Digital health interventions: widening access or widening inequalities?

Digital health technologies and inequalities: A scoping review of potential impacts and policy recommendations

Digital health technologies hold promises for reducing health care costs, enhancing access to care, and addressing labor shortages. However, they risk exacerbating inequalities by disproportionately benefitting a subset of the population. Use of digital technologies accelerated during the Covid-19 pandemic. Our scoping review aimed to describe how inequalities related to their use were conceptually assessed during and after the pandemic and understand how digital strategies and policies might support digital equity. We used the PRISMA Extension for scoping reviews, identifying 2055 papers through an initial search of 3 databases in 2021 and complementary search in 2022, of which 41 were retained. Analysis was guided by the eHealth equity framework. Results showed that digital inequalities were reported in the U.S. and other high-income countries and were mainly assessed through differences in access and use according to individual sociodemographic characteristics. Health disparities related to technology use and the interaction between context and technology implementation were more rarely documented. Policy recommendations stressed the adoption of an equity lens in strategy development and multilayered and intersectoral collaboration to align interventions with the needs of specific subgroups. Finally, findings suggested that evaluations of health and wellbeing distribution related to the use of digital technologies should inform digital strategies and health policies.

Patient Characteristics Associated With Disparities in Engagement With and Experience of COVID-19 Remote Home Monitoring Services: A Mixed-Methods Evaluation

INTRODUCTION

The adoption of remote healthcare methods has been accelerated by the COVID-19 pandemic, but evidence suggests that some patients need additional support to engage remotely, potentially increasing health disparities if needs are not met. This study of COVID-19 remote home monitoring services across England explores experiences of and engagement with the service across different patient groups.

METHODS

This was a mixed-methods study with survey and interview data collected from 28 services across England between February and June 2021. Surveys were conducted with staff and patients and carers receiving the service. Interviews with staff service leads, patients and carers were conducted in 17 sites. Quantitative data were analysed using univariate and multivariate methods, and qualitative data were analysed using thematic analysis.

FINDINGS

Survey responses were received from 292 staff and 1069 patients and carers. Twenty-three staff service leads, 59 patients and 3 carers were interviewed. Many service leads reported that they had considered inclusivity when adapting the service for their local population; strategies included widening the eligibility criteria, prioritising vulnerable groups and creating referral pathways. However, disparities were reported across patient groups in their experiences and engagement. Older patients reported the service to be less helpful (p = 0.004), were more likely to report a problem (p < 0.001) and had more difficulty in understanding information (p = 0.005). Health status (p = 0.004), ethnicity (p < 0.001), gender (p < 0.001) and employment (p = 0.007) were associated with differential engagement with monitoring, and minority ethnic groups reported more difficulty understanding service information (p = 0.001). Qualitative data found illness severity to be an important factor in the support required, and patients' living situation and social network affected whether they found the service reassuring.

CONCLUSION

Addressing health disparities must be a key focus in the design and delivery of remote care. Services should be tailored to match the needs of their local population, encourage access through collaboration and referral pathways with other services and monitor their inclusiveness. Involving patients and staff in service design can illuminate the diversity of patients' needs and experiences of care.

PATIENT OR PUBLIC CONTRIBUTION

The study team met with service user and public members of the BRACE PPI group and patient representatives from RSET in a series of workshops. Workshops informed study design, data collection tools, data interpretation and dissemination activities. Study documents (such as consent forms, topic guides, surveys and information sheets) were reviewed by PPI members; patient surveys and interview guides were piloted, and members also commented on the manuscript.

Rural disparities impact response to a web-based physical activity self-management intervention in COPD: A secondary analysis

PURPOSE

This secondary exploratory analysis examined rural-urban differences in response to a web-based physical activity self-management intervention for chronic obstructive pulmonary disease (COPD).

METHODS

Participants with COPD (N = 239 US Veterans) were randomized to either a multicomponent web-based intervention (goal setting, iterative feedback of daily step counts, motivational and educational information, and an online community forum) or waitlist-control for 4 months with a 12-month follow-up. General linear modeling estimated the impact of rural/urban status (using Rural-Urban Commuting Area [RUCA] codes) on (1) 4- and 12-month daily step-count change compared to waitlist-control, and (2) intervention engagement (weekly logons and participant feedback).

FINDINGS

Rural (n = 108) and urban (n = 131) participants' mean age was 66.7±8.8 years. Rural/urban status significantly moderated 4-month change in daily step counts between randomization groups (p = 0.041). Specifically, among urban participants, intervention participants improved by 1500 daily steps more than waitlist-control participants (p = 0.001). There was no difference among rural participants. In the intervention group, rural participants engaged less with the step-count graphs on the website than urban participants at 4 months (p = 0.019); this difference dissipated at 12 months. More frequent logons were associated with greater change in daily step counts (p = 0.004); this association was not moderated by rural/urban status.

CONCLUSIONS

The web-based intervention was effective for urban, but not rural, participants at 4 months. Rural participants were also less engaged at 4 months, which may explain differences in effectiveness. Technology-based interventions can help address urban-rural disparities in patients with COPD, but may also contribute to them unless resources are available to support engagement with the technology.

Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions

BACKGROUND

Digital health technologies have expanded tremendously in the last two decades, creating an emerging research and clinical field. They are regarded as cost-effective, and their use in healthcare is prioritized by many countries. However, the constant evolution of these technologies has led to an abundance of related literature. Thus, we conducted an umbrella review to identify and characterize digital supportive care interventions for patients with cancer and their relatives.

METHODS

A preregistered umbrella review was conducted (PROSPERO registration number CRD42022333110). Five databases were searched (Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library). To be considered, studies had to be systematic reviews or meta-analyses, be performed on pediatric or adult patients with cancer or survivors or their relatives, report results on web-based or app-based supportive care interventions, and measure psychological, functional, or behavioral variables or quality of life related to cancer. The methodological quality of the studies was assessed using the AMSTAR-2 tool.

FINDINGS

Twenty eligible studies were identified. Most of the included studies reported results from adult patients with cancer. Globally, digital interventions were shown to be effective for physical activity in patients with cancer but had mixed results regarding emotional outcomes and quality of life. Additionally, a lack of methodological quality was noted for most of the included reviews.

DISCUSSION

Digital supportive care interventions could be an effective tool in cancer care for some outcomes. Recommendations have been formulated for further research in this field using adapted methodologies for the development of digital health interventions.

Patient and staff experiences of using technology-enabled and analogue models of remote home monitoring for COVID-19 in England: A mixed-method evaluation

OBJECTIVE

To evaluate patient and staff experiences of using technology-enabled ('tech-enabled') and analogue remote home monitoring models for COVID-19, implemented in England during the pandemic.

METHODS

Twenty-eight sites were selected for diversity in a range of criteria (e.g. pre-hospital or early discharge service, mode of patient data submission). Between February and May 2021, we conducted quantitative surveys with patients, carers and staff delivering the service, and interviewed patients, carers, and staff from 17 of the 28 services. Quantitative data were analysed using descriptive statistics and both univariate and multivariate analyses. Qualitative data were interpreted using thematic analysis.

RESULTS

Twenty-one sites adopted mixed models whereby patients could submit their symptoms using either tech-enabled (app, weblink, or automated phone calls) or analogue (phone calls with a health professional) options; seven sites offered analogue-only data submission (phone calls or face-to-face visits with a health professional). Sixty-two patients and carers were interviewed, and 1069 survey responses were received (18 % response rate). Fifty-eight staff were interviewed, and 292 survey responses were received (39 % response rate). Patients who used tech-enabled modes tended to be younger (p = 0.005), have a higher level of education (p = 0.011), and more likely to identify as White British (p = 0.043). Most patients found relaying symptoms easy, regardless of modality, though many received assistance from family or friends. Staff considered the adoption of mixed delivery models beneficial, enabling them to manage large patient numbers and contact patients for further assessment as needed; however, they suggested improvements to the functionality of systems to better fit clinical and operational needs. Human contact was important in all remote home monitoring options.

CONCLUSIONS

Organisations implementing tech-enabled remote home monitoring at scale should consider adopting mixed models which can accommodate patients with different needs; focus on the usability and interoperability of tech-enabled platforms; and encourage digital inclusivity for patients.

Contraceptive use and pregnancy planning in Britain during the first year of the COVID-19 pandemic: findings from a large, quasi-representative survey (Natsal-COVID)

BACKGROUND

Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic.

METHODS

Natsal-COVID Wave 2 surveyed 6658 adults aged 18-59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness.

RESULTS

Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. 29.3% (26.9%-31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%-20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) scored as 'unplanned'; less planning was associated with younger age, lower social grade and unemployment.

CONCLUSIONS

Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

Digital health, cardiometabolic disease and ethnicity: an analysis of United Kingdom government policies from 2010 to 2022

Recent health policies in the United Kingdom (UK) and internationally have focussed on digitisation of healthcare. We examined UK policies for evidence of government action addressing health inequalities and digital health, using cardiometabolic disease as an exemplar. Using a systematic search methodology, we identified 87 relevant policy documents published between 2010 and 2022. We found increasing emphasis on digital health, including for prevention, diagnosis and management of cardiometabolic disease. Several policies also focused on tackling health inequalities and improving digital access. The COVID-19 pandemic amplified inequalities. No policies addressed ethnic inequalities in digital health for cardiometabolic disease, despite high prevalence in minority ethnic communities. Our findings suggest that creating opportunities for digital inclusion and reduce longer-term health inequalities, will require future policies to focus on: the heterogeneity of ethnic groups; cross-sectoral disadvantages which contribute to disease burden and digital accessibility; and disease-specific interventions which lend themselves to culturally tailored solutions.

Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV

INTRODUCTION

The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine.

METHODS

We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance.

RESULTS

Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81).

CONCLUSIONS

A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.

Migrants face Barriers to Obtaining Electronic Identification: A population-based Study Among Older Russian-speakers in Finland

As digital technologies continue to transform health care and health systems, they will continue to have a lasting impact on health services. Many health and social care services have rapidly become 'digital by default'. The electronic identification (e-ID) technology is needed for secure authentication to digital services. Recent studies have shown that the 'digital divide' is prominent between ethnic minorities and the majority populations and between older and younger adults. Inequalities related to not having an e-ID, which is in many countries required to access digital health services, remain under-researched. Moreover, there is a lack of knowledge of the use of digital services among older migrants. This study analyses general socio-demographic as well as migration specific factors that may be associated with not having an e-ID among older migrants. We used the Care, Health and Ageing of Russian-speaking Minority in Finland (CHARM) study, which is a nationally representative survey of community-dwelling Russian-speaking adults aged ≥ 50 years living in Finland (N = 1082, 57% men, mean age 63.2 years, standard deviation 8.4 years, response rate 36%). Our results showed that 21% of older Russian-speakers did not have an e-ID. Our regression analysis showed that older age and poorer economic situation were associated with a lower probability of having an e-ID. In addition, we found an association between not speaking local languages and not having an e-ID. This may relate to private banks regulating the requirements for obtaining the most common e-ID method, online banking ID. We argue that for individuals who are already in vulnerable positions, current e-ID practices might pose yet another obstacle to obtaining the health services they need and are entitled to.

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.

Influences on Patient Uptake of and Engagement With the National Health Service Digital Diabetes Prevention Programme: Qualitative Interview Study

BACKGROUND

Digital diabetes prevention programs (digital-DPPs) are being implemented as population-based approaches to type 2 diabetes mellitus prevention in several countries to address problems with the uptake of traditional face-to-face diabetes prevention programs. However, assessments of digital-DPPs have largely focused on clinical outcomes and usability among those who have taken them up, whereas crucial information on decision-making about uptake (eg, whether a user downloads and registers on an app) and engagement (eg, the extent of use of an app or its components over time) is limited. Greater understanding of factors that influence uptake and engagement decisions may support large-scale deployments of digital-DPPs in real-world settings.

OBJECTIVE

This study aimed to explore the key influences on uptake and engagement decisions of individuals who were offered the National Health Service Healthier You: Digital Diabetes Prevention Programme (NHS-digital-DPP).

METHODS

A qualitative interview study was conducted using semistructured interviews. Participants were adults, aged ≥18 years, diagnosed with nondiabetic hyperglycemia, and those who had been offered the NHS-digital-DPP. Recruitment was conducted via 4 providers of the NHS-digital-DPP and 3 primary care practices in England. Interviews were conducted remotely and were guided by a theoretically informed topic guide. Analysis of interviews was conducted using an inductive thematic analysis approach.

RESULTS

Interviews were conducted with 32 participants who had either accepted or declined the NHS-digital-DPP. In total, 7 overarching themes were identified as important factors in both decisions to take up and to engage with the NHS-digital-DPP. These were knowledge and understanding, referral process, self-efficacy, self-identity, motivation and support, advantages of digital service, and reflexive monitoring. Perceptions of accessibility and convenience of the NHS-digital-DPP were particularly important for uptake, and barriers in terms of the referral process and health care professionals' engagement were reported. Specific digital features including health coaches and monitoring tools were important for engagement.

CONCLUSIONS

This study adds to the literature on factors that influence the uptake of and engagement with digital-DPPs and suggests that digital-DPPs can overcome many barriers to the uptake of face-to-face diabetes prevention programs in supporting lifestyle changes aimed at diabetes prevention.

Secondary data for global health digitalisation

Substantial opportunities for global health intelligence and research arise from the combined and optimised use of secondary data within data ecosystems. Secondary data are information being used for purposes other than those intended when they were collected. These data can be gathered from sources on the verge of widespread use such as the internet, wearables, mobile phone apps, electronic health records, or genome sequencing. To utilise their full potential, we offer guidance by outlining available sources and approaches for the processing of secondary data. Furthermore, in addition to indicators for the regulatory and ethical evaluation of strategies for the best use of secondary data, we also propose criteria for assessing reusability. This overview supports more precise and effective policy decision making leading to earlier detection and better prevention of emerging health threats than is currently the case.

Assessing the feasibility of a web-based outcome measurement system in child and adolescent mental health services - myHealthE a randomised controlled feasibility pilot study

BACKGROUND

Interest in internet-based patient reported outcome measure (PROM) collection is increasing. The NHS myHealthE (MHE) web-based monitoring system was developed to address the limitations of paper-based PROM completion. MHE provides a simple and secure way for families accessing Child and Adolescent Mental Health Services to report clinical information and track their child's progress. This study aimed to assess whether MHE improves the completion of the Strengths and Difficulties Questionnaire (SDQ) compared with paper collection. Secondary objectives were to explore caregiver satisfaction and application acceptability.

METHODS

A 12-week single-blinded randomised controlled feasibility pilot trial of MHE was conducted with 196 families accessing neurodevelopmental services in south London to examine whether electronic questionnaires are completed more readily than paper-based questionnaires over a 3-month period. Follow up process evaluation phone calls with a subset (n = 8) of caregivers explored system satisfaction and usability.

RESULTS

MHE group assignment was significantly associated with an increased probability of completing an SDQ-P in the study period (adjusted hazard ratio (HR) 12.1, 95% CI 4.7-31.0; p = <.001). Of those caregivers' who received the MHE invitation (n = 68) 69.1% completed an SDQ using the platform compared to 8.8% in the control group (n = 68). The system was well received by caregivers, who cited numerous benefits of using MHE, for example, real-time feedback and ease of completion.

CONCLUSIONS

MHE holds promise for improving PROM completion rates. Research is needed to refine MHE, evaluate large-scale MHE implementation, cost effectiveness and explore factors associated with differences in electronic questionnaire uptake.

Exploring the use of digital technology to deliver healthcare services with explicit consideration of health inequalities in UK settings: A scoping review

Objective

To map and explore existing evidence on the use of digital technology to deliver healthcare services with explicit consideration of health inequalities in UK settings.

Methods

We searched six bibliographic databases, and the National Health Service (NHS) websites of each UK nation (England, Scotland, Wales, Northern Ireland). Restrictions were applied on publication date (2013-2021) and publication language (English). Records were independently screened against eligibility criteria by pairs of reviewers from the team. Articles reporting relevant qualitative and/or quantitative research were included. Data were synthesised narratively.

Results

Eleven articles, reporting data from nine interventions, were included. Articles reported findings from quantitative (n = 5), qualitative (n = 5), and mixed-methods (n = 1) studies. Study settings were mainly community based, with only one hospital based. Two interventions targeted service users, and seven interventions targeted healthcare providers. Two studies were explicitly and directly aimed at (and designed for) addressing health inequalities, with the remaining studies addressing them indirectly (e.g. study population can be classed as disadvantaged). Seven articles reported data on implementation outcomes (acceptability, appropriateness, and feasibility) and four articles reported data on effectiveness outcomes, with only one intervention demonstrating cost-effectiveness.

Conclusions

It is not yet clear if digital health interventions/services in the UK work for those most at risk of health inequalities. The current evidence base is significantly underdeveloped, and research/intervention efforts have been largely driven by healthcare provider/system needs, rather than those of service users. Digital health interventions can help address health inequalities, but a range of barriers persist, alongside a potential for exacerbation of health inequalities.

Development and usage of a health recommendation web tool (HeaRT) designed to inform women of personalized preventive health recommendations

BACKGROUND

Implementation of guidelines for evidence-based screening and disease prevention remains a core challenge in health care. The lack of access to accurate and personalized health recommendations may contribute to sub-optimal performance of medical screening, and ultimately increased risk for communicable and non-communicable disease. Many women do not monitor their cardiovascular disease (CVD) risk or receive regular medical screenings. A health recommendation tool (HeaRT) that provides women with profiled, individually tailored information about recommended tests and screening was designed to improve women's engagement in preventive health. This study characterized utilization of the tool in a real world setting.

OBJECTIVE

To describe the development and usage patterns of HeaRT, a novel health web-tool that provides personalized health recommendations for women.

METHODS

Extracted web-tool data including user input (age, BMI, smoking status and family history of CVD) and time spent in the results screen were analysed. Engagement was assessed by time spent in each results category, number of clicks and whether the user emailed/printed the recommendations. Usage patterns were analysed using multivariate analyses, logistic regression and cluster analyses.

RESULTS

HeaRT was used 13,749 times in the years between its launch and data extraction three years later. Web-tool analysis found that 68.6 % of users accessed results and approximately 15 % printed or emailed the list of recommendations. Further analysis found that almost all the users entered the nutrition category (78 %), followed by the risk-factor category (69.5 %) and Physical activity category (61.9 %). Three usage patterns were identified by cluster analysis, including a nutrition/physical activity cluster, a risk-factor cluster and an all-categories cluster. Cluster affiliation analysis found BMI and smoking status were not predictors of cluster affiliation, whereas users over the age of 65 were more likely to solely enter the risk-factor tab (P < .001) and users with family history of CVD were more likely to either enter only the risk-factor tab or to enter all tabs (P < .01).

CONCLUSIONS

HeaRT users looked at health recommendations on a variety of health topics, and 15 % printed or emailed the recommendations. A tailored health recommendation web-tool may empower women to seek preventive-care and health maintenance, and help them interact with health care providers from a position of shared responsibility. This tool and similar programs may enable health care consumers to actively participate in directing their own health maintenance by providing consumers with personalized health recommendations. Additionally, user characteristics may inform future web-tool designers on target population profile and usage patterns.

Desperately Seeking Intersectionality in Digital Health Disparity Research: Narrative Review to Inform a Richer Theorization of Multiple Disadvantage

BACKGROUND

Digital consultations between patients and clinicians increased markedly during the COVID-19 pandemic, raising questions about equity.

OBJECTIVE

This study aimed to review the literature on how multiple disadvantage-specifically, older age, lower socioeconomic status, and limited English proficiency-has been conceptualized, theorized, and studied empirically in relation to digital consultations. We focused mainly on video consultations as they have wider disparities than telephone consultations and relevant data on e-consultations are sparse.

METHODS

Using keyword and snowball searching, we identified relevant papers published between 2012 and 2022 using Ovid MEDLINE, Web of Science, Google Scholar, and PubMed. The first search was completed in July 2022. Papers meeting the inclusion criteria were analyzed thematically and summarized, and their key findings were tabulated using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research criteria. Explanations for digital disparities were critically examined, and a search was undertaken in October 2022 to identify theoretical lenses on multiple disadvantage.

RESULTS

Of 663 articles from the initial search, 27 (4.1%) met our inclusion criteria. In total, 37% (10/27) were commentaries, and 63% (17/27) were peer-reviewed empirical studies (11/27, 41% quantitative; 5/27, 19% qualitative; 1/27, 4% mixed methods; 1/27, 4% systematic reviews; and 1/27, 4% narrative reviews). Empirical studies were mostly small, rapidly conducted, and briefly reported. Most studies (25/27, 93%) identified marked digital disparities but lacked a strong theoretical lens. Proposed solutions focused on identifying and removing barriers, but the authors generally overlooked the pervasive impact of multiple layers of disadvantage. The data set included no theoretically informed studies that examined how different dimensions of disadvantage combined to affect digital health disparities. In our subsequent search, we identified 3 theoretical approaches that might help account for these digital disparities. Fundamental cause theory by Link and Phelan addresses why the association between socioeconomic status and health is pervasive and persists over time. Digital capital theory by Ragnedda and Ruiu explains how people mobilize resources to participate in digitally mediated activities and services. Intersectionality theory by Crenshaw states that systems of oppression are inherently bound together, creating singular social experiences for people who bear the force of multiple adverse social structures.

CONCLUSIONS

A limitation of our initial sample was the sparse and undertheorized nature of the primary literature. The lack of attention to how digital health disparities emerge and play out both within and across categories of disadvantage means that solutions proposed to date may be oversimplistic and insufficient. Theories of multiple disadvantage have bearing on digital health, and there may be others of relevance besides those discussed in this paper. We call for greater interdisciplinary dialogue between theoretical research on multiple disadvantage and empirical studies on digital health disparities.

Describing, predicting and explaining adherence to total skin self-examination (TSSE) in people with melanoma: a 12-month longitudinal study

OBJECTIVES

To describe trajectories in melanoma survivors' adherence to monthly total skin self-examination (TSSE) over 12 months, and to investigate whether adherence trajectories can be predicted from demographic, cognitive or emotional factors at baseline.

DESIGN

A longitudinal observational study nested within the intervention arm of the ASICA (Achieving Self-Directed Integrated Cancer Aftercare) randomised controlled trial.

SETTING

Follow-up secondary care in Aberdeen and Cambridge UK.

PARTICIPANTS

n=104 adults (48 men/56 women; mean age 58.83 years, SD 13.47, range 28-85 years; mean Scottish Index of Multiple Deprivation score 8.03, SD 1.73, range 2-10) who had been treated for stage 0-IIC primary cutaneous melanoma in the preceding 60 months and were actively participating in the intervention arm of the ASICA trial.

INTERVENTIONS

All participants were using the ASICA intervention-a tablet-based intervention designed to support monthly TSSE.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was adherence to guideline recommended (monthly) TSSE over 12 months. This was determined from time-stamped TSSE data recorded by the ASICA intervention app.

RESULTS

Latent growth mixture models identified three TSSE adherence trajectories (adherent -41%; drop-off -35%; non-adherent -24%). People who were non-adherent were less likely to intend to perform TSSE as recommended, intending to do it more frequently (OR=0.21, 95% CI 0.06 to 0.81, p=0.023) and were more depressed (OR=1.31, 95% CI 1.06 to 1.61, p=0.011) than people who were adherent. People whose adherence dropped off over time had less well-developed action plans (OR=0.78, 95% CI 0.63 to 0.96, p=0.016) and lower self-efficacy about TSSE (OR=0.92, 95% CI 0.86 to 0.99, p=0.028) than people who were adherent.

CONCLUSIONS

Adherence to monthly TSSE in people treated for melanoma can be differentiated into adherent, drop-off and non-adherent trajectories. Collecting information about intentions to engage in TSSE, depression, self-efficacy and/or action planning at outset may help to identify those who would benefit from additional intervention.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03328247).

Promoting Physical Activity in Older Adults With Type 2 Diabetes via an Anthropomorphic Conversational Agent: Development of an Evidence and Theory-Based Multi-Behavior Intervention

Introduction

Anthropomorphic conversational agents (ACA) are a promising digital tool to support self-management of type 2 diabetes (T2D), albeit little explored. There is a dearth of literature on the detailed content of these interventions, which may limit effectiveness and replication. Our aim is to describe the development of an evidence and theory-based intervention to improve physical activity in older adults with T2D, subsumed in a multi-behavior intervention via a mobile application with an ACA.

Methods

Overall decisions on the multi-behavior intervention design, such as the use of standardized behavior change techniques (BCTTv1), guided the development of the physical activity component. Firstly, recommendations on ambulatory activity were used to select the target behavior (walking). Meta-research on effective behavior change techniques (BCTs) was then identified. One meta-analysis linked effective BCTs with the three basic psychological needs of the self-determination theory (SDT). This meta-analysis, taken together with additional evidence on SDT, led to the selection of this theory to inform the design. BCTs were extracted from meta-research; we selected the most appropriate to be operationalized via the conversational agent through multidisciplinary discussions. Rules governing the dialogue flow and BCTs tailoring, taking the form "if some conditions hold then execute some action," were derived based on the Basic Psychological in Exercise Scale (competence, autonomy, and relatedness scores), in conjunction with published evidence and multidisciplinary discussions.

Results

Thirteen BCTs were implemented in the prototype via the ACA (e.g., goal setting behavior 1.1). Six if-then rules were derived and depicted in the dialogue steps through process flow diagrams, which map how the system functions. An example of a rule is "If competence score ≤ 10 then, apply BCT 1.1 with 500 steps increments as options for the daily walking goal; If competence score > 10 then, apply BCT 1.1 with 1,000 steps increments as options for the daily walking goal."

Conclusion

Evidence and SDT were translated into a mobile application prototype using an ACA to promote physical activity in older adults with T2D. This approach, which includes 13 BCTs and six if-then rules for their tailoring, may leverage the efforts of others in developing similar interventions.

Conducting Digital Intervention Research among Immigrant Survivors of Intimate Partner Violence: Methodological, Safety and Ethnical Considerations

Intimate partner violence, described as a global pandemic by the United Nations, has been found to disproportionately affect immigrant women. Many immigrant survivors of IPV are unable or unwilling to attend in-person services due to barriers related to immigration status, transportation, and social isolation. By providing remote support to women in abusive relationships, digital interventions can help address these barriers and ensure their health and safety. Research on safe and ethical approaches to digital service delivery for immigrant IPV survivors is a necessary first step to meeting these women's needs for remote support. The purpose of this qualitative study was to explore considerations and challenges of conducting digital intervention research (online, phone and text) with diverse groups of immigrant women. Data was collected via 5 focus groups and 46 in-depth interviews with immigrant survivors of IPV from different countries of origin. In addition, data was collected via key informant interviews with 17 service providers. Participants shared safety, ethical and methodological challenges to accessing interventions, such as their abusive partner being at home or lack of safe access to technology. Further, participants shared strategies for safe data collection, such as scheduling a contact time when participants are afforded privacy and deleting evidence of the intervention to retain personal safety. The findings will be informative for researchers conducting digital intervention studies or practitioners engaging in remote intervention approaches with marginalized populations such as immigrant women at high risk of violence.

Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis

Background

For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation.

Objective

To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool.

Methods

The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool.

Results

Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context.

Conclusions

These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-04464-2

Examining the Acceptability of a Resilience Building Intervention Among Adults Aging With HIV

ABSTRACT

Few interventions have targeted resilience resources in people living with HIV (PLWH). We tested the acceptability of an existing resilience intervention in middle-age and older PLWH. Fourteen PLWH attended one 3-hr group session, which included videos, quizzes, and written activities. Participants provided quantitative and qualitative feedback. The mean acceptability rating was 8.71 (1.27) on a 10-point scale. A majority of participants reported that the intervention was an appropriate length; that it improved their resilience, mood, and ability to manage HIV; and that they would likely continue using the tools. Average content retention accuracy was 75% (12.66). Qualitative feedback suggested addressing HIV-specific stressors, including disclosure concerns, stigma, health concerns, and treatment adherence. The resilience intervention was deemed highly acceptable among older PLWH. Uptake may increase by addressing HIV-specific stressors and improving comprehensibility. Future research should further refine and test the efficacy of a modified version of the intervention.

Frameworks for implementation, uptake and use of digital health interventions in ethnic minority populations: a scoping review using cardiometabolic disease as a case study. (Preprint)

Background

Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions.

Objective

We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease.

Methods

SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice.

Results

Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease.

Conclusions

Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Exploratory attitude survey of homeless persons regarding telecare services in shelters providing mid- and long-term accommodation: The importance of trust

BACKGROUND

With the expansion of digital health, it is imperative to consider intervention techniques in order not to be the cause of even more social health inequalities in underserved populations struggling with chronic diseases. Telemedicine solutions for homeless persons might compensate for shortcomings in access to valuable health services in different settings. The main aim of our research was to examine the attitudes and openness of homeless persons regarding telecare on a Hungarian sample.

METHODS

Quantitative survey among homeless people (n = 98) was completed in 4 shelters providing mid- and long-term accommodation in Budapest, Hungary. Attitudes regarding healthcare service accessibility and telecare were measured by a self-developed questionnaire of the research team. Telecare attitude comparison was made with data of a Hungarian weighted reference group of non-homeless persons recruited from 2 primary care units (n = 110).

RESULTS

A significant fraction of homeless people with mid- or long-term residency in homeless shelters did not oppose the use of telecare via live online video consultation and there was no difference compared to the national reference group (averages of 3.09 vs. 3.15, respectively). Results of the homeless group indicate that those more satisfied with healthcare services, in general, manifest more openness to telecare. It is clearly demonstrated by the multivariate analysis that those participants in the homeless group who had problems getting health care in the last year definitely preferred in-person doctor-patient consultations.

CONCLUSION

Digital health technologies offer a potentially important new pathway for the prevention and treatment of chronic conditions among homeless persons. Based on the attitudes towards telecare, initiating an on-site telecare program for mid- and long-term residents of homeless shelters might enable better care continuity. Our results draw attention to the key factors including building trust in the implementation of such programs among underserved and other vulnerable patient groups.

Challenges in the development of digital public health interventions and mapped solutions: Findings from a scoping review

Background

“Digital public health” has emerged from an interest in integrating digital technologies into public health. However, significant challenges which limit the scale and extent of this digital integration in various public health domains have been described. We summarized the literature about these challenges and identified strategies to overcome them.

Methods

We adopted Arksey and O’Malley's framework (2005) integrating adaptations by Levac et al. (2010). OVID Medline, Embase, Google Scholar, and 14 government and intergovernmental agency websites were searched using terms related to “digital” and “public health.” We included conceptual and explicit descriptions of digital technologies in public health published in English between 2000 and June 2020. We excluded primary research articles about digital health interventions. Data were extracted using a codebook created using the European Public Health Association's conceptual framework for digital public health.

Results and analysis

Overall, 163 publications were included from 6953 retrieved articles with the majority (64%, n = 105) published between 2015 and June 2020. Nontechnical challenges to digital integration in public health concerned ethics, policy and governance, health equity, resource gaps, and quality of evidence. Technical challenges included fragmented and unsustainable systems, lack of clear standards, unreliability of available data, infrastructure gaps, and workforce capacity gaps. Identified strategies included securing political commitment, intersectoral collaboration, economic investments, standardized ethical, legal, and regulatory frameworks, adaptive research and evaluation, health workforce capacity building, and transparent communication and public engagement.

Conclusion

Developing and implementing digital public health interventions requires efforts that leverage identified strategies to overcome diverse challenges encountered in integrating digital technologies in public health.

mHealth technology to assess, monitor and treat daily functioning difficulties in people with severe mental illness: A systematic review

Severe mental illness (SMI) is associated with poor daily functioning; however available interventions currently under-deliver on their recovery prospect. Mobile digital health (mHealth) interventions are increasingly being developed and evaluated, and have the potential to support recovery. This review evaluates the use of mHealth technology to assess, monitor and reduce functioning difficulties in people with SMI. Studies were systematically searched on multiple databases. Study quality was assessed and double-rated independently. Findings were organised using a narrative synthesis and results were summarised according to the mHealth device purpose, i.e., assessment and monitoring or intervention. Thirty-eight studies comprised of 2262 participants met the inclusion criteria. Smartphones were the most popular mHealth device; personal digital assistants, wearables and tablets were also used. mHealth was widely found to be acceptable and feasible, with preliminary findings suggesting it can support functional recovery by augmenting an intervention, simplifying the assessment, increasing monitoring frequency and/or providing more detailed information. Considerations for overcoming barriers to implementation, recommendations for future research to establish effectiveness, personalisation and specification of mHealth devices and methodologies are discussed. The value of mHealth for remote delivery of recovery based interventions is also considered.

Factors Related to Internet Adoption and Its Use to Seek Health Information in Mexico

The Internet has the potential to be a valuable resource for the dissemination of health promotion information to the general population, mainly in conditions with well-developed health and digital literacy. Few studies have been undertaken on the adoption of the Internet by the Mexican population and its use to seek health information. The aim of this paper was to identify the factors that determine Internet adoption and its use by the heads of Mexican households for obtaining health information. This study used data taken from a probabilistic and cross-sectional national survey (National Survey on the Availability and Use of Information Technologies in Households, or ENDUTIH), applying an economic approach based on utility maximization theory. We estimated a univariate probit model for Internet adoption and a consecutive bivariate probit model with sample selection for the use of the Internet to seek health information. The software package was used to adjust and estimate the proposed models. The first model (Internet adoption) identified several factors related to digital divides in the country, while the second (Internet use to seek health information) identified various factors influencing online searches for health information, such as the following: being a woman; being an adult; having a higher level of education; having a higher income; having superior digital skills; and, living in an urban area. This study highlights the need to strengthen digital policy in order to improve access to and the adoption and efficient use of the Internet, particularly in terms of improving an individual's engagement with their own health.

Disrupted prevention: condom and contraception access and use among young adults during the initial months of the COVID-19 pandemic. An online survey

BACKGROUND

The initial response to COVID-19 in the UK involved a rapid contraction of face-to-face sexual and reproductive health (SRH) services and widespread use of remote workarounds. This study sought to illuminate young people's experiences of accessing and using condoms and contraception in the early months of the pandemic.

METHODS

We analysed data, including open-text responses, from an online survey conducted in June-July 2020 with a convenience sample of 2005 16-24-year-olds living in Scotland.

RESULTS

Among those who used condoms and contraception, one quarter reported that COVID-19 mitigation measures had made a difference to their access or use. Open-text responses revealed a landscape of disrupted prevention, including changes to sexual risk-taking and preventive practices, unwanted contraceptive pathways, unmet need for sexually transmitted infection (STI) testing, and switches from freely provided to commercially sold condoms and contraception. Pandemic-related barriers to accessing free condoms and contraception included: (1) uncertainty about the legitimacy of accessing SRH care and self-censorship of need; (2) confusion about differences between SRH care and advice received from healthcare professionals during the pandemic compared with routine practice; and (3) exacerbation of existing access barriers, alongside reduced social support and resources to navigate SRH care.

CONCLUSIONS

Emerging barriers to STI and pregnancy prevention within the context of COVID-19 have the potential to undermine positive SRH practices, and widen inequalities, among young people. As SRH services are restored amid evolving pandemic restrictions, messaging to support navigation of condom and contraception services should be co-created with young people.

A Novel Mobile App ("CareFit") to Support Informal Caregivers to Undertake Regular Physical Activity From Home During and Beyond COVID-19 Restrictions: Co-design and Prototype Development Study

Background

Informal caregivers, or carers (unpaid family members and friends), are instrumental to millions worldwide for the ongoing delivery of health and well-being needs. The risk of crisis points (eg, hospitalizations) for caregivers increases with the absence of physical activity. The COVID-19 pandemic is highly likely to have increased the risk of crisis points for caregivers by increasing the amount of time spent indoors due to shielding and lockdown restrictions. Thus, accessible evidence-based tools to facilitate physical activity for caregivers indoors are urgently needed.

Objective

The aim of this study was to co-design and develop a novel mobile app to educate and support carers in the undertaking of regular physical activity at home during and beyond COVID-19 restrictions via integration of the transtheoretical model of behavior change and UK physical activity guidelines.

Methods

We co-designed a mobile app, “CareFit,” by directly involving caregivers, health care professionals, and social care professionals in the requirements, capturing, and evaluation phases of three Agile Scrum design and development sprints. Seven participants representing multistakeholder views took part in three co-design sessions, each of which was followed by a development sprint. Requirements for CareFit were grounded in a combination of behavioral change science and UK government guidelines for physical activity.

Results

Participants identified different barriers and enablers to physical activity, such as a lack of time, recognition of existing activities, and concerns regarding safely undertaking physical activity. Requirements analysis highlighted the importance of simplicity in design and a need to anchor development around the everyday needs of caregivers (eg, easy-to-use video instructions). Our final prototype app integrated guidance for undertaking physical activity at home through educational, physical activity, and communication components.

Conclusions

Integrating government guidelines with models of behavioral change into a mobile app to support the physical activity of carers is novel. We found that integrating core physical activity guidelines into a co-designed smartphone app with functionality such as a weekly planner and educational material for users is feasible. This work holds promise to fill the gap of effective physical activity solutions for caregivers both during and beyond the COVID-19 pandemic. Further work is now needed to explore the feasibility, acceptability, and usability of the approach in real-world settings.

Sociodemographic characteristics determine download and use of a Corona contact tracing app in Germany-Results of the COSMO surveys

During the SARS-CoV-2 pandemic mobile health applications indicating risks emerging from close contacts to infected persons have a large potential to interrupt transmission chains by automating contact tracing. Since its dispatch in Germany in June 2020 the Corona Warn App has been downloaded on 25.7 Mio smartphones by February 2021. To understand barriers to download and user fidelity in different sociodemographic groups we analysed data from five consecutive cross-sectional waves of the COVID-19 Snapshot Monitoring survey from June to August 2020. Questions on the Corona Warn App included information on download, use, functionality, usability, and consequences of the app. Of the 4,960 participants (mean age 45.9 years, standard deviation 16.0, 50.4% female), 36.5% had downloaded the Corona Warn App. Adjusted analysis found that those who had downloaded the app were less likely to be female (Adjusted Odds Ratio for men 1.16 95% Confidence Interval [1.02;1.33]), less likely to be younger (Adjusted Odds Ratio for age 18 to 39 0.47 [0.32;0.59] Adjusted Odds Ratio for age 40 to 64 0.57 [0.46;0.69]), less likely to have a lower household income (AOR 0.55 [0.43;0.69]), and more likely to live in one of the Western federal states including Berlin (AOR 2.31 [1.90;2.82]). Willingness to disclose a positive test result and trust in data protection compliance of the Corona Warn App was significantly higher in older adults. Willingness to disclose also increased with higher educational degrees and income. This study supports the hypothesis of a digital divide that separates users and non-users of the Corona Warn App along a well-known health gap of education, income, and region.

Patient connectivity with healthcare professionals and health insurer using digital health technologies during the COVID-19 pandemic: a German cross-sectional study

Background

Digital health technologies enable patients to make a personal contribution to the improvement of their health by enabling them to manage their health. In order to exploit the potential of digital health technologies, Internet-based networking between patients and health care providers is required. However, this networking and access to digital health technologies are less prevalent in sociodemographically deprived cohorts. The paper explores how the use of digital health technologies, which connect patients with health care providers and health insurers has changed during the COVID-19 pandemic.

Methods

The data from a German-based cross-sectional online study conducted between April 29 and May 8, 2020, were used for this purpose. A total of 1.570 participants were included in the study. Accordingly, the influence of sociodemographic determinants, subjective perceptions, and personal competencies will affect the use of online booking of medical appointments and medications, video consultations with providers, and the data transmission to health insurers via an app.

Results

The highest level of education (OR 1.806) and the presence of a chronic illness (OR 1.706) particularly increased the likelihood of using online booking. With regard to data transmission via an app to a health insurance company, the strongest increase in the probability of use was shown by belonging to the highest subjective social status (OR 1.757) and generation Y (OR 2.303). Furthermore, the results show that the higher the subjectively perceived restriction of the subjects' life situation was due to the COVID-19 pandemic, the higher the relative probability of using online booking (OR 1.103) as well as data transmission via an app to a health insurance company (OR 1.113). In addition, higher digital literacy contributes to the use of online booking (OR 1.033) and data transmission via an app to the health insurer (OR 1.034).

Conclusions

Socially determined differences can be identified for the likelihood of using digital technologies in health care, which persist even under restrictive conditions during the COVID-19 pandemic. Thus, the results indicate a digital divide with regard to the technologies investigated in this study.

Remote System for Daily Symptom Monitoring During Systemic Anticancer Treatment: Patient Acceptance, Usability, and Compliance

BACKGROUND

Electronic systems for remotely monitoring symptoms during cancer treatment are increasingly being used. Most of them are intended for weekly or periodic symptom monitoring.

OBJECTIVE

The aim of this study was to explore the feasibility and usability of a remote system for daily symptom monitoring during systemic anticancer treatment.

METHODS

We offered a remote system for daily symptom monitoring to patients starting their first ever systemic therapy. Patient acceptance was observed as the proportion of patients showing interest in using the system. System users were invited to complete the "Health information Technology Usability Evaluation Scale," and the number of patients' self-reports was used to evaluate patient compliance.

RESULTS

Of 465 patients, 239 (51.4%) showed interest in using the system; 111 system users reported a fairly good overall usability score (4 of 5), and perceived ease of use scored the highest (4.7 of 5) and perceived usefulness lowest (3.7 of 5). Their daily compliance was 68.8% (±31.1) at 3 weeks and 59.1% (±31.2) at 12 weeks after the start of treatment. Less than half of respondents (49.5%) and only one third (31.2%) perceived that their symptom reports were used by the nurses and doctors, respectively.

CONCLUSION

Half of patients starting their first ever systemic treatment showed interest in using a remote system for daily symptom monitoring. For these patients, daily symptom monitoring seems acceptable, and the system is well complied within the first 12 weeks of treatment.

IMPLICATION FOR PRACTICE

A remote system for daily symptom monitoring is feasible and enables quick response to deteriorating symptoms. Use by healthcare professionals is a point of improvement.

Digital Technologies and Data Science as Health Enablers: An Outline of Appealing Promises and Compelling Ethical, Legal, and Social Challenges

Digital technologies and data science have laid down the promise to revolutionize healthcare by transforming the way health and disease are analyzed and managed in the future. Digital health applications in healthcare include telemedicine, electronic health records, wearable, implantable, injectable and ingestible digital medical devices, health mobile apps as well as the application of artificial intelligence and machine learning algorithms to medical and public health prognosis and decision-making. As is often the case with technological advancement, progress in digital health raises compelling ethical, legal, and social implications (ELSI). This article aims to succinctly map relevant ELSI of the digital health field. The issues of patient autonomy; assessment, value attribution, and validation of health innovation; equity and trustworthiness in healthcare; professional roles and skills and data protection and security are highlighted against the backdrop of the risks of dehumanization of care, the limitations of machine learning-based decision-making and, ultimately, the future contours of human interaction in medicine and public health. The running theme to this article is the underlying tension between the promises of digital health and its many challenges, which is heightened by the contrasting pace of scientific progress and the timed responses provided by law and ethics. Digital applications can prove to be valuable allies for human skills in medicine and public health. Similarly, ethics and the law can be interpreted and perceived as more than obstacles, but also promoters of fairness, inclusiveness, creativity and innovation in health.

Patient-generated data in the management of HIV: a scoping review

OBJECTIVES

Patient-generated data (PGData) are an emergent research area and may improve HIV care. The objectives of this scoping review were to synthesise, evaluate and make recommendations based on the available literature regarding PGData use in HIV care.

DESIGN

Scoping review.

DATA SOURCES

Embase, Medline, CINAHL Plus, Web of Science, Scopus, PsycINFO and Emcare databases.

ELIGIBILITY CRITERIA

Studies involving PGData use within HIV care for people living with HIV and/or healthcare professionals (HCPs) published before February 2021.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a table and the Mixed Methods Appraisal Tool was used to assess empirical rigour. We used thematic analysis to evaluate content.

RESULTS

11 articles met the eligibility criteria. Studies were observational, predominantly concerned hypothetical or novel digital platforms, mainly conducted in high-income settings, and had small sample sizes (range=10-160). There were multiple definitions of PGData. In the majority of studies (n=9), participants were people living with HIV, with a few studies including HCPs, informatics specialists or mixed participant groups. Participants living with HIV were aged 23-78 years, mostly men, of diverse ethnicities, and had low educational, health literacy and income levels.We identified four key themes: (1) Perceptions of PGData and associated digital platforms; (2) Opportunities; (3) Anticipated barriers and (4) Potential impact on patient-HCP relationships.

CONCLUSIONS

Use of PGData within HIV care warrants further study, especially with regard to digital inequalities, data privacy and security. There is a need for longitudinal data on use within HIV in a variety of settings with a broad range of users, including impact on clinical outcomes. This will allow greater understanding of the role of PGData use in improving the health and well-being of people living with HIV, which is increasingly pertinent as digital healthcare becomes more widespread as a result of COVID-19.

Perspectives on electronic portal use among patients treated with medications for opioid use disorder in primary care

OBJECTIVES

Office-based opioid treatment (OBOT) with buprenorphine is increasingly integrated in primary care to treat opioid use disorder (OUD). Online portals seek to engage patients in care of their chronic medical conditions, yet we know little about how patients with OUD experience these portals. Our study explores how patients with OUD perceive the impact of portal use on addiction treatment and clinical care.

MATERIALS AND METHODS

We purposively sampled patients with an active portal account enrolled in an OBOT program embedded within primary care, stratifying by recent or distant portal use. The study conducted individual semistructured interviews to understand how patients perceived and interfaced with the portal until the study reached saturation of themes. The research team analyzed the data via thematic analysis and three investigators independently coded the data to identify themes, which all authors then refined.

RESULTS

Among 17 participants, 9 were recent users and 8 were distant. Though we stratified analyses by level of portal use, the study observed no differences in resultant themes, thus the study combined themes, which we present here. Portal use was felt to (1) facilitate and reinforce OUD and other substance use treatment goals, (2) improve health care participation, (3) enable monitoring and addressing broader health concerns beyond SUD treatment, and (4) have mixed impacts on patient-provider trust.

DISCUSSION

Our findings suggest that patients with OUD identify aspects of the patient portal contributing to their engagement and retention in substance use treatment. Lingering concerns remain about the potential of portal use to negatively impact the patient-provider relationship.

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.

Challenges and opportunities of digital health in a post-COVID19 world

Digital health as a rapidly growing medical field relies comprehensively on human health data. Conventionally, the collection of health data is mediated by officially diagnostic instruments, operated by health professionals in clinical environments and under strict regulatory conditions. Mobile health, telemedicine, and other smart devices with Internet connections are becoming the future choices for collecting patient information. Progress of technologies has facilitated smartphones, wearable devices, and miniaturized health-care devices. These devices allow the gathering of an individual's health-care information at the patient's home. The data from these devices will be huge, and by integrating such enormous data using Artificial Intelligence, more detailed phenotyping of disease and more personalized medicine will be realistic. The future of medicine will be progressively more digital, and recognizing the importance of digital technology in this field and pandemic preparedness planning has become urgent.

A Question of Access: Exploring the Perceived Benefits and Barriers of Intelligent Voice Assistants for Improving Access to Consumer Health Resources Among Low-Income Older Adults

Intelligent voice assistants (IVAs) such as Amazon Echo and Google Home present a promising opportunity to improve access to consumer health information and resources for older adults. However, researchers know little about older adults’ opinions of using IVAs for these potentially critical tasks, particularly those with already limited access. In this paper, we explore older adults’ views about IVAs for consumer health and wellness information with the goal of better understanding what they envision as benefits and barriers of using such technology in the future. We shared an IVA prototype with ten older adults (60 years of age or older). We interviewed them about how a similar system might impact their access to consumer health information. Participants saw the potential for IVAs to improve their search experiences and support them with other health tasks. However, participants were also concerned about adopting an IVA for health due to access barriers, confidentiality risks, and concerns about receiving trusted information. Based on our findings, we discuss considerations for designing IVAs for underserved, older adult populations.

COVID-19 and digital inequalities: Reciprocal impacts and mitigation strategies

With more than three billion people in isolation, the status of digital spaces is switching from an amenity to a necessity, as they become not only the main way to access information and services, but also one of the only remaining vectors for economic, educational, and leisure activities as well as for social interactions to take place. However, not all are equals in terms of access to networks or connected devices, or when it comes to the skills required to navigate computerized spaces optimally. Digital inequalities were already existing, yet the COVID-19 crisis is exacerbating them dramatically. On the one hand, the crisis will worsen digital inequalities within the population. On the other hand, digital inequalities represent a major risk factor of vulnerability for exposure to the virus itself, and for the non-sanitary consequences of the crisis. Therefore, this paper aims at exploring the reciprocal impacts of the COVID-19 crisis and digital inequalities, and to propose operative solutions to help fight the nefarious consequences of the crisis. We first describe how digital inequalities are a determinant of health. We then investigate how COVID-19 can potentiate digital inequalities, and how digital inequalities potentiate vulnerability to COVID-19. Finally, in order to contribute to the mitigation of this crisis, we propose a set of multi-layered strategies focusing on actionability that can be implemented at multiple structural levels, ranging from governmental to corporate and community levels.

Integration of Conversion Factors for the Development of an Inclusive eHealth Tool With Caregivers of Functionally Dependent Older Persons: Social Justice Design

BACKGROUND

eHealth can help reduce social health inequalities (SHIs); at the same time, it also has the potential to increase them. Several conversion factors can be integrated into the development of an eHealth tool to make it inclusive: (1) providing physical, technical, and financial access to eHealth; (2) enabling the integration of people at risk of SHIs into the research and development of digital projects targeting such populations (co-design or participatory research); (3) promoting consistency between the digital health literacy level of future users (FUs) and the eHealth tool; (4) developing an eHealth tool that is consistent with the technological skills of FUs; (5) ensuring that the eHealth tool is consistent with the help-seeking process of FUs; (6) respecting the learning capacities of FUs; and (7) being sensitive to FUs' cultural context. However, only little empirical evidence pointing out how these conversion factors can be integrated into an effective eHealth tool is available.

OBJECTIVE

On the basis of Amartya Sen's theoretical framework of social justice, the objective of this study was to explore how these 7 conversion factors can be integrated into an eHealth tool for caregivers of functionally dependent older persons.

METHODS

This study was based on a social justice design and participant observation as part of a large-scale research project funded by the Ministère de la Famille through the Quebec Ami des Aînés Program. Data were collected by recording the preparation sessions, the co-design and advisory committee sessions, as well as the debriefing sessions. The results were analyzed using Miles and Huberman's method.

RESULTS

A total of 78 co-designers participated in 11 co-design sessions, 24 preparation sessions, and 11 debriefing sessions. Of the 7 conversion factors, 5 could be explored in this experiment. The integration of conversion factors has been uneven. The participation of FUs in the development of the tool supports other conversion factors. Respecting the eHealth literacy level of FUs means that their learning abilities and technological skills are also respected because they are closely related to one another and are therefore practically difficult to be distinguished.

CONCLUSIONS

Conversion factors can be integrated into the development of eHealth tools that are intended to be inclusive and contribute to curbing SHIs by integrating FU participation into the tool design process.

Exploring the equity impact of mobile health-based human immunodeficiency virus interventions: A systematic review of reviews and evidence synthesis

Objective

While mobile health-based human immunodeficiency virus (HIV) interventions are often designed to promote health equity, systematic differences in the use of and access to mobile technologies may counteract that and widen treatment gaps. This systematic review applies an equity lens to investigate whether existing research provides adequate evidence on the ethical implications of mHealth technologies in HIV treatment and prevention.

Methods

This study included a two-stage methodology, consisting of (a) a systematic review of systematic reviews and (b) an evidence synthesis of primary studies. For the review of reviews we searched eight electronic databases, eight electronic journals and Google Scholar. We also screened reference lists and consulted authors of included studies. Primary studies were extracted from eligible reviews. We based our data extraction and analysis on the Place of residence, Race, Occupation, Gender/Sex, Religion, Education, Socioeconomic status, Social capital and other disadvantage related characteristics (PROGRESS-Plus) framework and the use of harvest plots, focusing on the socio-demographic distribution of mHealth effects.

Results

A total of 8786 citations resulted in 19 eligible reviews and 39 eligible primary studies. Existing reviews did not provide any analyses of the equity impacts of mobile health-based HIV initiatives. Information availability was higher in primary studies, predominantly suggesting no social gradient of mobile health-based HIV interventions. Overall, evidence remains weak and not sufficient to allow for confident equity statements.

Conclusions

Despite the negative force of socio-demographic inequities and the emerging nature of mobile health technologies, evidence on the equity implications of mobile health interventions for HIV care remains scarce. Not knowing how the effects of mobile health technologies differ across population subgroups inevitably limits our capacities to equitably adopt, adjust and integrate mobile health interventions towards reaching those disproportionally affected by the epidemic.

The work and relatedness of ties mediated online in supporting long-term condition self-management

The 'care transition' is characterised by reduced state involvement in chronic illness management in response to socio-political movements aimed at meeting the challenges presented by an increased prevalence of chronic illness. Amongst these changes has been online communities' rising importance in everyday interactions and attention is being increasingly paid towards the ways online contacts might contribute to self-management. Whilst research has illuminated the relevance of personal networks in long-term condition management, it is relevant to extend this work to consider the place of ties mediated online in this bricolage of support, including better understanding the work drawn from them and the strategies involved in eliciting it. This study examined the work and relatedness of 30 participants, who used online communities. Participants were asked about the role of on and offline ties and ego network mapping was used to frame conversations about the nature of this support. The context of engagement followed three main themes. Participants drew from online communities in response to deficits in offline support, they used online ties to leverage support or action from offline ties and they used online ties to substitute offline support, with less intimate online ties.

Effects of media-assisted therapeutic approaches on physical activity of obese adults: a systematic review

BACKGROUND

The number of patients with obesity continues to increase in our society. At the same time, digitalization defines our everyday life. Therefore, the question arises whether to use digital media for effective treatments against obesity. Aim of this review is a concise presentation of effects of media-assisted therapeutic approaches.

METHODS

A systematic literature research in multiple scientific databases, PubMed, Web of Science and Cochrane Library, was performed for literature published in the last 10 years (cut-off date 12.07.2017). Only randomized controlled trials using digital support for treatment and/or aftercare of obese adults aged between 18 to 70 years were included into the analysis.

RESULTS

Overall, 14 trials with data on a total of 4979 participants were included in this review. Generally, there are positive trends for increased moderate to vigorous physical activity by the use of digital media. A simultaneous usage of various digital media, which focus on important aspects of activity behavior, has proven to be effective. A combination of various digital media shows the greatest positive effect and could significantly increase physical activity. However, the biggest potential was found in mixed approaches combining digital devices and personal face-to-face support.

CONCLUSIONS

Therapeutic approaches using digital media for supporting obesity treatment did not show superior benefit over traditional personal therapeutic methods. Nevertheless, using both methods together offered the greatest potential for successful obesity therapy. However, there is a backlog of transparency concerning information about the content of treatment. Furthermore, there is a lack of valid data about aftercare and follow-up.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

Background

Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants.

Objective

This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups.

Methods

In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate.

Results

Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups.

Conclusions

eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.

[Digital divide-social inequalities in the utilisation of digital healthcare]

Today, health inequalities are one of the most important issues in public health worldwide. The digitalisation of healthcare is frequently attributed with the potential to reduce health inequalities. At the same time, effective internet usage is a prerequisite of the successful utilisation of digital health interventions. This might be a new obstacle for those who lack the necessary material resources or individual skills.Evidence on how exactly digital health interventions affect health inequalities is scarce. The aim of this study was to present a narrative review of the available literature. The majority of studies showed an association between the usage of digital health interventions and sociodemographic factors. The utilisation was generally higher among younger people and those with higher education and higher income. Only few studies showed no association. Other studies reported higher utilisation among those with higher levels of health literacy while health literacy showed a social gradient to the disadvantage of those in lower socioeconomic position. With a low overall level of evidence, there is currently no indication that digital health interventions are reducing health inequalities.The studies analysed in this review indicate that existing inequalities persist in the digital realm. Further evidence is needed to create a better understanding of the importance of sociodemographic factors for digital health interventions.

Is digital health care more equitable? The framing of health inequalities within England's digital health policy 2010-2017

Informed by a discourse analysis, this article examines the framing of equity within the UK's digital health policies between 2010 and 2017, focusing on England's development of NHS Digital and its situation within the UK Government's wider digital strategy. Analysis of significant policy documents reveals three interrelated discourses that are engaged within England's digital health policies: equity as a neoliberal imaginary of digital efficiency and empowerment; digital health as a pathway towards democratising health care through data-sharing, co-creation and collaboration; and finally, digital health as a route towards extending citizen autonomy through their access to data systems. It advances knowledge of the relationship between digital health policy and health inequalities. Revealing that while inclusion remains a priority area for policymakers, equity is being constituted in ways that reflect broader discourses of neoliberalism, empowerment and the turn to the market for technological solutionism, which may potentially exacerbate health inequalities.