Designing consumer health IT to enhance usability among different racial and ethnic groups within the United States

How do adolescents experience a newly developed Online Single Session Sleep Intervention? A Think-Aloud Study

BACKGROUND

Sleep problems are common in adolescents and have detrimental impacts on physical and mental health and daily functioning. Evidence-based treatment like cognitive behaviour therapy for insomnia (CBT-I) is often hard to access, and adolescents may not engage in and adhere to longer, clinician-delivered interventions. Brief, self-guided, and accessible sleep interventions are needed.

OBJECTIVE

To explore the user experience of a prototype online self-help single session sleep intervention developed for adolescents.

METHODS

Eleven participants aged 17-19 years (8 females, 3 males) took part in online retrospective think-aloud interviews. Participants first completed the prototype intervention independently and were then shown the intervention page by page and asked to verbalise their thoughts and experiences. Transcripts were analyzed thematically.

RESULTS

Participants found the intervention helpful. Four themes were generated - 'Educative: Learning, but more fun', 'Effortless: Quicker and Easier', 'Personalization: Power of Choice', and 'Positivity: Just Good Vibes'. The theme 'Educative: Learning, but more fun' encompassed two sub-themes 'Opportunity to Learn' and 'Aesthetics and Learning'. These themes reflected participants' views that the intervention was educative, personalised, solution-oriented and easy to use, but could incorporate more graphics and visuals to aid in learning and could be made more effortless and positive through modifications to its design.

CONCLUSIONS

Findings convey the importance of ensuring educative well-designed content, personalization, a positive tone, and ease of use while designing interventions targeting adolescents's sleep and mental health. They also indicate areas for further developing the intervention.

Understanding Symptom Self-Monitoring Needs Among Postpartum Black Patients: Qualitative Interview Study

BACKGROUND

Pregnancy-related death is on the rise in the United States, and there are significant disparities in outcomes for Black patients. Most solutions that address pregnancy-related death are hospital based, which rely on patients recognizing symptoms and seeking care from a health system, an area where many Black patients have reported experiencing bias. There is a need for patient-centered solutions that support and encourage postpartum people to seek care for severe symptoms.

OBJECTIVE

We aimed to determine the design needs for a mobile health (mHealth) patient-reported outcomes and decision-support system to assist Black patients in assessing when to seek medical care for severe postpartum symptoms. These findings may also support different perinatal populations and minoritized groups in other clinical settings.

METHODS

We conducted semistructured interviews with 36 participants-15 (42%) obstetric health professionals, 10 (28%) mental health professionals, and 11 (31%) postpartum Black patients. The interview questions included the following: current practices for symptom monitoring, barriers to and facilitators of effective monitoring, and design requirements for an mHealth system that supports monitoring for severe symptoms. Interviews were audio recorded and transcribed. We analyzed transcripts using directed content analysis and the constant comparative process. We adopted a thematic analysis approach, eliciting themes deductively using conceptual frameworks from health behavior and human information processing, while also allowing new themes to inductively arise from the data. Our team involved multiple coders to promote reliability through a consensus process.

RESULTS

Our findings revealed considerations related to relevant symptom inputs for postpartum support, the drivers that may affect symptom processing, and the design needs for symptom self-monitoring and patient decision-support interventions. First, participants viewed both somatic and psychological symptom inputs as important to capture. Second, self-perception; previous experience; sociocultural, financial, environmental, and health systems-level factors were all perceived to impact how patients processed, made decisions about, and acted upon their symptoms. Third, participants provided recommendations for system design that involved allowing for user control and freedom. They also stressed the importance of careful wording of decision-support messages, such that messages that recommend them to seek care convey urgency but do not provoke anxiety. Alternatively, messages that recommend they may not need care should make the patient feel heard and reassured.

CONCLUSIONS

Future solutions for postpartum symptom monitoring should include both somatic and psychological symptoms, which may require combining existing measures to elicit symptoms in a nuanced manner. Solutions should allow for varied, safe interactions to suit individual needs. While mHealth or other apps may not be able to address all the social or financial needs of a person, they may at least provide information, so that patients can easily access other supportive resources.

The Intersectional Impact of Race/Ethnicity and Sex on Access to Technology Among Older Adults

BACKGROUND AND OBJECTIVES

Research on technological access and usage has revealed a digital divide based on several sociodemographic factors, including race/ethnicity, sex, income, and education. While several studies have examined these factors separately, few studies have considered how multiple vulnerable identities may combine to influence access to technology. Using the theory of intersectionality, this study assesses the combined impact of race/ethnicity and sex on access to a working cellphone and a working laptop/computer among U.S. older adults.

RESEARCH DESIGN AND METHODS

Data were derived from the 2018 National Health and Aging Trends Study. Chi-square tests were used to test group differences, and four multivariable logistic regression models were used to examine the association between the intersection of race/ethnicity and sex, and access to a working cellphone and a working laptop/computer.

RESULTS

After accounting for other explanatory variables, White female participants, Black male participants, Black female participants, Hispanic male participants, and Hispanic female participants were all less likely to have a working cellphone or a working laptop/computer compared to White male participants.

DISCUSSION AND IMPLICATIONS

The results of this study point to a significant disparity in access to technology based on intersectional identities, with Black and Hispanic female participants having the least access to technology. Interventions aiming to improve access to technology should target these two groups, with a focus on reducing the cost of purchasing technological equipment and the provision of training programs that improve technological skills.

Effectiveness and implementation of a text messaging intervention to reduce depression and anxiety symptoms among Latinx and Non-Latinx white users during the COVID-19 pandemic

Text messaging interventions are increasingly used to help people manage depression and anxiety. However, little is known about the effectiveness and implementation of these interventions among U.S. Latinxs, who often face barriers to using mental health tools. The StayWell at Home (StayWell) intervention, a 60-day text messaging program based on cognitive behavioral therapy (CBT), was developed to help adults cope with depressive and anxiety symptoms during the COVID-19 pandemic. StayWell users (n = 398) received daily mood inquiries and automated skills-based text messages delivering CBT-informed coping strategies from an investigator-generated message bank. We conduct a Hybrid Type 1 mixed-methods study to compare the effectiveness and implementation of StayWell for Latinx and Non-Latinx White (NLW) adults using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Effectiveness was measured using the PHQ-8 depression and GAD-7 anxiety scales, assessed before starting and after completing StayWell. Guided by RE-AIM, we conducted a thematic text analysis of responses to an open-ended question about user experiences to help contextualize quantitative findings. Approximately 65.8% (n = 262) of StayWell users completed pre-and-post surveys. On average, depressive (-1.48, p = 0.001) and anxiety (-1.38, p = 0.001) symptoms decreased from pre-to-post StayWell. Compared to NLW users (n = 192), Latinx users (n = 70) reported an additional -1.45 point (p < 0.05) decline in depressive symptoms, adjusting for demographics. Although Latinxs reported StayWell as relatively less useable (76.8 vs. 83.9, p = 0.001) than NLWs, they were more interested in continuing the program (7.5 vs. 6.2 out of 10, p = 0.001) and recommending it to a family member/friend (7.8 vs. 7.0 out of 10, p = 0.01). Based on the thematic analysis, both Latinx and NLW users enjoyed responding to mood inquiries and sought bi-directional, personalized text messages and texts with links to more information to resources. Only NLW users stated that StayWell provided no new information than they already knew from therapy or other sources. In contrast, Latinx users suggested that engagement with a behavioral provider through text or support groups would be beneficial, highlighting this group's unmet need for behavioral health care. mHealth interventions like StayWell are well-positioned to address population-level disparities by serving those with the greatest unmet needs if they are culturally adapted and actively disseminated to marginalized groups. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04473599.

Designing an mHealth Roadmap for the Journey to Self-Management: A Qualitative Study with Adolescents and Young Adults Living with Chronic Illness

OBJECTIVES

Adolescents and young adults (AYA) with chronic illnesses often struggle with illness self-management. The objective of this study is to understand how AYA with various chronic illnesses develop self-management skills and which mobile health (mHealth) strategies they believe could be helpful.

METHODS

Semi-structured interviews were conducted with patients, between 16 to 20 years old, living with at least one chronic illness (N = 19), between 2018 and 2019 in Los Angeles, CA. Three coders completed thematic coding to understand how AYA develop and maintain self-management skills, to inform the development of mHealth interventions appropriate across a variety of chronic conditions.

RESULTS

Results suggest that AYA develop self-management skills through several strategies, including (1) getting organized, (2) making it work for me and (3) keeping the right mentality. AYA described developing these strategies through: (1) receiving social support, (2) accessing helpful tools and technologies, and (3) going through a maturation process. They provided recommendations for mHealth intervention developers.

DISCUSSION

The results suggest that an appealing mHealth intervention could support AYA patients in proactively acquiring self-management skills and prevent having to rely on trial and error or uneven access to guidance and support. Interventions should be responsive to individual technology preferences and practices.

How general practitioners and patients discuss type 2 diabetes mellitus and cardiovascular diseases concerns during consultations: Implications for digital health

Objective

To analyse general practitioner-patient consultations about type 2 diabetes mellitus or cardiovascular diseases and describe (i) the nature of self-management discussions; (ii) actions required from patients during and after consultation regarding self-management; and (iii) implications for digital health to support patients during (and after) consultation.

Method

This study screened 281 general practitioner consultations conducted in 2017 within the UK general practice setting from an existing dataset containing videos and transcripts of consultations between GPs and patients. Secondary analysis was conducted using a multi-method approach, including descriptive, content, and visualisation analysis, to inform the nature of self-management discussions, what actions are required from patients, and whether digital technology was mentioned during the consultation to support self-management.

Results

Analysis of eligible 19 consultations revealed a discord between what self-management actions are required of patients during and after consultations. Lifestyle discussions are often discussed in depth, but these discussions rely heavily on subjective inquiry and recall. Some patients in these cohorts are overwhelmed by self-management, to the detriment of their personal health. Digital support for self-management was not a major topic of discussion, however, we identified a number of emergent gaps where digital technology can support self-management concerns.

Conclusion

There is potential for digital technology to reconcile what actions are required of patients during and after consultations. Furthermore, a number of emergent themes around self-management have implications for digitalisation.

Designing a Framework for Remote Cancer Care Through Community Co-design: Participatory Development Study

BACKGROUND

Recent shifts to telemedicine and remote patient monitoring demonstrate the potential for new technology to transform health systems; yet, methods to design for inclusion and resilience are lacking.

OBJECTIVE

The aim of this study is to design and implement a participatory framework to produce effective health care solutions through co-design with diverse stakeholders.

METHODS

We developed a design framework to cocreate solutions to locally prioritized health and communication problems focused on cancer care. The framework is premised on the framing and discovery of problems through community engagement and lead-user innovation with the hypothesis that diversity and inclusion in the co-design process generate more innovative and resilient solutions. Discovery, design, and development were implemented through structured phases with design studios at various locations in urban and rural Kentucky, including Appalachia, each building from prior work. In the final design studio, working prototypes were developed and tested. Outputs were assessed using the System Usability Scale as well as semistructured user feedback.

RESULTS

We co-designed, developed, and tested a mobile app (myPath) and service model for distress surveillance and cancer care coordination following the LAUNCH (Linking and Amplifying User-Centered Networks through Connected Health) framework. The problem of awareness, navigation, and communication through cancer care was selected by the community after framing areas for opportunity based on significant geographic disparities in cancer and health burden resource and broadband access. The codeveloped digital myPath app showed the highest perceived combined usability (mean 81.9, SD 15.2) compared with the current gold standard of distress management for patients with cancer, the paper-based National Comprehensive Cancer Network Distress Thermometer (mean 74.2, SD 15.8). Testing of the System Usability Scale subscales showed that the myPath app had significantly better usability than the paper Distress Thermometer (t63=2.611; P=.01), whereas learnability did not differ between the instruments (t63=-0.311; P=.76). Notable differences by patient and provider scoring and feedback were found.

CONCLUSIONS

Participatory problem definition and community-based co-design, design-with methods, may produce more acceptable and effective solutions than traditional design-for approaches.

Understanding Caregiving and Caregivers: Supporting Children and Youth With Special Health Care Needs at Home

Caregiving encompasses the nurturing, tasks, resources, and services that meet the day-to-day needs of children and youth with special health care needs (CYSHCN) at home. Many gaps exist in the strategies currently offered by the health care system to meet the caregiving needs of CYSHCN. The work of family caregivers of CYSHCN is known to be extensive, but it is so poorly understood that it has been described as "invisible". This invisibility leads to poor communication and gaps in understanding between professional health care providers and family caregivers. To address these gaps, health care researchers must work with family caregivers to incorporate their expertise on caregiving and create meaningful and sustainable research partnerships. A growing body of research is attempting to remedy the problem of caregiving invisibility and lay better foundations for successful integration between health care settings, family caregiving, professional caregiving, and community supports for families of CYSHCN. We identify high-priority gaps in CYSHCN caregiving research and propose research questions that are designed to accelerate growth in evidence-based understanding of the work of family caregivers of CYSHCN and how best to support them.

Considerations of diversity, equity, and inclusion in mental health apps: A scoping review of evaluation frameworks

Mental health applications or apps are a promising approach to reduce the pervasive unmet mental health need observed among marginalized groups. However, these groups face unique challenges to engage in and benefit from these interventions, and apps that consider issues of diversity, equity, and inclusion (DEI) may be better positioned to reach them. App evaluation frameworks emerge as crucial tools for researchers, clinicians, and users to select evidence-based apps. Nevertheless, it is unclear the extent to which existing assessment tools capture DEI factors. The present scoping review identified 68 studies that employed one or more assessment tools to evaluate a mental health app, leading to 44 unique app evaluation frameworks. Results showed that most frameworks were developed after 2015, and only 58% of them considered at least one DEI criterion. Frameworks that performed exceptionally well were those that combined multiple standardized and validated measures. This lack of consideration for DEI variables may limit the ability of app-based interventions to serve marginalized communities, or even worse, create new disparities. Therefore, we provide recommendations to improve current app evaluation frameworks' cultural robustness and clinical utility, maximizing their effectiveness when working with individuals from marginalized communities.

Addressing the Digital Inverse Care Law in the Time of COVID-19: Potential for Digital Technology to Exacerbate or Mitigate Health Inequalities

Digital technologies have been transforming methods of health care delivery and have been embraced within the health, social, and public response to the COVID-19 pandemic. However, this has directed attention to the “inverse information law” (also called “digital inverse care law”) and digital inequalities, as people who are most in need of support (in particular, older people and those experiencing social deprivation) are often least likely to engage with digital platforms. The response to the COVID-19 pandemic represents a sustained shift to the adoption of digital approaches to working and engaging with populations, which will continue beyond the COVID-19 pandemic. Therefore, it is important to understand the underlying factors contributing to digital inequalities and act immediately to avoid digital inequality contributing to health inequalities in the future. The response to COVID-19 represents a sustained shift to adopting digital approaches to working and engaging with populations which will continue beyond this pandemic. Therefore it is important that we understand the underlying factors contributing to digital inequalities, and act now to protect against digital inequality contributing to health inequalities in the future.

Involving End Users in Adapting a Spanish Version of a Web-Based Mental Health Clinic for Young People in Colombia: Exploratory Study Using Participatory Design Methodologies

BACKGROUND

Health information technologies (HITs) hold enormous promise for improving access to and providing better quality of mental health care. However, despite the spread of such technologies in high-income countries, these technologies have not yet been commonly adopted in low- and middle-income countries. People living in these parts of the world are at risk of experiencing physical, technological, and social health inequalities. A possible solution is to utilize the currently available HITs developed in other counties.

OBJECTIVE

Using participatory design methodologies with Colombian end users (young people, their supportive others, and health professionals), this study aimed to conduct co-design workshops to culturally adapt a Web-based Mental Health eClinic (MHeC) for young people, perform one-on-one user-testing sessions to evaluate an alpha prototype of a Spanish version of the MHeC and adapt it to the Colombian context, and inform the development of a skeletal framework and alpha prototype for a Colombian version of the MHeC (MHeC-C).

METHODS

This study involved the utilization of a research and development (R&D) cycle including 4 iterative phases: co-design workshops; knowledge translation; tailoring to language, culture, and place (or context); and one-on-one user-testing sessions.

RESULTS

A total of 2 co-design workshops were held with 18 users-young people (n=7) and health professionals (n=11). Moreover, 10 users participated in one-on-one user-testing sessions-young people (n=5), supportive others (n=2), and health professionals (n=3). A total of 204 source documents were collected and 605 annotations were coded. A thematic analysis resulted in 6 themes (ie, opinions about the MHeC-C, Colombian context, functionality, content, user interface, and technology platforms). Participants liked the idea of having an MHeC designed and adapted for Colombian young people, and its 5 key elements were acceptable in this context (home page and triage system, self-report assessment, dashboard of results, booking and video-visit system, and personalized well-being plan). However, to be relevant in Colombia, participants stressed the need to develop additional functionality (eg, phone network backup; chat; geolocation; and integration with electronic medical records, apps, or electronic tools) as well as an adaptation of the self-report assessment. Importantly, the latter not only included language but also culture and context.

CONCLUSIONS

The application of an R&D cycle that also included processes for adaptation to Colombia (language, culture, and context) resulted in the development of an evidence-based, language-appropriate, culturally sensitive, and context-adapted HIT that is relevant, applicable, engaging, and usable in both the short and long term. The resultant R&D cycle allowed for the adaptation of an already available HIT (ie, MHeC) to the MHeC-C-a low-cost and scalable technology solution for low- and middle-income countries like Colombia, which has the potential to provide young people with accessible, available, affordable, and integrated mental health care at the right time.

Using Participatory Design Methodologies to Co-Design and Culturally Adapt the Spanish Version of the Mental Health eClinic: Qualitative Study

Background

The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students.

Objective

We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype.

Methods

A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype.

Results

We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P<.001) and content (kappa=.92; P<.001) and substantial agreement for the user interface (kappa=.785; P<.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking.

Conclusions

Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries.

The Digital Divide in Health-Related Technology Use: The Significance of Race/Ethnicity

Background and Objectives

Technology can enhance the health and quality of life of diverse populations and may play an important role in reducing health disparities. Although a "digital divide" between the young and the old has been noted, it is unclear whether the use of technology for managing health differs by race/ethnicity among older adults. This study uses nationally representative data from community-dwelling older Americans to characterize racial/ethnic differences in health-related technology use.

Design and Methods

Data came from 1,336 white, black, and Hispanic adults aged 54 and older who completed the 2014 technology module of the Health and Retirement Study. Racial/ethnic differences in overall health-related technology use were assessed using Poisson regression. Then, F-tests were used to assess differences in the use of phone calls, text messages, E-mails, social media, health management sites, health-related mobile applications, web searches, and brain games for health purposes.

Results

Compared to whites, older blacks and Hispanics were less likely to use technology for health-related purposes after accounting for demographic characteristics, education, and health conditions. They were also less likely to make or receive phone calls, use health management sites, search the web for health information, and use brain games for their health.

Discussion and Implications

Older racial and ethnic minorities are less likely than whites to use certain technologies when managing their health. These findings highlight the importance of understanding the patterns of health-related technology use across racially and ethnically diverse populations to appropriately tailor interventions aimed at improving minority health and eliminating health disparities.

Patient work from a context and time use perspective: a mixed-methods study protocol

INTRODUCTION

Self-management is widely promoted but less attention is focused on the work required from patients. To date, many individuals struggle to practise self-management. 'Patient work', a concept that examines the 'work' involved in self-management, is an approach to understanding the tasks, effort, time and context from patient perspective. The purpose of our study is to use a novel approach combining non-obstructive observations via digital devices with in-depth qualitative data about health behaviours and motivations, to capture the full range of patient work experienced by people with type 2 diabetes and chronic comorbidities. It aims to yield comprehensive insights about 'what works' in self-management, potentially extending to populations with other chronic health conditions.

METHODS AND ANALYSIS

This mixed-methods observational study involves a (1) prestudy interview and questionnaires, (2) a 24-hour period during which participants wear a camera and complete a time-use diary, and a (3) poststudy interview and study feedback. Adult participants living with type 2 diabetes with at least one chronic comorbidity will be recruited using purposive sampling to obtain a balanced gender ratio and of participants using insulin and those using only oral medication. Interviews will be analysed using thematic analysis. Data captured by digital devices, diaries and questionnaires will be used to analyse the duration, time, context and patterns of health-related behaviours.

ETHICS AND DISSEMINATION

The study was approved by the Macquarie University Human Research Ethics Committee for Medical Sciences (reference number 5201700718). Participants will carry a wallet-sized card that explains the purpose of the study to third parties, and can remove the camera at any stage. Before the poststudy interview begins, participants will view the camera images in private and can delete any images. Should any images be used in future publications or presentations, identifying features such as human faces and names will be obscured.

Uncovering the invisible patient work system through a case study of breast cancer self-management

As patients transition from passive recipients to actors in their health management, there is an opportunity to enhance theoretical frameworks describing the patient work system. Previous macroergonomic frameworks depict how patients manage health outside the institutional healthcare system, though none formally integrate the concept of invisible work - self-management practices undervalued or unseen by healthcare providers. This article overlays invisible work onto the patient work system through a case study of breast cancer self-management. Thirty breast cancer survivors were interviewed about positive and negative experiences post-diagnosis. Invisible and visible components of participants' work systems were explicated through qualitative content analysis. The results demonstrate that all participants had invisible work system components, and based on these findings, this article theorises the existence of an 'invisible patient work system.' Future research and design to support self-management practices should explicitly address the invisible characteristics of the work systems in which patients are embedded.Practitioner Summary: This article seeks to enhance the healthcare human factors literature by integrating the concept of invisible work into preexisting patient work system models. Through a secondary analysis of an interview study with 30 breast cancer survivors, we found that all participants recalled invisible components of their respective work systems. Abbreviations CHIT Consumer Health Information Technology SEIPS Systems Engineering Initiative for Patient Safety IRB Institutional Review Board SES Socioeconomic Status mHealth Mobile Health PHR Patient Health Record ICAN Instrument for Patient Capacity Assessment HIPAA Health Insurance Portability and Accoutability Act.

From loquacious to reticent: understanding patient health information communication to guide consumer health IT design

Background and significance

It is increasingly recognized that some patients self-manage in the context of social networks rather than alone. Consumer health information technology (IT) designed to support socially embedded self-management must be responsive to patients' everyday communication practices. There is an opportunity to improve consumer health IT design by explicating how patients currently leverage social media to support health information communication.

Objective

The objective of this study was to determine types of health information communication patterns that typify Facebook users with chronic health conditions to guide consumer health IT design.

Materials and methods

Seven hundred participants with type 2 diabetes were recruited through a commercial survey access panel. Cluster analysis was used to identify distinct approaches to health information communication both on and off Facebook. Analysis of variance (ANOVA) methods were used to identify demographic and behavioral differences among profiles. Secondary analysis of qualitative interviews ( n  = 25) and analysis of open-ended survey questions were conducted to understand participant rationales for each profile.

Results

Our analysis yielded 7 distinct health information communication profiles. Five of 7 profiles had consistent patterns both on and off Facebook, while the remaining 2 demonstrated distinct practices, with no health information communication on Facebook but some off Facebook. One profile was distinct from all others in both health information communication practices and demographic composition. Rationales for following specific health information communication practices were categorized under 6 themes: altruism, instrumental support, social support, privacy and stigma, convenience, and Facebook knowledge.

Conclusion

Facebook has been widely adopted for health information communication; This study demonstrates that Facebook has been widely adopted for health information communication. It also shows that the ways in which patients communicate health information on and off Facebook are diverse.

Patient adoption of an internet based diabetes medication tool to improve adherence: A pilot study

OBJECTIVE

To investigate the effect of a video intervention, Managing Your Diabetes Medicines, on patient self-efficacy, problems with using medication, and medication adherence in a rural, mostly African American population.

METHODS

Patients selected their problem areas in medication use and watched one of nine 2-min videos with a research assistant at a clinic or pharmacy and were given an access code to watch all the videos at their convenience. Outcomes were measured at baseline and 3-month follow-up.

RESULTS

Fifty-one patients were enrolled; 84% were African American and 80% were female (mean age: 54 years). Seventy-three percent watched at least one module after the initial visit. Improved self-efficacy was associated with a decrease in concerns about medications (r=-0.64). Low literate patients experienced greater improvement in self-efficacy than more literate patients (t=2.54, p=0.02). Patients' mean number of problems declined from 6.14 to 5.03. The number of patients with high or medium adherence rose from 33% at baseline to 43% at 3-month follow-up.

CONCLUSIONS

A practical, customized video intervention may help improve patient self-efficacy, reduce problems with medication use, and improve medication adherence in diabetes patients.

PRACTICE IMPLICATIONS

Providers should consider implementing technology-based interventions in the clinic to address common problems that patients have with self-management.

Spanish-Language Consumer Health Information Technology Interventions: A Systematic Review

Background

As consumer health information technology (IT) becomes more thoroughly integrated into patient care, it is critical that these tools are appropriate for the diverse patient populations whom they are intended to serve. Cultural differences associated with ethnicity are one aspect of diversity that may play a role in user-technology interactions.

Objective

Our aim was to evaluate the current scope of consumer health IT interventions targeted to the US Spanish-speaking Latino population and to characterize these interventions in terms of technological attributes, health domains, cultural tailoring, and evaluation metrics.

Methods

A narrative synthesis was conducted of existing Spanish-language consumer health IT interventions indexed within health and computer science databases. Database searches were limited to English-language articles published between January 1990 and September 2015. Studies were included if they detailed an assessment of a patient-centered electronic technology intervention targeting health within the US Spanish-speaking Latino population. Included studies were required to have a majority Latino population sample. The following were extracted from articles: first author’s last name, publication year, population characteristics, journal domain, health domain, technology platform and functionality, available languages of intervention, US region, cultural tailoring, intervention delivery location, study design, and evaluation metrics.

Results

We included 42 studies in the review. Most of the studies were published between 2009 and 2015 and had a majority percentage of female study participants. The mean age of participants ranged from 15 to 68. Interventions most commonly focused on urban population centers and within the western region of the United States. Of articles specifying a technology domain, computer was found to be most common; however, a fairly even distribution across all technologies was noted. Cancer, diabetes, and child, infant, or maternal health were the most common health domains targeted by consumer health IT interventions. More than half of the interventions were culturally tailored. The most frequently used evaluation metric was behavior/attitude change, followed by usability and knowledge retention.

Conclusions

This study characterizes the existing body of research exploring consumer health IT interventions for the US Spanish-speaking Latino population. In doing so, it reveals three primary needs within the field. First, while the increase in studies targeting the Latino population in the last decade is a promising advancement, future research is needed that focuses on Latino subpopulations previously overlooked. Second, preliminary steps have been taken to culturally tailor consumer health IT interventions for the US Spanish-speaking Latino population; however, focus must expand beyond intervention content. Finally, the field should work to promote long-term evaluation of technology efficacy, moving beyond intermediary measures toward measures of health outcomes.

Exploring patients' health information communication practices with social network members as a foundation for consumer health IT design

BACKGROUND

There is a need to ensure that the growing number of consumer health information technologies designed to support patient engagement account for the larger social context in which health is managed. Basic research on how patients engage this larger social context is needed as a precursor to the development of patient-centered consumer health information technology (IT) solutions.

PURPOSE

The purpose of this study was to inform the broader design of consumer health IT by characterizing patients' existing health information communication practices with their social network members.

METHODS

This qualitative study took place between 2010 and 2012 in a Midwestern city. Eighteen patients with chronic conditions participated in a semi-structured interview that was analyzed using qualitative content analysis and descriptive statistics. Emphasis was placed on recruiting a sample representing diverse cultural groups and including participants of low socioeconomic status.

RESULTS

Participants' social networks included a wide range of individuals, spanning biological relatives, divinities, and second-degree relationships. Participants' rationales for health information communication reflected seven themes: (1) characteristics and circumstances of the person, (2) characteristics and circumstances of the relationship, (3) structure and composition of the social network, (4) content of the message, (5) orientation of the goal, (6) dimensions of the context, and (7) adaptive practices.

CONCLUSIONS

This study demonstrates that patients' health information communication practices are multidimensional, engaging individuals beyond formal and informal caregivers and driven by characteristics of their personal lives and larger social contexts in addition to their health problem. New models of consumer health IT must be created to better align with the realities of patients' communication routines.

Applying Human Factors Principles to Mitigate Usability Issues Related to Embedded Assumptions in Health Information Technology Design

Background

There is growing recognition that design flaws in health information technology (HIT) lead to increased cognitive work, impact workflows, and produce other undesirable user experiences that contribute to usability issues and, in some cases, patient harm. These usability issues may in turn contribute to HIT utilization disparities and patient safety concerns, particularly among “non-typical” HIT users and their health care providers. Health care disparities are associated with poor health outcomes, premature death, and increased health care costs. HIT has the potential to reduce these disparate outcomes. In the computer science field, it has long been recognized that embedded cultural assumptions can reduce the usability, usefulness, and safety of HIT systems for populations whose characteristics differ from “stereotypical” users. Among these non-typical users, inappropriate embedded design assumptions may contribute to health care disparities. It is unclear how to address potentially inappropriate embedded HIT design assumptions once detected.

Objective

The objective of this paper is to explain HIT universal design principles derived from the human factors engineering literature that can help to overcome potential usability and/or patient safety issues that are associated with unrecognized, embedded assumptions about cultural groups when designing HIT systems.

Methods

Existing best practices, guidance, and standards in software usability and accessibility were subjected to a 5-step expert review process to identify and summarize those best practices, guidance, and standards that could help identify and/or address embedded design assumptions in HIT that could negatively impact patient safety, particularly for non-majority HIT user populations. An iterative consensus-based process was then used to derive evidence-based design principles from the data to address potentially inappropriate embedded cultural assumptions.

Results

Design principles that may help identify and address embedded HIT design assumptions are available in the existing literature.

Conclusions

Evidence-based HIT design principles derived from existing human factors and informatics literature can help HIT developers identify and address embedded cultural assumptions that may underlie HIT-associated usability and patient safety concerns as well as health care disparities.

Beyond traditional advertisements: leveraging Facebook's social structures for research recruitment

Background

Obtaining access to a demographically and geographically diverse sample for health-related research can be costly and time consuming. Previous studies have reported mixed results regarding the potential of using social media-based advertisements to overcome these challenges.

Objective

Our aim was to develop and assess the feasibility, benefits, and challenges of recruiting for research studies related to consumer health information technology (IT) by leveraging the social structures embedded in the social networking platform, Facebook.

Methods

Two recruitment strategies that involved direct communication with existing Facebook groups and pages were developed and implemented in two distinct populations. The first recruitment strategy involved posting a survey link directly to consenting groups and pages and was used to recruit Filipino-Americans to a study assessing the perceptions, use of, and preferences for consumer health IT. This study took place between August and December 2013. The second recruitment strategy targeted individuals with type 2 diabetes and involved creating a study-related Facebook group and asking administrators of other groups and pages to publicize our group to their members. Group members were then directly invited to participate in an online pre-study survey. This portion of a larger study to understand existing health management practices as a foundation for consumer health IT design took place between May and June 2014. In executing both recruitment strategies, efforts were made to establish trust and transparency. Recruitment rate, cost, content of interaction, and characteristics of the sample obtained were used to assess the recruitment methods.

Results

The two recruitment methods yielded 87 and 79 complete responses, respectively. The first recruitment method yielded a rate of study completion proportionate to that of the rate of posts made, whereas recruitment successes of the second recruitment method seemed to follow directly from the actions of a subset of administrators. Excluding personnel time, the first recruitment method resulted in no direct costs, and the second recruitment method resulted in a total direct cost of US $118.17. Messages, posts, and comments received using both recruitment strategies reflected ten themes, including appreciation, assistance, clarification, concerns, encouragement, health information, interest, promotion, solicitations, and support. Both recruitment methods produced mixed results regarding sample representativeness with respect to characteristics such as gender, race, and ethnicity.

Conclusions

The results of the study demonstrate that leveraging the social structures of Facebook for health-related research was feasible for obtaining small samples appropriate for qualitative research but not for obtaining large samples needed for quantitative research. The content of interactions with members of the target population prompted ethical deliberations concerning suitable target communities and appropriate boundaries between researchers and participants. Widespread replication of this method would benefit from a broad discussion among researchers, social media users, social media companies, and experts in research ethics to address appropriate protocols for such interactions.

Transforming consumer health informatics through a patient work framework: connecting patients to context

Designing patient-centered consumer health informatics (CHI) applications requires understanding and creating alignment with patients' and their family members' health-related activities, referred to here as 'patient work'. A patient work approach to CHI draws on medical social science and human factors engineering models and simultaneously attends to patients, their family members, activities, and context. A patient work approach extends existing approaches to CHI design that are responsive to patients' biomedical realities and personal skills and behaviors. It focuses on the embeddedness of patients' health management in larger processes and contexts and prioritizes patients' perspectives on illness management. Future research is required to advance (1) theories of patient work, (2) methods for assessing patient work, and (3) techniques for translating knowledge of patient work into CHI application design. Advancing a patient work approach within CHI is integral to developing and deploying consumer-facing technologies that are integrated with patients' everyday lives.

Initial design of culturally informed behavioral intervention technologies: developing an mHealth intervention for young sexual minority men with generalized anxiety disorder and major depression

BACKGROUND

To our knowledge, there is no well-articulated process for the design of culturally informed behavioral intervention technologies.

OBJECTIVE

This paper describes the early stages of such a process, illustrated by the methodology for the ongoing development of a behavioral intervention technology targeting generalized anxiety disorder and major depression among young sexual minority men.

METHODS

We integrated instructional design for Internet behavioral intervention technologies with greater detail on information sources that can identify user needs in understudied populations, as well as advances in the understanding of technology-specific behavioral intervention technology dimensions that may need to be culturally tailored.

RESULTS

General psychological theory describing how to effect change in the clinical target is first integrated with theory describing potentially malleable factors that help explain the clinical problem within the population. Additional information sources are then used to (1) evaluate the theory, (2) identify population-specific factors that may affect users' ability to relate to and benefit from the behavioral intervention technology, and (3) establish specific skills, attitudes, knowledge, etc, required to change malleable factors posited in the theory. User needs result from synthesis of this information. Product requirements are then generated through application of the user needs to specific behavioral intervention technology dimensions (eg, technology platform). We provide examples of considerations relevant to each stage of this process and how they were applied.

CONCLUSIONS

This process can guide the initial design of other culturally informed behavioral intervention technologies. This first attempt to create a systematic design process can spur development of guidelines for design of behavioral intervention technologies aimed to reduce health disparities.

A question of trust: user-centered design requirements for an informatics intervention to promote the sexual health of African-American youth

OBJECTIVE

We investigated the user requirements of African-American youth (aged 14-24 years) to inform the design of a culturally appropriate, network-based informatics intervention for the prevention of HIV and other sexually transmitted infections (STI).

MATERIALS AND METHODS

We conducted 10 focus groups with 75 African-American youth from a city with high HIV/STI prevalence. Data analyses involved coding using qualitative content analysis procedures and memo writing.

RESULTS

Unexpectedly, the majority of participants' design recommendations concerned trust. Youth expressed distrust towards people and groups, which was amplified within the context of information technology-mediated interactions about HIV/STI. Participants expressed distrust in the reliability of condoms and the accuracy of HIV tests. They questioned the benevolence of many institutions, and some rejected authoritative HIV/STI information. Therefore, reputational information, including rumor, influenced HIV/STI-related decision making. Participants' design requirements also focused on trust-related concerns. Accordingly, we developed a novel trust-centered design framework to guide intervention design.

DISCUSSION

Current approaches to online trust for health informatics do not consider group-level trusting patterns. Yet, trust was the central intervention-relevant issue among African-American youth, suggesting an important focus for culturally informed design. Our design framework incorporates: intervention objectives (eg, network embeddedness, participation); functional specifications (eg, decision support, collective action, credible question and answer services); and interaction design (eg, member control, offline network linkages, optional anonymity).

CONCLUSIONS

Trust is a critical focus for HIV/STI informatics interventions for young African Americans. Our design framework offers practical, culturally relevant, and systematic guidance to designers to reach this underserved group better.