaxis (PrEP) adherence and persistence; however, most tools have focused on men who have sex with men (MSM), and few are available in Spanish. To maximize the potential impact of these tools in reducing gender and racial/ethnic disparities and promoting health equity, mHealth tools tailored to Spanish-speaking people and transgender women are critically needed.

OBJECTIVE

The aim of this study is to adapt and tailor 2 mHealth technologies, PrEPmate and DOT Diary, to support daily PrEP adherence and persistence among Spanish-speaking MSM and English- and Spanish-speaking transgender women and to evaluate the feasibility and acceptability of these tools.

METHODS

PrEPmate, an interactive, bidirectional, text messaging intervention that promotes personalized communication between PrEP users and providers, and DOT Diary, a mobile app that promotes self-management of PrEP use and sexual health through an integrated electronic pill-taking and sexual activity diary, were previously developed for English-speaking MSM. We conducted 3 focus groups with 15 English- and Spanish-speaking transgender women and MSM in San Francisco and Miami to culturally tailor these tools for these priority populations. We then conducted a 1-month technical pilot among 21 participants to assess the usability and acceptability of the adapted interventions and optimize the functionality of these tools.

RESULTS

Participants in focus groups liked the "human touch" of text messages in PrEPmate and thought it would be helpful for scheduling appointments and asking questions. They liked the daily reminder messages, especially the fun facts, gender affirmations, and transgender history topics. Participants recommended changes to tailor the language and messages for Spanish-speaking and transgender populations. For DOT Diary, participants liked the adherence tracking and protection level feedback and thought the calendar functions were easy to use. Based on participant recommendations, we tailored language within the app for Spanish-speaking MSM and transgender women, simplified the sexual diary, and added motivational badges. In the technical pilot of the refined tools, mean System Usability Scale scores were 81.2/100 for PrEPmate and 76.4/100 for DOT Diary (P=.48), falling in the "good" to "excellent" range, and mean Client Satisfaction Questionnaire scores were 28.6 and 28.3 for PrEPmate and DOT Diary, respectively (maximum possible score=32). Use of both tools was high over the 1-month pilot (average of 10.5 messages received from each participant for PrEPmate; average of 17.6 times accessing the DOT Diary app), indicating good feasibility for both tools.

CONCLUSIONS

Using a user-centered design approach, we culturally tailored PrEPmate and DOT Diary to support daily PrEP use among Spanish-speaking MSM and English- and Spanish-speaking transgender women. Our positive findings in a technical pilot support further testing of these mHealth interventions in an upcoming comparative effectiveness trial.

Cancer care and treatment during homelessness

People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.

SMS text intervention for uncontrolled hypertension among hypertensive homeless adults in shelter clinics of New York City: protocol for a pragmatic randomised trial study

INTRODUCTION

Uncontrolled hypertension (HTN) is prevalent in persons experiencing homelessness (PEH) and contributes to significant suffering and financial cost. Mobile health approaches such as short messaging service (SMS) texting have led to better control of HTN in the general population. Despite the high utilisation of mobile phones by PEH, SMS texting to support HTN control has not been evaluated among this population. We hypothesise that an SMS testing programme will enhance health communication, information management, outreach and care coordination, and provide behavioural support to address some barriers to HTN management in PEH.

METHODS AND ANALYSIS

This study will use a mixed-methods study design to address two objectives: First, it will evaluate, in a randomised controlled trial, the efficacy of a 6-month SMS texting strategy vs an attention control on blood pressure reduction and adherence to medications and clinical appointments in 120 adults PEH with uncontrolled HTN. Outcomes will be measured at 0, 2, 4 and 6 months. Second, it will assess patients' and providers' acceptability and experience of SMS texting using semistructured interviews with PEH (n=30) and providers (n=10). The study will be conducted in shelter clinics in New York City in collaboration with community organisations. The primary statistical analysis will be on an intention-to-treat basis. The trial results will be reported as comparative summary statistics (difference in response rate or means) with 95% CIs and in accordance with the Consolidated Standards of Reporting Trials (CONSORT). Interviews will be transcribed, coded and analysed using an inductive grounded theory analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board (IRB) at George Washington University. Written consent will be obtained from participants. The findings will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05187013.

Attending to the Mental Health of People Who Are Homeless by Mobile Telephone Follow-Up: A Systematic Review

BACKGROUND

More than 20% of the world's population has no decent or suitable home. People who are homeless have more health problems than the rest of the population, especially mental health-type problems. The main objective of this study was to identify follow-up interventions by using mobile telephones to improve the mental health of people who are homeless and to analyze their efficiency.

METHODS

To do so, a systematic review was carried out in the Web of Science, PubMed, Scopus, Ebscohost, and PsyInfo databases.

RESULTS

Studies conclude that mobile phone use is a suitable means to improve adherence to medication and the mental health of the homeless. However, significant attempts to demonstrate health benefits by means of reliable and valid instruments that supplement qualitative satisfaction and feedback instruments appear to be lacking.

CONCLUSIONS

The literature about mental health benefits through technology for people who are homeless is scarce and shows methodological limitations that can lead to failure when setting up methodologies in clinical practice.

Development and evaluation of an online vocational program for veterans with legal convictions and psychiatric illness

PURPOSE

We describe the development and pilot evaluation of an online vocational rehabilitation program, the About Face Online System (AFOS), for veterans with a history of felony convictions and either mental illness and/or substance use disorders.

METHOD

Phase One was the development and acceptability testing of the online system. Phase Two was a small, randomized trial comparing the likelihood of obtaining employment among people using the AFOS, compared to people receiving a self-directed hardcopy manual, after 6 months.

RESULTS

In Phase One, 17 veterans provided feedback as the system was being developed. The final system allows veterans to receive education on vocational reintegration skills, watch short videos describing the techniques, and communicate with a vocational staff member via chat features. Veterans found the AFOS to be as acceptable as a hardcopy manual that covered similar material. In Phase Two, 38 veterans with a history of felony convictions and either mental illness or substance use disorder were randomized to receive the AFOS or a hardcopy manual. After 6 months, people randomized to the AFOS were more likely to obtain employment than people randomized to the hardcopy manual.

CONCLUSION

An online vocational program may help veterans who cannot attend traditional in-person vocational services to successfully obtain employment.

Use of digital technologies by users of psychiatric inpatient services in Berlin, Germany: a cross-sectional patient survey

Few studies and almost exclusively from the USA have recently investigated mobile phone and computer use among users of psychiatric services, which is of high relevance regarding the increasing development of digital health applications and services.

OBJECTIVE, DESIGN AND SETTING

In a cross-sectional patient survey, we examined (a) rates and purposes of mobile phone, computer, internet and social media use, and (b) the role of social and clinical predictors on rates of utilisation among psychiatric inpatients in Berlin, Germany.

PARTICIPANTS AND RESULTS

Descriptive analyses showed that among 496 participants, 84.9% owned a mobile phone and 59.3% a smartphone. Among 493 participants, 68.4% used a computer regularly. Multivariate logistic regression models revealed being homeless, diagnosis of a psychotic illness, being of older age and a lower level of education to be significant predictors for not owning a mobile phone, not using a computer regularly or having a social media account, respectively.

CONCLUSIONS

Users of psychiatric services may have access to mobile phones and computers, although rates are lower than in the general population. However, key barriers that need to be addressed regarding the development of and engagement with digital health interventions are factors of social exclusion like marginalised housing as well as clinical aspects like psychotic illness.

SMS texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial

BACKGROUND

Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes.

METHODS AND ANALYSIS

This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10).

DISCUSSION

DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

Unsheltered Homelessness and Health: A Literature Review

Context

In recent years, cities across the world have seen widespread growth in unsheltered homelessness, in which a person sleeps in a place not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings. It is widely understood that people experiencing homelessness have poorer health outcomes than the general population. Less is known about the health of people who are unsheltered, yet they may be exposed to greater health risks than their sheltered counterparts. The purpose of this literature review is to evaluate and summarize the evidence on unsheltered homelessness and health.

Evidence Acquisition

A literature search was conducted using PubMed to identify publications on unsheltered homelessness and health. A total of 42 studies were included for review.

Evidence Synthesis

Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse than sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower healthcare utilization and often lack health insurance.

Conclusions

Evaluating the impact of shelter status on health outcomes has important implications for the allocation of housing and health services. Longitudinal studies are needed to examine the relationship between the duration of sheltered and unsheltered homelessness and health outcomes and explore the mediating mechanisms that lead to poor health among unsheltered populations. Despite these limitations, our results also suggest an urgent need to address the unique and severe challenges facing unsheltered populations and the need for intervention approaches that are sensitive to these unique disease burdens.

The Prevalence and Perceived Utility of Mobile Health Technology Among Recently Incarcerated Homeless Adults

Mobile technologies can deliver physical and mental health services for recently incarcerated homeless adults (RIHAs). The purpose of this study was to examine the prevalence and perceived utility of mobile technology to support health behavior change among RIHAs. Participants (n = 324) from an ongoing clinical trial at a homeless shelter in Texas were included in the current descriptive cross-sectional analyses. Over one fourth (28.4%) of participants had an active cell phone. Nearly 90 percent (88.6%) of participants reported at least weekly use of the internet, 77 percent used email (77.2%), and more than half used Facebook (55.2%). Although most participants (82.8%) believed that smartphone applications (apps) could help change their behavior, only a quarter (25.1%) had used an app for this purpose. These findings highlight the potential for smartphone-based intervention technologies, and future studies should examine whether smartphone apps that address mental health and health behaviors are feasible among RIHAs.

[Health Service Utilization by Homeless Persons: Analysis of the Role of Enabling Factors, Pain and Gender using the Gelberg-Andersen Model]

The aim of the study was to find factors that influence health service utilization by homeless people. In a field study, a sample of 51 homeless men and 47 homeless women in the German county of Baden-Württemberg participated in face-to-face-interviews with a questionnaire designed for this study. Analyses were performed using multiple logistic regression models. Variables were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Satisfied subsistence needs (OR 1.33, 95%-CI [1.03-1.72] regarding utilization of vaccinations), a stable source of primary care (OR 12.2 [1.81-82] regarding utilization of early detection examinations; quasi-complete separation regarding use of GP services) social networks (OR 2.9 [1.13-7.5] regarding utilisation of early detection examinations; OR 0.63 [0.41-0.98] regarding emergency department visits) and technological ressources (OR 2.2 [1.13-4.4] regarding use of GP services) had a positive influence on the pattern of health service utilization. Pain was correlated with more emergency department visits (OR 1.72 [1.22-2.4]) and hospitalizations (OR 1.66 [1.19-2.3]). The results showed differences between homeless men and women. The factors of influence found in this study should be addressed in the care of homeless persons. Integration of social care into the regular health care system is necessary for early detection and treatment of complex social and medical needs of vulnerable populations. This requires interprofessional approaches in medical education and training focussing on the situation of vulnerable populations and on social determinants of health.

Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience

Objective

While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions.

Methods

We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques.

Results

All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as “lifelines” to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones.

Conclusion

The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.

Implications of the COVID-19 Pandemic for Youth Housing and Homelessness Services

Youth homelessness is a growing crisis in the United States that is associated with a range of adverse outcomes. A variety of social service programs exist to address youth homelessness and its consequences, such as street outreach and diversion services, emergency shelters, transitional housing programs, and rapid rehousing services, among others. The coronavirus disease 2019 (COVID-19) pandemic reached the United States in early 2020, altering nearly every facet of daily life, including the way social service organizations structure and deliver their programming. To understand the implications of the pandemic on housing and homelessness services for youth, the current study examines data from interviews conducted with staff from a large non-profit in Austin, Texas, serving vulnerable transition-age youth. Through these interviews, programmatic changes that occurred as a result of COVID-19-as well as challenges and facilitators to service delivery-were identified. This article provides an overview of these key learnings, as well as recommendations derived from these key learnings, for other organizations adapting their housing and homelessness services in response to the COVID-19 pandemic.

Access to employment and the labor market among women living homeless in Madrid, Spain

BACKGROUND

People living homeless represent one of the most extreme embodiments of the phenomena of poverty and social exclusion, and women are a particularly vulnerable group among people living homeless.

METHODS

Various factors in a sample of women living homeless in Madrid, Spain (n = 136) have been analyzed for relationships to connections to the employment and labor market. Information was collected using a structured interview.

RESULTS

Results show the considerable difficulties women living homeless have in accessing the employment and labor market, despite largely having worked throughout their lives, mainly in unstable jobs, in the informal sector or in related marginal activities. In general, women living homeless tended to attribute their difficulties in accessing the labor market to personal characteristics, dispositional factors, or situational factors beyond their control. A large number of interviewees wanted to work, although few of them did so. Interviewees who reported that they were seeking employment were primarily younger women, in better health, who had been unemployed for a short time, had spent less time homeless, and were of foreign origin.

GPS Mobile Health Intervention Among People Experiencing Homelessness: Pre-Post Study

BACKGROUND

People experiencing homelessness are at risk for gaps in care after an emergency department (ED) or hospital visit, which leads to increased use, poor health outcomes, and high health care costs. Most people experiencing homelessness have a mobile phone of some type, which makes mobile health (mHealth) interventions a feasible way to connect a person experiencing homelessness with providers.

OBJECTIVE

This study aims to investigate the accuracy, acceptability, and preliminary outcomes of a GPS-enabled mHealth (GPS-mHealth) intervention designed to alert community health paramedics when people experiencing homelessness are in the ED or hospital.

METHODS

This study was a pre-post design with baseline and 4-month postenrollment assessments. People experiencing homelessness, taking at least 2 medications for chronic conditions, scoring at least 10 on the Patient Health Questionnaire-9, and having at least 2 ED or hospital visits in the previous 6 months were eligible. Participants were issued a study smartphone with a GPS app programmed to alert a community health paramedic when a participant entered an ED or hospital. For each alert, community health paramedics followed up via telephone to assess care coordination needs. Participants also received a daily email to assess medication adherence. GPS alerts were compared with ED and hospital data from the local health information exchange (HIE) to assess accuracy. Paired t tests compared scores on the Patient Health Questionnaire-9, Medical Outcomes Study Social Support Survey, and Adherence Starts with Knowledge-12 adherence survey at baseline and exit. Semistructured exit interviews examined the perceptions and benefits of the intervention.

RESULTS

In total, 30 participants were enrolled; the mean age was 44.1 (SD 9.7) years. Most participants were male (20/30, 67%), White (17/30, 57%), and not working (19/30, 63%). Only 19% (3/16) of the ED or hospital visit alerts aligned with HIE data, mainly because of patients not having the smartphone with them during the visit, the smartphone being off, and gaps in GPS technology. There was a significant difference in depressive symptoms between baseline (mean 16.9, SD 5.8) and exit (mean 12.7, SD 8.2; t₁₉=2.9; P=.009) and a significant difference in adherence barriers between baseline (mean 2.4, SD 1.4) and exit (mean 1.5, SD 1.5; t₁₇=2.47; P=.03). Participants agreed that the app was easy to use (mean 4.4/5, SD 1.0, with 5=strongly agree), and the email helped them remember to take their medications (mean 4.6/5, SD 0.6). Qualitative data indicated that unlimited smartphone access allowed participants to meet social needs and maintain contact with case managers, health care providers, family, and friends.

CONCLUSIONS

mHealth interventions are acceptable to people experiencing homelessness. HIE data provided more accurate ED and hospital visit information; however, unlimited access to reliable communication provided benefits to participants beyond the study purpose of improving care coordination.

DOT Diary: Developing a Novel Mobile App Using Artificial Intelligence and an Electronic Sexual Diary to Measure and Support PrEP Adherence Among Young Men Who Have Sex with Men

Young men who have sex with men (YMSM) are highly vulnerable to HIV. While pre-exposure prophylaxis (PrEP) has demonstrated effectiveness, adherence has been low among YMSM and difficult to measure accurately. In collaboration with a healthcare company, we configured an automated directly-observed therapy (aDOT) platform for monitoring and supporting PrEP use. Based on interest expressed in focus groups among 54 YMSM, we combined aDOT with an electronic sexual diary to provide feedback on level of protection during sex and to motivate app use. In an 8-week optimization pilot with 20 YMSM in San Francisco and Atlanta, the app was found to be highly acceptable, with median System Usability Scale scores in the "excellent" range (80/100). App use was high, with median PrEP adherence of 91% based on aDOT-confirmed dosing. Most (84%) participants reported the app helped with taking PrEP. These promising findings support further evaluation of DOT Diary in future effectiveness studies.

The use of eHealth interventions among persons experiencing homelessness: A systematic review

Objective

eHealth interventions are being developed to meet the needs of diverse populations. Despite these advancements, little is known about how these interventions are used to improve the health of persons experiencing homelessness. The aim of this systematic review was to examine the feasibility, effectiveness, and experience of eHealth interventions for the homeless population.

Methods

Following PRISMA guidelines, a systematic search of PsycINFO, PubMed, Web of Science, and Google Scholar was conducted along with forward and backward citation searching to identify relevant articles.

Results

Eight articles met eligibility criteria. All articles were pilot or feasibility studies that used modalities, including short message service, mobile apps, computers, email, and websites, to deliver the interventions. The accessibility, flexibility, and convenience of the interventions were valued by participants. However, phone retention, limited adaptability, a high level of human involvement, and preference for in-person communication may pose future implementation challenges.

Conclusions

eHealth interventions are promising digital tools that have the potential to improve access to care and service delivery. eHealth interventions are feasible and usable for persons experiencing homelessness. These interventions may have health benefits by augmenting existing services and if implementation challenges are addressed. Further evaluation of the effectiveness of eHealth interventions is needed before widespread implementation. Those with lived experience should also be engaged in developing and evaluating these interventions.

Smartphone application plus brief motivational intervention reduces substance use and sexual risk behaviors among homeless young adults: Results from a randomized controlled trial

Homeless young adults are more likely than their never-homeless counterparts to abuse substances and engage in sexual risk behaviors. This study evaluated the feasibility and preliminary effectiveness of OnTrack, a smartphone application to self-monitor substance use and sexual risk behaviors, plus a brief motivational intervention (BMI), in reducing substance use and sexual risk among homeless young adults. A randomized controlled pilot trial (N = 60) compared OnTrack + BMI to treatment as usual (TAU) at an inner-city crisis shelter for homeless young adults (aged 18-21 years). Participants were assessed at baseline and 2 weeks, 4 weeks, and 6 weeks after baseline to evaluate substance use and sexual risk behaviors. Kruskal-Wallis tests determined differences between baseline and postintervention assessments. Logistic regression models examined treatment effect on change in outcomes between baseline and postintervention follow-up assessment, controlling for baseline levels. Participants in OnTrack + BMI significantly reduced past 2-week number of drinks (p = .023), times used marijuana (p = .046), times engaged in unprotected sex (p = .012), and times used drugs before sexual activity (p = .019). No reductions of substance use or sexual risk behaviors were found among participants in TAU (all ps > .05). After adjusting for baseline levels of substance use and sexual risk, participants in OnTrack + BMI had significantly lower odds than those in TAU for drinking alcohol (adjusted OR = 0.14; p = .01) and having unprotected sex (adjusted OR = 0.151; p = .032). OnTrack + BMI is feasible and effective in reducing past 2-week alcohol use and unprotected sex among homeless young adults. A larger randomized trial is warranted to replicate and extend present results. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Cedar Project - Mobile Phone Use and Acceptability of Mobile Health Among Young Indigenous People Who Have Used Drugs in British Columbia, Canada: Mixed Methods Exploratory Study

Background

Indigenous leaders continue to be concerned about high rates of HIV and barriers to HIV treatment among young Indigenous people involved in substance use. Growing evidence suggests that using mobile phones for health (mHealth) may be a powerful way to support connection with health services, including HIV prevention and treatment.

Objective

This study examined the patterns of mobile phone ownership and use among young Indigenous people who have used drugs living with or vulnerable to HIV and explored the acceptability of mHealth to support access to health care in this population.

Methods

The Cedar Project is a cohort study involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia. This mixed methods exploratory study involved 131 Cedar Project participants enrolled in our WelTel mHealth program. At enrollment, participants completed a questionnaire related to mobile phone use and interest in mHealth. Data were linked to Cedar Project questionnaires and serodata. We present comparative statistics (quantitative) and results of a rapid thematic analysis (qualitative) related to mobile phone patterns and interest in receiving mHealth.

Results

Less than half of the participants (59/130; 45.4%) reported owning a phone. Among those with a phone, the majority owned a smartphone (46/59; 78%). Most participants with a phone reported having an unlimited texting plan (39/55; 71%), using the internet on their phone (44/59; 75%), and texting daily (44/55; 80%). A majority reported that using a mobile phone for health would be invaluable (120/130; 92.3%). There were no differences in mHealth acceptance between participants who owned a phone and those who did not (P>.99). All but one participant living with HIV felt using a mobile phone would be helpful for their health, while a small proportion of HIV-negative participants remained unsure (1.9% vs 11.7%; P=.047). In response to open-ended questions asking why using a mobile phone may be helpful for health, participants identified a diverse set of anticipated benefits: (1) connection for emotional, mental, and spiritual support, (2) connection to family, (3) staying in touch and/or being reachable, (4) overcoming current barriers to phone use, (5) convenience, privacy, and safety, and (6) access to health care and emergency services.

Conclusions

We observed high acceptance and interest in using mobile phone technology for health despite low rates of personal mobile phone connectivity among young Indigenous people who have used drugs living with and vulnerable to HIV in British Columbia, Canada. Mobile phones were viewed as a way to support connections and relationships that are seen as critical to health and well-being among young Indigenous people in this study. Findings may be useful for health care providers preparing to scale up mHealth programs to support HIV prevention and treatment in this population.

Association Between Technology Use and Social Integration Among Veterans With Disabilities

Social connectedness has positive effects on physical and mental health. Many aspects of life, including social networks, are increasingly technology-based, influenced by access to computers. Individuals with psychiatric disabilities may experience unique barriers to computer use. The current study evaluated computer use among 199 veterans in Connecticut and Houston, Texas, with psychiatric and/or physical disabilities, and its association with social integration. Two-thirds had used a computer within the past month, most commonly for information seeking, but also for social interaction. However, computer use and social integration were not significantly associated. The study suggests a greater rate of computer use than anticipated, encouraging given society's increasing reliance on technology. Future research into experience with other modalities is needed, as is research into veterans' willingness and desire to use technology for various purposes.

A text message intervention for quitting cigarette smoking among young adults experiencing homelessness: study protocol for a pilot randomized controlled trial

BACKGROUND

Cigarette smoking is much more prevalent among young people experiencing homelessness than in the general population of adolescents and young adults. Although many young homeless smokers are motivated to quit, there are no empirically-evaluated smoking cessation programs for this population. It is important that any such program address the factors known to be associated with quitting-related outcomes among homeless young people, to provide ongoing support in a way that accommodates the mobility of this population, and does not rely on scarce service provider resources for its delivery. The objective of this project is to develop and pilot test a text messaging-based intervention (TMI), as an adjunct to brief cessation counseling and provision of nicotine patches, to help homeless young people who want to quit smoking.

METHODS/DESIGN

This pilot study will utilize a cluster cross-over randomized controlled design with up to 80 current smokers who desire to quit and are recruited from three drop-in centers serving young people experiencing homelessness in the Los Angeles area. All participants will be provided with a minimum standard of care: a 30-min group-based smoking cessation counseling session and free nicotine replacement. Half of these smokers will then also receive the TMI, as an adjunct to this standard care, which will provide 6 weeks of ongoing support for quitting. This support includes continued and more intensive education regarding nicotine dependence, quitting smoking, and relapse; does not require additional agency resources; can be available "on demand" to users; and includes features to personalize the quitting experience. This study will investigate whether receiving the TMI adjunct to standard smoking cessation care results in greater reductions in cigarette smoking compared to standard care alone over a 3-month period.

DISCUSSION

This study has the potential to address an important gap in the clinical research literature on cigarette smoking cessation and provide empirical support for using a TMI to provide ongoing assistance and support for quitting among young smokers experiencing homelessness. Trial registration ClinicalTrials.gov Identifier NCT03874585. Registered March 14, 2019, https://clinicaltrials.gov/ct2/show/record/NCT03874585.

Asociación entre el nivel de soledad percibido y el uso de Internet en las personas sin hogar

Resumen El objetivo de este estudio fue explorar la asociación entre los niveles de soledad percibida y el acceso a Internet en personas sin hogar. La muestra estuvo compuesta por un total de 129 personas sin hogar que asistieron a un albergue en Monterrey, México (n=129). Para medir las variables del estudio (uso de Internet y niveles de soledad de las personas sin hogar que asisten a albergues) se administró un cuestionario a cada participante, que contenía tres secciones principales: (1) datos de control; (2) uso de Internet y tecnologías de información; y (3) niveles de soledad social y emocional. Los resultados mostraron que: (1) los niveles de soledad están muy por encima del promedio reportado en estudios con otras poblaciones vulnerables; (2) el 51.9% de los participantes han usado Internet en algún momento y lo usan principalmente para contactar a familiares y amigos; y (3) existe una diferencia nominal, aunque no estadísticamente significativa, entre los niveles de soledad de los que usan Internet y los que no. Los resultados de esta investigación sugieren que proporcionar acceso a Internet en los albergues tiene potencial de impactar positivamente la calidad de vida de sus beneficiarios.

Association of Fear and Mistrust with Stress Among Sheltered Homeless Adults and the Moderating Effects of Race and Sex

In shelter settings, homeless individuals often congregate and sleep in proximity to one another, with limited secure places for belongings: a living environment that may engender perceived vulnerability to victimization. Fear of victimization and mistrust of others in the shelter environment may result in greater stress, and racial minority residents and women may be particularly affected. Here, we aimed to examine the associations between fear, mistrust, and fear and mistrust, and stress among sheltered homeless adults, and explore moderation by race and sex. Data were from a convenience sample of adults from a homeless shelter in Dallas, TX (N = 225; 67% black; 27% women). Participants completed the fear and mistrust scale and the urban life stressors scale. Linear regressions were used to measure associations of fear, mistrust, and fear and mistrust with stress, adjusted for age, education, sex, race, history of schizophrenia/schizoaffective disorder, and discrimination. Moderation was assessed with interaction terms. Adjusted results indicated that fear, mistrust, fear and mistrust was positively associated with stress (p < 0.001). Race, but not sex, was a significant moderator of associations between fear and stress, whereby black adults with high levels of fear were more likely than white adults to experience high stress levels. Thus, although more research is needed, results suggest that interventions aimed at reducing fear of victimization may reduce stress for black adults. Given the association of stress with myriad undesirable health outcomes that can further exacerbate known health disparities, further work in this area is critical. Future research should investigate environmental sources of fear to provide further direction for interventions.

Developing a text messaging-based smoking cessation intervention for young smokers experiencing homelessness

Introduction

Cigarette smoking is highly prevalent among young people experiencing homelessness, and many of these smokers are motivated to quit. However, there is a lack of readily available cessation services for this population, which is highly mobile and can be challenging to engage in services.

Aims

We describe the development of a smoking cessation text messaging intervention (TMI) for homeless youth who are interested in quitting smoking.

Methods

Participants were 18–25 years old and recruited from drop-in centers serving homeless youth. Three focus groups (N = 18) were conducted with smokers to refine the TMI content, and a separate sample of smokers (N = 8) provided feedback on the TMI after using it for 1 week. Survey data assessed the TMI's acceptability and feasibility.

Results

Participants generally rated the TMI as helpful and relevant, and nearly all had cell phone plans that included unlimited texting and were able to view TMI content with few difficulties. Qualitative feedback on strengths/limitations of the TMI in terms of content, tone, and delivery parameters was used to finalize the TMI for a future evaluation.

Conclusions

Results suggest that a TMI is a feasible and acceptable option for young people experiencing homelessness who are interested in quitting smoking.

Acceptability of technological solutions for overdose monitoring: Perspectives of people who use drugs

INTRODUCTION

Rising overdose deaths are a devastating problem across the United States and Canada. Despite the availability of observed consumption sites in British Columbia (BC), data suggest people who use drugs (PWUD) alone in private residences are most at risk of overdose death. These individuals may not use consumption sites due to fear of stigmatization, lack of privacy, or personal preference. It is this population that would benefit from overdose monitoring alternatives.

METHODS

This 2018 study employed two sources of data. (1) A provincial harm reduction distribution site client survey administered at 27 sites across BC asked about cell phone possession and functionality. (2) Structured interviews with PWUD in Vancouver gathered perspectives regarding monitoring devices and alerting systems. Results: The client survey was administered to 486 individuals. Among 443 respondents, 48% (n = 212) owned a cellphone and 68% (n = 115) of individuals with a cellphone with access to internet (n = 168) would use an application to mitigate opioid-related overdose deaths. Thirty qualitative interviews were performed; thematic analysis of the responses identified three major themes - safety, public versus private drug use, and technological monitoring and function. The relevance of technological devices was affected by the inconsistent availability of cellphones, concerns about anonymity, as well as personal comfort while using drugs. Conclusions: Technological applications may not be suitable for clients with transient lifestyles, no permanent home, and lack of consistent access to a mobile device. Thorough needs assessments, considerations of lifestyle limitations, and understanding perceptions around cellphone and overdose monitoring can increase the potential that devices will be used.Highlights45% (n = 219) of client survey respondents owned a cellphoneOut of cellphone owners, 59% (n = 102) of client survey respondents had access to internetOf 168 with internet access, 68% willing to use any applications for overdose responseApplications not suitable for transient lifestyles, no permanent home, and lack of consistent access to cellphone.

Exposure to pro- and anti-tobacco messages online and off-line among people experiencing homelessness

The prevalence of cigarette smoking among people experiencing homelessness is 70%. The internet is a common mode of exposure to tobacco-related messaging, yet little is known about these exposures among people experiencing homelessness. Using time-location sampling, we recruited a sample of adults experiencing homelessness who were current cigarette smokers (i.e. smoked in the past 30 days) from shelters and service sites in San Francisco. We administered a survey to explore self-reported use of the internet and online streaming services; and exposure to tobacco messaging online and offline. Of the 470 participants, 75.5% reported using the internet and 67.2% reported using online streaming video in a typical week. Many participants had seen online advertisements for tobacco products (N = 197, 41.7%) or anti-tobacco industry messages (N = 215, 45.6%), although participants reported seeing both advertisements and warnings related to tobacco more frequently offline than online. Respondents who reported using the internet for more than 4 h in a typical week were more likely to recall seeing tobacco-related warnings or advertisements online. Respondents who reported seeing tobacco-related warnings and advertisements were more likely to have attempted to quit smoking within the past year. These findings suggest an opportunity to use the internet to communicate the harms of tobacco products with messages tailored towards adults experiencing homelessness. Our results suggest further that now is the time to saturate the internet and online streaming services with anti-tobacco industry messages before advertisements for tobacco products become as ubiquitous online as they are elsewhere.

Developing a Mobile App (LYNX) to Support Linkage to HIV/Sexually Transmitted Infection Testing and Pre-Exposure Prophylaxis for Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) in the United States have among the highest incidence of HIV and sexually transmitted infection (STI) and the lowest uptake of HIV and STI testing and pre-exposure prophylaxis (PrEP). Nearly universal mobile phone ownership among youth provides an opportunity to leverage mobile health apps to increase HIV/STI testing and PrEP uptake among YMSM.

OBJECTIVE

The goals of this project are to develop and refine LYNX, a novel mobile app to support linkage to HIV/STIs testing and PrEP services among YMSM in the United States, and to evaluate the acceptability and feasibility of LYNX in a pilot randomized controlled trial (RCT).

METHODS

This research protocol will be conducted in 3 phases: an iterative development phase with a series of 3 focus groups among 20 YMSM to refine the LYNX app; an open technical pilot among 15 YMSM to optimize usability of the app; and then a 6-month pilot RCT among 60 HIV-uninfected YMSM at risk for HIV acquisition. Developed using the Information, Motivation, and Behavioral skills theoretical model, the LYNX app includes an electronic diary to track sexual behaviors (information), a personalized risk score to promote accurate risk perception (information/motivation), testing reminders (motivation/behavioral skills), and access to home-based HIV/STI testing options and geospatial-based HIV/STI testing care sites (behavioral skills). Feasibility and acceptability will be assessed through app analytics of usage patterns and acceptability scales administered via computer-assisted self-interview at 3 and 6 months. We will also evaluate preliminary efficacy by comparing the proportion of YMSM who test at least once during the 6-month pilot and the proportion who successfully link to a PrEP provider in the intervention versus control groups.

RESULTS

Formative work is currently underway. The LYNX pilot RCT will begin enrollment in October 2018, with study results available in 2019.

CONCLUSIONS

The LYNX app is one of the first mobile apps designed to increase HIV/STI testing and PrEP uptake among YMSM. As low-perceived risk is a barrier to HIV/STI testing and PrEP use among youth, the personalized risk assessment and interactive sexual diary in LYNX could assist YMSM in better understanding their HIV risk and providing motivation to test for HIV/STIs and initiate PrEP. Coupled with community-based recruitment, this novel mobile app has great potential to reach and engage YMSM not currently involved in care and increase rates of HIV/STI testing and PrEP uptake in this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03177512; https://clinicaltrials.gov/ct2/show/NCT03177512 (Archived by WebCite at http://www.webcitation.org/73c917wAw).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/10659.

Social networks of unaccompanied women experiencing homelessness

This study explored strengths, barriers, and role of social networks among unaccompanied women experiencing homelessness. Twenty women from two local shelters participated in semistructured, face-to-face interviews. A constant comparative analysis revealed 4 themes: support as a coping mechanism, loss of support as a path to homelessness, support as a drain, and support as a way to give. Almost universally, women experienced considerable barriers to housing, including physical health, mental health, substance abuse, or domestic violence. Despite precarious circumstances, women showed optimism, interest, and readiness to move forward and exit homelessness. Most women utilized social networks to cope with their difficult situations. Their networks, however, were limited such that abusive relationships and substance abuse commonly contributed to homelessness and delayed entrance into secure housing. Together with identifying unaccompanied women as a subgroup in the homeless population, targeted interventions can help women capitalize on healthy relationships to promote housing security and well-being.

Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study

BACKGROUND

The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults.

OBJECTIVE

This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years.

METHODS

We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies.

RESULTS

Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72).

CONCLUSIONS

Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

The Role of Technology-Based Interventions for Substance Use Disorders in Primary Care: A Review of the Literature

The burden of alcohol and drug use disorders (substance use disorders [SUDs]) has intensified efforts to expand access to cost-effective psychosocial interventions and pharmacotherapies. This article provides an overview of technology-based interventions (eg, computer-based and Web-based interventions, text messaging, interactive voice recognition, smartphone apps, and emerging technologies) that are extending the reach of effective addiction treatments both in substance use treatment and primary care settings. It discusses the efficacy of existing technology-based interventions for SUDs, prospects for emerging technologies, and special considerations when integrating technologies in primary care (eg, privacy and regulatory protocols) to enhance the management of SUDs.

Using mHealth to Increase Treatment Utilization Among Recently Incarcerated Homeless Adults (Link2Care): Protocol for a Randomized Controlled Trial

Background

There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive professional coordination of individualized care (ie, case management) during the period following their release from jail experience fewer mental health and substance use problems, are more likely to obtain stable housing, and are less likely to be reincarcerated. This is because case managers work to meet the various needs of their clients by helping them to overcome barriers to needed services (eg, food, clothing, housing, job training, substance abuse and mental health treatment, medical care, medication, social support, proof of identification, and legal aid). Many barriers (eg, limited transportation, inability to schedule appointments, and limited knowledge of available services) prevent homeless adults who were recently released from incarceration from obtaining available case management, crisis management, substance abuse, and mental health services.

Objective

The aim of the Link2Care study is to assess the effectiveness of a smartphone app for increasing case management and treatment service utilization, and in turn reduce homelessness and rearrest. The goals of this research are to (1) assess the impact of an innovative smartphone app that will prompt and directly link recently incarcerated homeless adults to community-based case management services and resources and (2) utilize in-person and smartphone-based assessments to identify key variables (eg, alcohol or drug use, social support, psychological distress, and quality of life) that predict continued homelessness and rearrest.

Methods

Homeless adults (N=432) who enroll in a shelter-based Homeless Recovery Program after release from the Dallas County Jail will be randomly assigned to one of the three treatment groups: (1) usual case management, (2) usual case management plus smartphone, and (3) usual case management with a study-provided smartphone that is preloaded with an innovative case management app (smartphone-based case management). Those assigned to smartphone-based case management will receive smartphones that prompt (twice weekly) connections to shelter-based case managers. The app will also offer direct links to case managers (available during normal business hours) and crisis interventionists (available 24 hours a day, 7 days a week) with the touch of a button.

Results

Recruitment began in the spring of 2018, and data collection will conclude in 2021.

Conclusions

This research represents an important step toward integrated service connection and health care service provision for one of the most underserved, high need, and understudied populations in the United States.

Trial Registration

ClinicalTrials.gov NCT03399500; https://clinicaltrials.gov/ct2/show/NCT03399500 (Archived by WebCite at http://www.webcitation.org/6zSJwdgUS)

Registered Report Identifier

RR1-10.2196/9868

Text message reminders for improving patient appointment adherence in an office-based buprenorphine program: A feasibility study

BACKGROUND AND OBJECTIVES

Missed visits are common in office-based buprenorphine treatment (OBOT). The feasibility of text message (TM) appointment reminders among OBOT patients is unknown.

METHODS

This 6-month prospective cohort study provided TM reminders to OBOT program patients (N = 93). A feasibility survey was completed following delivery of TM reminders and at 6 months.

RESULTS

Respondents reported that the reminders should be provided to all OBOT patients (100%) and helped them to adhere to their scheduled appointment (97%). At 6 months, there were no reports of intrusion to their privacy or disruption of daily activities due to the TM reminders. Most participants reported that the TM reminders were helpful in adhering to scheduled appointments (95%), that the reminders should be offered to all clinic patients (95%), and favored receiving only TM reminders rather than telephone reminders (95%). Barriers to adhering to scheduled appointment times included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic wait-times (9%), being hospitalized or sick (8%), feeling sad or depressed (6%), and child care (6%).

CONCLUSIONS

This study demonstrated the acceptability and feasibility of TM appointment reminders in OBOT. Older age and longer duration in buprenorphine treatment did not diminish interest in receiving the TM intervention. Although OBOT patients expressed concern regarding the privacy of TM content sent from their providers, privacy issues were uncommon among this cohort. Scientific Significance Findings from this study highlighted patient barriers to adherence to scheduled appointments. These barriers included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic lines (9%), and other factors that may confound the effect of future TM appointment reminder interventions. Further research is also required to assess 1) the level of system changes required to integrate TM appointment reminder tools with already existing electronic medical records and appointment records software; 2) acceptability among clinicians and administrators; and 3) financial and resource constraints to healthcare systems. (Am J Addict 2017;26:581-586).

Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study

Background

Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts.

Objective

This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL.

Methods

We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log₁₀ VL by number of responses while controlling for mean log₁₀ VL in the control year.

Results

Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study.

Conclusions

WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons.

Trial Registration

Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)

Mobile Phone and Social Media Use of Homeless Youth in Denver, Colorado

The purpose of this study was to investigate homeless youth mobile phone and social media use, to plan health promotion efforts. Nearly half (46.7%) of runaway/homeless youth in this sample (n = 181) owned a mobile phone and a majority of those devices were smart phones. Ownership did not vary significantly by shelter location, though regular use of Facebook was more prevalent among those in housing programs or camping, than those living on the streets. Over 90% of youth in the sample reported using Facebook. Such media use might facilitate parent, family, and health provider communications with homeless youth.

Using Cell Phones for Data Collection: Benefits, Outcomes, and Intervention Possibilities with Homeless Youth

While many homeless youth use cell phones to stay socially connected, and maintaining positive social ties can contribute to pathways out of homelessness, little is known about how using cell phones for data collection can improve these young people's lives. We conducted baseline and follow-up interviews with 150 homeless youth as well as provided them with a cell phone for 30 days to gather daily data using short message service (SMS) surveying. This paper examines youths' opinions about study participation and how they used the cell phone. Results revealed that youth liked participating in the study because the SMS texting portion, for example, made them feel that someone still cared about them, prompted them to self-reflect on their life, and allowed them to make a difference (e.g. educating the public about homelessness). Despite numerous benefits of study participation, improvements that youth discussed for future studies included changing the format of our text questions to allow for explanations and the use of higher quality phones. In terms of study phone usage, youth reported using the phone to schedule appointments, contact employers, and to keep in touch with family and friends. Finally, we highlight ways in which cell phones via SMS could be used with homeless youth to provide informational resources along with educational and employment opportunities, all of which are important intervention strategies in improving life situations for this population.

How Feasible is Multiple Time Point Web-Based Data Collection with Individuals Experiencing Street Homelessness?

Three barriers investigators often encounter when conducting longitudinal work with homeless or other marginalized populations are difficulty tracking participants, high rates of no-shows for follow-up interviews, and high rates of loss to follow-up. Recent research has shown that homeless populations have substantial access to information technologies, including mobile devices and computers. These technologies have the potential both to make longitudinal data collection with homeless populations easier and to minimize some of these methodological challenges. This pilot study's purpose was to test whether individuals who were homeless and sleeping on the streets-the "street homeless"-would answer questions remotely through a web-based data collection system at regular "follow-up" intervals. We attempted to simulate longitudinal data collection in a condensed time period. Participants (N = 21) completed an in-person baseline interview. Each participant was given a remotely reloadable gift card. Subsequently, weekly for 8 weeks, participants were sent an email with a link to a SurveyMonkey questionnaire. Participants were given 48 h to complete each questionnaire. Data were collected about life on the streets, service use, community inclusion, substance use, and high-risk sexual behaviors. Ten dollars was remotely loaded onto each participant's gift card when they completed the questionnaire within the completion window. A substantial number of participants (67% of the total sample and 86% of the adjusted sample) completed at least seven out of the eight follow-up questionnaires. Most questionnaires were completed at public libraries, but several were completed at other types of locations (social service agencies, places of employment, relative/friend/acquaintance's domiciles, or via mobile phone). Although some of the questions were quite sensitive, very few participants skipped any questions. The only variables associated with questionnaire completion were frequency of computer use and education-both positive associations. This pilot study suggests that collecting longitudinal data online may be feasible with a subpopulation of persons experiencing homelessness. We suspect that participant follow-up rates using web-based data collection methods have the potential to exceed follow-up rates using traditional in-person interviews. If this population of persons experiencing street homelessness can be successful with this method of data collection, perhaps other disenfranchised, difficult-to-track, or difficult-to-reach populations could be followed using web-based data collection methods. Local governments are striving to decrease the "digital divide," providing free or greatly discounted wi-fi connectivity as well as mobile computer lab access to low-income geographic areas. These actions, in combination with increased smart phone ownership, may permit vulnerable populations to connect and communicate with investigators.

No Digital Divide? Technology Use among Homeless Adults

Homeless adults experience increased risk of negative health outcomes, and technology-based interventions may provide an opportunity for improving health in this population. However, little is known about homeless adults' technology access and use. Utilizing data from a study of 421 homeless adults moving into PSH, this paper presents descriptive technology findings, and compares results to age-matched general population data. The vast majority (94%) currently owned a cell phone, although there was considerable past 3-month turnover in phones (56%) and phone numbers (55%). More than half currently owned a smartphone, and 86% of those used Android operating systems. Most (85%) used a cell phone daily, 76% used text messaging, and 51% accessed the Internet on their cell phone. One-third reported no past 3-month Internet use. These findings suggest that digital technology may be a feasible means of disseminating health and wellness programs to this at-risk population, though important caveats are discussed.

Homeless patients' perceptions about using cell phones to manage medications and attend appointments

OBJECTIVES

The objectives of this study were to (1) describe homeless persons' access and use of cell phones and their perceptions about using cell phone alerts to help manage medications and attend health care appointments and (2) identify demographic characteristics, medication use and appointment history and perceptions associated with interest in receiving cell phone alerts to manage medications and appointments.

METHODS

A cross-sectional survey was conducted in 2013 at a homeless clinic in Virginia. The questionnaire comprised items about cell phone usage, ownership and functions such as text messaging. Participants reported medication use and appointment history, perceptions about cell phone alerts and interest in receiving alerts to manage medications and appointments. Descriptive statistics for all variables are reported. Logistic regression was used to examine predictors of interest in using a cell phone to manage medications and appointments.

KEY FINDINGS

A total of 290 participants completed the survey; 89% had a cell phone. Seventy-seven percent were interested in appointment reminders, whereas 66%, 60% and 54% were interested in refill reminders, medication taking reminders and medication information messages respectively. Those who believed reminders were helpful were more likely to be interested in medication taking, refill and appointment reminder messages compared to those who did not believe reminders were helpful. A history of running out of medicine and forgetting appointments were predictors of interest in refill and appointment reminders.

CONCLUSIONS

Mobile technology is a feasible method for communicating medication and appointment information to those experiencing or at risk for homelessness.

Strategies for mHealth research: lessons from 3 mobile intervention studies

The capacity of Mobile Health (mHealth) technologies to propel healthcare forward is directly linked to the quality of mobile interventions developed through careful mHealth research. mHealth research entails several unique characteristics, including collaboration with technologists at all phases of a project, reliance on regional telecommunication infrastructure and commercial mobile service providers, and deployment and evaluation of interventions "in the wild", with participants using mobile tools in uncontrolled environments. In the current paper, we summarize the lessons our multi-institutional/multi-disciplinary team has learned conducting a range of mHealth projects using mobile phones with diverse clinical populations. First, we describe three ongoing projects that we draw from to illustrate throughout the paper. We then provide an example for multidisciplinary teamwork and conceptual mHealth intervention development that we found to be particularly useful. Finally, we discuss mHealth research challenges (i.e. evolving technology, mobile phone selection, user characteristics, the deployment environment, and mHealth system "bugs and glitches"), and provide recommendations for identifying and resolving barriers, or preventing their occurrence altogether.

U.S. Minority Homeless Youth's Access to and Use of Mobile Phones: Implications for mHealth Intervention Design

Few interventions for homeless youth have leveraged the potential of mHealth technologies, in part because of the limited data on phone behaviors, perceptions, and intervention preferences among youth experiencing homelessness. We conducted 9 focus groups (n = 52 homeless youth) and 41 individual structured interviews also with homeless youth in underserved communities in Baltimore and Washington, DC, to ascertain how youth perceived their mobile phone, acquired and maintained mobile services over time, and thought mHealth programs for this population should be designed. We also measured phone use, functionality, source, duration of ownership, and reasons for changing phones or numbers. Results showed that mobile coverage was high, as most youth self-purchased phones or received gift payments from others. Maintaining mobile connectivity was often challenging because of financial constraints and interpersonal conflict. Youth valued phones to access social support but used several tactics to avoid perceived negative consequences of phone ownership, such as harassment, theft, or relational disputes. Youth most preferred mHealth content relating to sexual, reproductive, and mental health provided that mobile communication was confidential, empowering, and integrated with other digital media. Integrating hidden phones, financial support, and safety management may improve homeless youth's access to and engagement with mHealth strategies over time.

Short-term effects of a brief intervention to reduce alcohol use and sexual risk among homeless young adults: Results from a randomized controlled trial

BACKGROUND

Homeless young adults are more likely than their never-homeless counterparts to abuse alcohol and engage in risky sexual behaviors, yet no interventions to simultaneously reduce both these behaviors among this vulnerable population have been systematically designed and evaluated. We therefore developed a brief intervention (BI) to reduce both alcohol use and sexual risk behaviors among homeless young adults. The results of a randomized trial testing the BI against an education comparison (EC) are presented.

METHOD

Young adults (N=61; age 17-22 years) from an urban, Northeastern crisis shelter were randomly assigned to either the 2-session, individual-level BI or a time-matched, 2-session, individual-level EC. Generalized linear mixed models for repeated measures determined effects of treatment condition on outcomes.

RESULTS

The BI significantly increased participant readiness to change alcohol use. However, it did not significantly decrease primary alcohol or HIV sexual risk outcomes, independently or relative to EC (all ps>.05). Participants in the EC reduced times engaged in unprotected sex between baseline and post-intervention to a significantly greater extent (p<.01) than those in the BI condition. Participants in both conditions reported satisfaction with respective interventions.

CONCLUSIONS

Findings suggest that the BI was acceptable and successful in getting participants to consider changing their drinking. However, lack of change in alcohol and sexual behavior outcomes indicates the need for further research to determine how to translate readiness to change into actual behavioral change among homeless young adults.

Mobile phone use patterns and preferences in safety net office-based buprenorphine patients

BACKGROUND

Integrating mobile phone technologies in addiction treatment is of increasing importance and may optimize patient engagement with their care and enhance the delivery of existing treatment strategies. Few studies have evaluated mobile phone and text message (TM) use patterns in persons enrolled in addiction treatment, and none have assessed the use in safety net, office-based buprenorphine practices.

METHODS

A 28-item, quantitative and qualitative semistructured survey was administered to opiate-dependent adults in an urban, publicly funded, office-based buprenorphine program. Survey domains included demographic characteristics, mobile phone and TM use patterns, and preferences pertaining to their recovery.

RESULTS

Surveyors approached 73 of the 155 eligible subjects (47%); 71 respondents completed the survey. Nearly all participants reported mobile phone ownership (93%) and TM use (93%), and most reported "very much" or "somewhat" comfort sending TM (79%). Text message contact with 12-step group sponsors, friends, family members, and counselors was also described (32%). Nearly all preferred having their providers' mobile phone number (94%), and alerting the clinic via TM in the event of a potential relapse to receive both supportive TM and a phone call from their buprenorphine provider was also well received (62%).

CONCLUSIONS

Mobile phone and TM use patterns and preferences among this sample of office-based buprenorphine participants highlight the potential of adopting patient-centered mobile phone-based interventions in this treatment setting.

Rates and Predictors of Uncontrolled Hypertension Among Hypertensive Homeless Adults Using New York City Shelter-Based Clinics

PURPOSE

We undertook a study to determine the rates, predictors, and barriers to blood pressure control among homeless and nonhomeless hypertensive adult patients from 10 New York City shelter-based clinics.

METHODS

The study was a retrospective chart review of blood pressure measurements, sociodemographic characteristics, and factors associated with homelessness and hypertension extracted from the medical records of a random sample of hypertensive patients (N = 210) in 2014.

RESULTS

Most patients were African American or Hispanic; 24.8% were female, and 84.3% were homeless for a mean duration of 3.07 years (SD = 5.04 years). Homeless adult patients were younger, had less insurance, and were more likely to be a current smoker and alcohol abuser. Of the 210 hypertensive patients, 40.1% of homeless and 33.3% of nonhomeless patients had uncontrolled blood pressure (P = .29) when compared with US rates for hypertensive adults, which range between 19.6% and 24.8%, respectively; 15.8% of homeless patients had stage 2 hypertension (P = .27). Homeless hypertensive patients with diabetes or multiple chronic diseases had better blood pressure control (P <.01). In logistic regression, lack of insurance was associated with inadequate blood pressure control (P <.05).

CONCLUSIONS

The high rate of uncontrolled hypertension among hypertensive homeless adults is alarming. We propose comprehensive approaches to improve social support, access to medical insurance, and medication adherence, the lack of which complicate blood pressure control, targeted health education, and life style modifications using mobile health strategies for this mobile population.

Text message content preferences to improve buprenorphine maintenance treatment in primary care

Few studies have evaluated text message content preferences to support evidence-based treatment approaches for opioid use disorders, and none in primary care office-based buprenorphine treatment settings. This study assessed the acceptability and preferences for a tailored text message intervention in support of core office-based buprenorphine treatment medical management components (e.g., treatment adherence, encouraging abstinence, 12-step group participation, motivational interviewing, and patient-provider communication as needed). There were 97 patients enrolled in a safety net office-based buprenorphine treatment program who completed a 24-item survey instrument that consisted of multiple-choice responses, 7-point Likert-type scales, binomial "Yes/No" questions, and open-ended responses. The sample was predominately male (81%), had an average age of 46 years, and was diverse (64% ethnic/racial minorities); 56% lacked stable employment. Respondents were interested in receiving text message appointment reminders (90%), information pertaining to their buprenorphine treatment (76%), supportive content (70%), and messages to reduce the risk of relapse (88%). Participants preferred to receive relapse prevention text messages during all phases of treatment: immediately after induction into buprenorphine treatment (81%), a "few months" into treatment (57%), and after discontinuing buprenorphine treatment (72%). Respondents also expressed interest in text message content enhancing self-efficacy, social support, and frequent provider communication to facilitate unobserved "home" induction with buprenorphine. Older participants were significantly less receptive to receiving text message appointment reminders; however, they were as interested in receiving supportive, informational, and relapse prevention components compared to younger respondents. Implications for integrating a text message support system in office-based buprenorphine treatment are discussed.

Perceptions, Attitudes, and Experience Regarding mHealth Among Homeless Persons in New York City Shelters

Mobile health may be an effective means of providing access and education to the millions of homeless Americans. We conducted semi-structured interviews with 50 homeless people from different shelters in New York City to evaluate their perceptions, attitudes, and experiences regarding mobile health. Participants' average age was 51.66 (SD = 11.34) years; duration of homelessness was 2.0 (SD = 3.10) years. The majority had a mobile phone with the ability to receive and send text messages. Most participants attempted to maintain the same phone number over time. The homeless were welcoming and supportive of text messaging regarding health care issues, including appointment reminders, health education, or management of diseases considering their barriers and mobility, and believed it would help them access necessary health care. Overwhelmingly they preferred text reminders that were short, positively framed, and directive in nature compared to lengthy or motivational texts. The majority believed that free cell phone plans would improve their engagement with, help them navigate, and ultimately improve their access to care. These positive attitudes and experience could be effectively used to improve health care for the homeless. Policies to improve access to mobile health and adapted text messaging strategies regarding the health care needs of this mobile population should be considered.

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans' IT use. This study examines homeless veterans' access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

Feasibility, acceptability, and preliminary efficacy of a smartphone intervention for schizophrenia

The FOCUS smartphone intervention was developed to provide automated real-time/real-place illness management support to individuals with schizophrenia. The system was specifically designed to be usable by people with psychotic disorders who may have cognitive impairment, psychotic symptoms, negative symptoms, and/or low reading levels. FOCUS offers users both prescheduled and on-demand resources to facilitate symptom management, mood regulation, medication adherence, social functioning, and improved sleep. In this study, 33 individuals with schizophrenia or schizoaffective disorder used FOCUS over a 1-month period in their own environments. Participants were able to learn how to use the intervention independently, and all but one participant completed the trial successfully and returned the smartphones intact. Completers used the system on 86.5% of days they had the device, an average of 5.2 times a day. Approximately 62% of use of the FOCUS intervention was initiated by the participants, and 38% of use was in response to automated prompts. Baseline levels of cognitive functioning, negative symptoms, persecutory ideation, and reading level were not related to participants' use of the intervention. Approximately 90% of participants rated the intervention as highly acceptable and usable. Paired samples t tests found significant reductions in psychotic symptoms, depression, and general psychopathology, after 1 month of FOCUS use. This study demonstrated the feasibility, acceptability, and preliminary efficacy of the FOCUS intervention for schizophrenia and introduces a new treatment model which has promise for extending the reach of evidence-based care beyond the confines of a physical clinic using widely available technologies.

Increasing the response rate of text messaging data collection: a delayed randomized controlled trial

OBJECTIVE

To test the effectiveness of multiple interventions on increasing the response rate of text messaging for longitudinal data collection.

METHODS

Our cohort included 283 caregivers of children aged 6-12 months who were participating in an anemia program in rural China. Using text messages to collect data on anemia medication adherence, we conducted a delayed randomized controlled trial to test multiple interventions (an additional four reminders; a ¥5.0 (US$0.79) credit reward for replying; and a feedback text message). After a 6-week pilot study with week 7 as the baseline measurement, we randomly allocated all participants into two groups: group 1 (n = 142) and group 2 (n = 141). During weeks 8-11, we introduced the interventions to group 1, and in weeks 12-15 the intervention was introduced to both groups. We compared the response rates between groups and explored factors affecting the response rate.

RESULTS

During weeks 8-11, the response rates in group 1 increased and were significantly higher than in group 2 (p<0.05). During weeks 12-15, the response rate increased significantly in group 2 (p>0.05) and slightly decreased in group 1. Younger participants or participants who had children with lower hemoglobin concentration were more likely to reply (p = 0.02). Sending four reminders on the second day contributed to only 286 (11.7%) extra text messages.

DISCUSSION

Our study showed that multiple interventions were effective in increasing response rate of text messaging data collection in rural China.

CONCLUSIONS

Larger multi-site studies are needed to find the most effective way of using these interventions to allow usage of text messaging data collection for health research.

Exploring ethical conflicts in emergency trauma research: the COMBAT (Control of Major Bleeding after Trauma) study experience

BACKGROUND

Up to 25% of severely injured patients develop trauma-induced coagulopathy. To study interventions for this vulnerable population for whom consent cannot be obtained easily, the Food and Drug Administration issued regulations for emergency research with an exception from informed consent (ER-EIC). We describe the community consultation and public disclosure (CC/PD) process in preparation for an ER-EIC study, namely the Control Of Major Bleeding After Trauma (COMBAT) study.

METHODS

The CC/PD was guided by the four bioethical principles. We used a multimedia approach, including one-way communications (newspaper ads, brochures, television, radio, and web) and two-way communications (interactive in-person presentations at community meetings, printed and online feedback forms) to reach the trials catchment area (Denver County's population: 643,000 and the Denver larger metro area where commuters reside: 2.9 million). Particular attention was given to special-interests groups (eg, Jehovah Witnesses, homeless) and to Spanish-speaking communities (brochures and presentations in Spanish). Opt-out materials were available during on-site presentations or via the COMBAT study website.

RESULTS

A total of 227 community organizations were contacted. Brochures were distributed to 11 medical clinics and 3 homeless shelters. The multimedia campaign had the potential to reach an estimated audience of 1.5 million individuals in large metro Denver area, the majority via one-way communication and 1900 in two-way communications. This resource intensive process cost more than $84,000.

CONCLUSION

The CC/PD process is resource-intensive, costly, and complex. Although the multimedia CC/PD reached a large audience, the effectiveness of this process remains elusive. The templates can be helpful to similar ER-EIC studies.