Has the Digital Health Divide Widened? Trends of Health-Related Internet Use Among Older Adults From 2003 to 2011

Digital Health Technology Use Across Socioeconomic Groups Prior to and During the COVID-19 Pandemic: Panel Study

BACKGROUND

Digital technologies have become more important in the health care sector in the past decades. This transition from conventional to digital health care has been accelerated by the impact of the COVID-19 pandemic, which poses the risk of creating a "digital divide," inadvertently placing those who are older, economically disadvantaged, and have a lower level of education at a disadvantage.

OBJECTIVE

This study focuses on the influence of socioeconomic factors on the adoption of digital health technology in the Frisian population and how this relation is affected by the COVID-19 pandemic.

METHODS

In 2019 and 2020, a panel study was conducted on digital health in the Frisian population in the Netherlands. In the survey, the use of digital health technology was operationalized in a broad sense, going beyond the care context by also including preventative health-promoting solutions generally available on the consumer market, such as wearables and lifestyle apps. First, to assess the influence of socioeconomic factors on the total use of digital health apps, a generalized linear model was fitted with use of digital health app as the dependent variable and socioeconomic factors as between-subject factors on the 2019 data. Second, to analyze whether the use of separate health apps increased from 2019 to 2020, we conducted chi-square tests on different digital health app types. Third, to examine the influence of COVID-19 on the use of digital health apps, a generalized linear mixed model was fitted with the use of digital health apps as the dependent variable, COVID-19 as the within-subject variable, and socioeconomic factors as between-subject factors.

RESULTS

The results indicated that prior to the COVID-19 pandemic, digital health technology use was higher in women, younger people, and those who are well educated and economically more privileged. Moreover, the percentage of people who reported using digital health technology rose from 70% (1580/2258) to 82.5% (1812/2197) due to the COVID-19 pandemic. This increase was significant for all separate types of digital health technology (all P<.001). In addition, we found the interaction effects of COVID-19 with age and education attainment, indicating that the lower total use among older people and people with lower education attainment became slightly less apparent from 2019 to 2020.

CONCLUSIONS

These findings on the influence of the COVID-19 pandemic on the digital divide indicated that the use of all types of digital health apps increased and that older individuals and people with a lower level of education caught up a little during COVID-19. Future research should gain more insight into this effect and examine whether it persists beyond the COVID-19 pandemic. Additionally, future endeavors should focus on vulnerable groups, ensuring they receive adequate attention to guarantee access to health care, preventative health-promoting solutions, and social services.

Diverticulosis and Diverticulitis on YouTube: Is Popular Information the Most Reliable?

Background Patients utilize online health information to inform their medical decision-making. YouTube is one of the most popular media platforms with abundant health-related resources, yet the quality of the disseminated information remains unclear. This study aims to evaluate the quality and reliability of content pertaining to diverticulosis and diverticulitis on YouTube. Methods One author queried the terms "diverticulosis," "diverticulitis," "acute diverticulitis," and "chronic diverticulitis" on YouTube. The first 50 videos per search were selected for analysis. Duplicates, non-English videos, or procedural content were excluded. Video characteristics including view count, likes, comments, duration, days since upload, view ratio, video power index, and video sources (professional organizations (POs), health information websites (HIWs), and entertainment/independent users (EIUs)) were collected. Videos were scored using the mDISCERN and Global Quality Score (GQS). Results Sixty-four videos were included. DISCERN scores significantly differed between POs (n=20, mean=4.35), HIWs (n=29, mean=2.97), and EIUs (n=15, mean=1.83). GQS also significantly differed between POs (n=20, mean=4.47), HIWs (n=29, mean=3.62), and EIUs (n=15, mean=2.5). Video characteristics significantly differed between groups, with most user engagement seen in EIUs. Conclusion POs and HIWs disseminate higher quality health information about diverticular disease on YouTube. The higher viewer engagement with EIUs is concerning, as these sources were found to have lower quality content. Although YouTube has the capability to provide valuable information on diverticulosis and diverticulitis, enhanced content screening is needed to ensure accuracy and validation.

Social transition, socioeconomic status and self-rated health in China: evidence from a national cross-sectional survey (CGSS)

Background

Social transition is one of the multi-level mechanisms that influence health disparities. However, it has received less attention as one of the non-traditional social determinants of health. A few studies have examined China's social transition and its impact on health inequality in self-rated health (SRH). Therefore, this study explores the impact of China's market-oriented reforms-social transition and socioeconomic status (SES)-on residents' SRH.

Methods

Using the cross-sectional data from the Chinese General Social Survey (CGSS) in 2017, we analyzed the effects of social transition and SES on the SRH of Chinese residents using the RIF (Recentered influence function) method. The RIF decomposition method investigated health differences among different populations and their determinants.

Results

Social transition and SES have significant positive effects on the SRH of Chinese residents. The correlation between SES and the SRH of Chinese residents is moderated by social transition, implying that social transition can weaken the correlation between SES and the SRH of Chinese residents. The impacts of SES and social transition on SRH vary across populations.

Conclusion

Promoting social transition and favoring disadvantaged groups with more resources are urgently needed to promote equitable health outcomes.

Healthcare provider experiences of deploying a continuous remote patient monitoring pilot program during the COVID-19 pandemic: a structured qualitative analysis

Objective

To describe the healthcare provider (HCP) experience of launching a COVID-19 remote patient monitoring (CRPM) program during the global COVID-19 pandemic.

Methods

We conducted qualitative, semi-structured interviews with eight HCPs involved in deploying the CRPM pilot program in the Military Health System (MHS) from June to December 2020. Interviews were audio recorded, transcribed, and analyzed thematically using an inductive approach. We then deductively mapped themes from interviews to the updated Consolidated Framework for Implementation Research (CFIR).

Results

We identified the following main themes mapped to CFIR domains listed in parentheses: external and internal environments (outer and inner settings), processes around implementation (implementation process domain), the right people (individuals domain), and program characteristics (innovation domain). Participants believed that buy-in from leadership and HCPs was critical for successful program implementation. HCP participants showed qualities of clinical champions and believed in the CRPM program.

Conclusion

The MHS deployed a successful remote patient monitoring pilot program during the global COVID-19 pandemic. HCPs found the CRPM program and the technology enabling the program to be acceptable, feasible, and usable. HCP participants exhibited characteristics of clinical champions. Leadership engagement was the most often-cited key factor for successful program implementation.

Refined Analysis of Older eHealth Users From an Agency Perspective: Quantitative Telephone Interview Study

BACKGROUND

Most studies on the eHealth divide among older people have compared users to nonusers and found that age, gender, and education were associated with eHealth misuse. They assumed that these characteristics were structural barriers to eHealth adoption. Furthermore, eHealth practices have been examined in a narrow and incomplete way, and the studies disagree about the association between health conditions and eHealth use. Using a more dynamic theoretical lens, we investigated the potential motivations driving older adults' agential adoption of eHealth practices despite their advanced age.

OBJECTIVE

This study aimed to obtain a complete and detailed description of eHealth uses among older adults; examine whether demographic characteristics such as age, gender, and education (previously related to eHealth misuse) are still associated with the various eHealth clusters; and determine whether contextual factors such as changes in the health condition of older eHealth users or their loved ones are associated with older adult eHealth use.

METHODS

We conducted a 30-minute telephone interview with a representative sample of 442 Israeli adults (aged ≥50 years) with a sampling error of 2.04%. The interviews were conducted in Hebrew, Arabic, and Russian. Using factor analysis with 21 eHealth use questions, we identified 4 eHealth clusters: instrumental and administrative information seeking, information sharing, seeking information from peers, and web-based self-tracking. In addition to age, gender, education, internet experience, frequency of internet use, perceived eHealth literacy, and self-rated health, we asked respondents to indicate how much they had used offline health services because of a health crisis in the past year.

RESULTS

We found differences in the number of older eHealth users in the various clusters. They used instrumental and administrative information (420/442, 95%) and obtained information from peers (348/442, 78.7%) the most; followed by web-based self-tracking related to health issues (305/442, 69%), and only a few (52/442, 11.3%) uploaded and shared health information on the web. When controlling for personal attributes, age, gender, and education were no longer predictors of eHealth use, nor was a chronic ailment. Instead, internet experience, frequency of internet use, and perceived eHealth literacy were associated with 3 eHealth clusters. Looking for health information for family and friends predicted all 4 eHealth clusters.

CONCLUSIONS

Many older adults can overcome structural barriers such as age, gender, and education. The change in their or their loved ones' circumstances encouraged them to make deliberate efforts to embrace the new practices expected from today's patients. Seeking health information for family and friends and dealing with unexpected health crises motivates them to use eHealth. We suggest that health professionals ignore their tendency to label older people as nonusers and encourage them to benefit from using eHealth and overcome stereotypical ways of perceiving these patients.

Smart senior care cognition and health among Chinese elderly: A moderated mediation model featuring parent-child relationship and internet use

In the context of digital transformation, smart senior care (SSC) cognition among elderly individuals has become an important contributor to their health. Using a sample of 345 older adults derived from the cross-sectional data of a questionnaire survey on the application of home-based SSC services and products among elderly individuals, this study explored how the parent‒child relationship mediated the linkage between SSC cognition and elderly health. To examine the moderating role of internet use, we applied the multigroup structural equation modeling (SEM) approach to test whether significant disparities exist between older adults who use the internet and those who do not on the pathways in the mediation model. After controlling for gender, age, hukou (household registration permit), ethnicity, income, marital status, and education level, we found that SSC cognition exerted significant positive effects on elderly health, in which the parent‒child relationship exerted a mediating effect. As for differences between the elderly with internet use and those without, on the three pathways connecting SSC cognition and health, SSC cognition and parent‒child relationship, and parent‒child relationship and health among elderly individuals, older adults who used the internet were more susceptible than those who did not. The findings are helpful for improving the policy-making on elderly health and may serve as a practical guide and theoretical reference for the promotion of active aging.

Reshaping care in the aftermath of the pandemic. Implications for cardiology health systems

In the last two years, the COVID-19 pandemic has undeniably changed everyday life and significantly reshaped the healthcare systems. Besides the direct effect on daily care leading to significant excess mortality, several collateral damages have been observed during the pandemic. The impact of the pandemic led to staff shortages, disrupted education, worse healthcare professional well-being, and a lack of proper clinical training and research. In this review we highlight the results of these important changes and how can the healthcare systems can adapt to prevent unprecedented events in case of future catastrophes.

Online health information seeking and the association with anxiety among older adults

Introduction

The Internet supplies users with endless access to a wealth of information and is generally the first source searched by U.S. adults (18 years and older) when seeking health information. Age and anxiety are associated with online health information seeking (OHIS). Older adults (65 years and older) are increasing their OHIS. Importantly, OHIS can potentially lead to improved health outcomes for older adults. The relationship between OHIS and anxiety is less clear. Studies report those with more symptoms of anxiety are more likely to be OHIS, while other studies find the reverse pattern or no association. Generalized anxiety disorder affects up to 11% of older adults and is oftentimes unrecognized and untreated.

Methods

To address the mixed findings in the literature, we analyzed six waves (2015-2020) of data from the National Health and Aging Trends Study to assess the causal relationship between anxiety and OHIS using a Random Intercept Cross-lagged Panel Model framework.

Results

We found that while anxiety symptoms lead to OHIS in the next wave, OHIS was not associated with anxiety symptoms in the next wave.

Discussion

This suggests that for this sample of older adults, OHIS does not reduce or exacerbate older adults' symptoms of anxiety.

Does the Internet Moderate the Neighborhood Effect? Internet Use, Neighborhoods, and Mental Health among Older Adults in Shanghai

Internet use may reduce the impact of the neighborhood on residents' well-being by helping people utilize resources beyond their immediate neighborhoods or strengthen neighborhood influences by widening the digital divide across neighborhoods. This study investigates how internet use moderates neighborhood effects on mental health among older adults in Shanghai. Using data from the Shanghai Urban Neighborhood Survey (SUNS) and population census, hierarchical linear models reveal that older adults who more frequently use the internet report lower levels of mental distress. Internet use attenuates the negative effects of living in low-socioeconomic status (SES) neighborhoods. We also examine the roles of three types of internet use: social networking, leisure, and information seeking. The results show that only social networking and leisure internet use are significantly associated with improved mental health among older adults. The results suggest that social programs are needed to increase internet literacy among older adults to promote active aging, and priority should be given to relatively disadvantaged neighborhoods.

The association between information and communication technologies, loneliness and social connectedness: A scoping review

Older adults are at a higher risk of loneliness, compared to other demographics. The use of Internet Communication and Technologies (ICTs) among older adults is steadily increasing and given ICTs provide a means of enhancing social connectedness suggests they may have positive effects on reducing loneliness. Therefore, the aim of this scoping review was to examine the research that explores how ICTs may be implicated in mitigating loneliness and increasing social connectedness among older adults. After the examination of 54 articles, we identified three major themes within the literature: (1) ICTs were associated with a reduction in loneliness and increase in wellbeing. (2) ICTs promoted social connectedness by facilitating conversations. (3) Factors such as training, self-efficacy, self-esteem, autonomy, and the design/features, or affordances, of ICTs contribute toward the associations between ICT use and wellbeing. The heterogeneity of methodologies, statistical reporting, the small sample sizes of interventional and observational studies, and the diversity of the experimental contexts underline the challenges of quantitative research in this field and highlights the necessity of tailoring ICT interventions to the needs and contexts of the older users.

Factors associated with internet use and health information technology use among older people with multi-morbidity in the United States: findings from the National Health Interview Survey 2018

BACKGROUND

The number of older adults with physical multi-morbidity is increasing. As Internet-based eHealth and mHealth increasingly require patients to use technology, it is important to examine the use of Internet/health information technology (HIT) among older adults with physical multi-morbidity. Here we examine the distribution of physical multi-morbidity, Internet use, and HIT use, and further explored the factors associated with Internet use and HIT use among older adults with physical multi-morbidity.

METHODS

One wave of data from the 2018 US National Health Interview Survey (NHIS) was analysed. We included respondents aged 65 years and older. We used 13 physical non-communicable diseases to measure physical multi-morbidity. Descriptive statistics and logistic regression models, with sociodemographic factors, health status, health insurance, health care service use, and satisfaction with health care as covariates, were used to examine the research questions.

RESULTS

Of 72,746 respondents in NHIS, 7060 were eligible for our analysis. 5380 (76.2%) eligible respondents had physical multi-morbidity in this study. Overall, 60% of older adults reported using the Internet, with 38.9% using eHealth services (defined as looking up health information online, filling a prescription, scheduling an appointment with a health care provider, or communicating with a health care provider via email). Gender, age, marital status, region, race, education, and family income were significant factors associated with the Internet and HIT use among people with multi-morbidity. The study also showed that after adjusting for confounders, good health status, having Medicare, receiving home care from a health professional, and low satisfaction with health care were positive predictors of the Internet and HIT use.

CONCLUSIONS

In summary, our study found that Internet and HIT use among older patients with chronic diseases is far from the Healthy People 2030 target. Internet and HIT use vary depending on a number of sociodemographic factors. Relevant influencing factors should be fully considered in health education interventions promoted.

Factors associated with eHealth use among community dwelling older adults

BACKGROUND

With the proliferation of the internet and the development of internet-based healthcare interventions, eHealth is expected to be an effective complement to traditional healthcare services. However, without understanding the characteristics of the user population, eHealth itself can isolate older adults.

AIM

This study aims to identify the characteristics of internet use and the factors associated with eHealth use among older adults.

METHODS

A secondary data analysis was conducted from a cross-sectional descriptive study. A convenience sample of 186 community dwelling older adults was recruited at two senior welfare centres in Korea. The data collected included demographic characteristics, health related characteristics, internet use, eHealth use and eHealth literacy. Multiple linear regression was utilized to determine factors related to eHealth use.

RESULTS

Among 186 respondents, 98 reported that they used the internet. Internet usage was associated with educational attainment, marital status, cognitive function and possession of internet-enabled devices. The results of multiple regression analysis showed that greater eHealth usage was related to more positive perception of eHealth usability and better eHealth literacy among older adults.

CONCLUSION

Educational programmes for older adults should be developed to facilitate digital capability and eHealth literacy. Useful and effective online health resources that are easy to use should be also developed.

The Factors Associated With Nonuse of Social Media or Video Communications to Connect With Friends and Family During the COVID-19 Pandemic in Older Adults: Web-Based Survey Study

BACKGROUND

Digital technologies have enabled social connection during prolonged periods of physical distancing and travel restrictions throughout the COVID-19 pandemic. These solutions may exclude older adults, who are at higher risk for social isolation, loneliness, and severe outcomes if infected with SARS-CoV-2.

OBJECTIVE

This study investigated factors associated with nonuse of social media or video communications to connect with friends and family among older adults during the pandemic's first wave.

METHODS

A web-based, cross-sectional survey was administered to members of a national retired educators' organization based in Ontario, Canada, between May 6 and 19, 2020. Respondents (N=4879) were asked about their use of social networking websites or apps to communicate with friends and family, their internet connection and smartphone access, loneliness, and sociodemographic characteristics. Factors associated with nonuse were evaluated using multivariable logistic regression. A thematic analysis was performed on open-ended survey responses that described experiences with technology and virtual connection.

RESULTS

Overall, 15.4% (751/4868) of respondents did not use social networking websites or apps. After adjustment, male gender (odds ratio [OR] 1.60, 95% CI 1.33-1.92), advanced age (OR 1.88, 95% CI 1.38-2.55), living alone (OR 1.68, 95% CI 1.39-2.02), poorer health (OR 1.33, 95% CI 1.04-1.71), and lower social support (OR 1.44, 95% CI 1.20-1.71) increased the odds of nonuse. The reliability of internet connection and access to a smartphone also predicted nonuse. Many respondents viewed these technologies as beneficial, especially for maintaining pre-COVID-19 social contacts and routines, despite preferences for in-person connection.

CONCLUSIONS

Several factors including advanced age, living alone, and low social support increased the odds of nonuse of social media in older adults to communicate with friends and family during COVID-19's first wave. Our findings identified socially vulnerable subgroups who may benefit from intervention (eg, improved access, digital literacy, and telephone outreach) to improve social connection.

Engagement in Digital Health App-Based Prevention Programs Is Associated With Weight Loss Among Adults Age 65+

Background

Digital health programs have been shown to be feasible and effective for the prevention of chronic diseases such as diabetes. Contrary to expectations, findings also suggest that older adults have higher levels of engagement with digital health programs than younger adults. However, there is a paucity of research examining outcomes among older adults in digital health programs and whether higher engagement is related to better outcomes.

Methods

We examined weight loss outcomes for 538 users aged 65 and older participating in one of two app-based prevention programs called the Diabetes Prevention Program and the Prevention Program, respectively. Both programs were available on a single artificial intelligence (AI)-powered digital health platform and shared a common goal of weight loss. We also examined the relationship between key engagement metrics (i.e., conversing with the AI-powered coach, weigh-ins, and initiating educational lessons early in the program) and weight loss outcomes.

Results

The average weight loss of all enrollees having a weight measurement after after the 9th week was 4.51%, and the average weight loss of the Diabetes Prevention Program enrollees meeting a minimum engagement level was 8.56%. Greater weight loss was associated with a greater number of days with AI-powered coaching conversations (p = 0.03), more weigh-ins (p = 0.00), and early educational lesson initiation (p = 0.02).

Conclusions

Digital health programs powered by AI offer a promising solution for health management among older adults. The results show positive health outcomes using app-based prevention programs, and all three engagement metrics were independently associated with weight loss.

Factors Associated with Reducing Disparities in Electronic Personal Heath Records Use Among Non-Hispanic White and Hispanic Adults

OBJECTIVES

Personal health records (PHR) use has improved individuals' health outcomes. The adoption of PHR remains low with documented racial disparities. We aim to determine factors associated with reducing racial and ethnic disparities among Hispanic adults in PHR use.

METHODS

Participants included non-Hispanic White (NHW) and Hispanic adults (age ≥ 18 years) enrolled in Health Information National Trends Survey in 2018 and 2019. We identified PHR use as online medical record access in the last 12 months. We considered three factors (1. accessing mHealth Apps on the phone, 2. having a usual source of care, and 3. electronically communicating (e-communication) with healthcare providers) as facilitating PHR use. Multivariable logistic regressions with replicate weights were analyzed to determine factors associated with racial/ethnic disparities in PHR use after controlling for general characteristics (i.e., sex, age, education, insurance status, and income).

RESULTS

A lower percentage of Hispanics than NHWs used PHR (42.0% vs. 53.5%, P < .001). When adjusted for individual general characteristics, the adjusted odds ratio (AOR) of e-communication with healthcare providers associated with PHR use was 1.49 (1.19-1.86, P < .001), AOR was 2.06 (1.62-2.6, P < .001) on accessing to mHealth App, and 2.60 (1.86-3.63, P < .001) on having a usual source of care. However, the racial difference was not statistically significant after adjusting three factors promoting PHR use (AOR = 0.90, 95% CI = 0.66, 1.22, P = .48).

CONCLUSIONS

Ethnic disparities were reduced when PHR use was facilitated by having a usual source of care, active e-communication, and having access to mHealth apps. Interventions focusing on these three factors may potentially reduce racial/ethnic disparities.

Health and self-perceived barriers to internet use among older migrants: a population-based study

Background

In older adults, including those with a migrant background, ill health is associated with less internet use. However, it is not known what are the specific self-perceived barriers to internet use among older migrants with different health conditions. The aim of this study was to investigate the associations between different health conditions and self-perceived barriers to internet use among older migrants.

Methods

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%). Postal survey data were collected in 2019. Health indicators were self-rated health (SRH), depressive symptoms, cognitive functioning, and doctor-diagnosed conditions. Linear regression analyses were used to investigate the associations between health indicators and a summary scale consisting of the following barriers of internet use: (1) internet use is too complicated and hard to learn; (2) having concerns about safety issues; (3) internet use is too expensive; (4) physical limitations hinder the internet use; (5) memory problems hinder the internet use. In addition, the two most commonly reported barriers (the first two) were examined separately using logistic regression analyses. The analyses were adjusted for age, sex, education, marital status, local language proficiency, and income support, and the health conditions, and were performed with weights accounting for the survey design and non-response.

Results

After adjustments, spine/back problems (b=0.13; p=0.049), depressive symptoms (b=0.40; p=0.007), and problems in learning new things (b=0.60; p<0.0005) were associated with higher level of overall barriers to internet use. In addition, a number of health conditions were associated with individual barriers, albeit some health conditions appeared protective.

Conclusions

In general, older migrants with declining health experience more barriers to internet use than their counterparts with better health. To provide better access to healthcare for older adults, including older migrants, rapidly changing devices, software and apps need to be modified and adapted for those with specific health-related needs.

Online Health Information Seeking Behaviors Among Older Adults: Systematic Scoping Review

Background

With the world’s population aging, more health-conscious older adults are seeking health information to make better-informed health decisions. The rapid growth of the internet has empowered older adults to access web-based health information sources. However, research explicitly exploring older adults’ online health information seeking (OHIS) behavior is still underway.

Objective

This systematic scoping review aims to understand older adults’ OHIS and answer four research questions: (1) What types of health information do older adults seek and where do they seek health information on the internet? (2) What are the factors that influence older adults’ OHIS? (3) What are the barriers to older adults’ OHIS? (4) How can we intervene and support older adults’ OHIS?

Methods

A comprehensive literature search was performed in November 2020, involving the following academic databases: Web of Science; Cochrane Library database; PubMed; MEDLINE; CINAHL Plus; APA PsycINFO; Library and Information Science Source; Library, Information Science and Technology Abstracts; Psychology and Behavioral Sciences Collection; Communication & Mass Media Complete; ABI/INFORM; and ACM Digital Library. The initial search identified 8047 publications through database search strategies. After the removal of duplicates, a data set consisting of 5949 publications was obtained for screening. Among these, 75 articles met the inclusion criteria. Qualitative content analysis was performed to identify themes related to the research questions.

Results

The results suggest that older adults seek 10 types of health information from 6 types of internet-based information sources and that 2 main categories of influencing factors, individual-related and source-related, impact older adults’ OHIS. Moreover, the results reveal that in their OHIS, older adults confront 3 types of barriers, namely individual, social, and those related to information and communication technologies. Some intervention programs based on educational training workshops have been created to intervene and support older adults’ OHIS.

Conclusions

Although OHIS has become increasingly common among older adults, the review reveals that older adults’ OHIS behavior is not adequately investigated. The findings suggest that more studies are needed to understand older adults’ OHIS behaviors and better support their medical and health decisions in OHIS. Based on the results, the review proposes multiple objectives for future studies, including (1) more investigations on the OHIS behavior of older adults above 85 years; (2) conducting more longitudinal, action research, and mixed methods studies; (3) elaboration of the mobile context and cross-platform scenario of older adults’ OHIS; (4) facilitating older adults’ OHIS by explicating technology affordance; and (5) promoting and measuring the performance of OHIS interventions for older adults.

Usability of the Swedish Accessible Electronic Health Record: a Qualitative Study (Preprint)

Background

Patient portals are increasingly being implemented worldwide to ensure that patients have timely access to their health data, including patients’ access to their electronic health records. In Sweden, the e-service Journalen is a national patient-accessible electronic health record (PAEHR), accessible on the web through the national patient portal. User characteristics and perceived benefits of using a PAEHR will influence behavioral intentions to use and adoption; however, poor usability, which increases effort expectancy, may have a negative impact. Therefore, it is of interest to further explore how users of the PAEHR Journalen perceive its usability and usefulness.

Objective

On the basis of the analysis of the survey respondents’ experiences of the usability of the Swedish PAEHR, this study aimed to identify specific usability problems that may need to be addressed in the future.

Methods

A survey study was conducted to elicit opinions and experiences of patients using Journalen. Data were collected from June to October 2016. The questionnaire included a free-text question regarding the usability of the system, and the responses were analyzed using content analysis with a sociotechnical framework as guidance when grouping identified usability issues.

Results

During the survey period, 423,141 users logged into Journalen, of whom 2587 (0.61%) completed the survey (unique users who logged in; response rate 0.61%). Of the 2587 respondents, 186 (7.19%) provided free-text comments on the usability questions. The analysis resulted in 19 categories, which could be grouped under 7 of the 8 dimensions in the sociotechnical framework of Sittig and Singh. The most frequently mentioned problems were related to regional access limitations, structure and navigation of the patient portal, and language and understanding.

Conclusions

Although the survey respondents, who were also end users of the PAEHR Journalen, were overall satisfied with its usability, they also experienced important challenges when accessing their records. For all patients to be able to reap the benefits of record access, it is essential to understand both the usability challenges they encounter and, more broadly, how policies, regulations, and technical implementation decisions affect the usefulness of record access. The results presented here are specific to the Swedish PAEHR Journalen but also provide important insights into how design and implementation of record access can be improved in any context.

Are lifestyle changes from online information associated with discussing the information with a doctor? A cross -sectional study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. Lifestyle changes in a positive direction may reduce morbidity and mortality in patients with diabetes. The main objective of this study was to test the association between lifestyle changes based on online information seeking and discussing the information with a doctor.

METHODS

In this cross-sectional study we used e-mail survey data from 1250 members of The Norwegian Diabetes Association, collected in 2018. Included in the analyses were 847 men and women aged 18 to 89 years diagnosed with diabetes and who reported use of eHealth within the previous year. We used descriptive statistics to estimate lifestyle changes based on information from the internet. Logistic regressions were used to estimate the associations between lifestyle changes after online information seeking and discussing the information with a doctor. Analyses were adjusted for gender, age, education, and self-rated health.

RESULTS

Lifestyle changes accomplished after online information seeking was reported by 46.9% (397/847) of the participants. The odds of changing lifestyle were more than doubled for those who had discussed information from the internet with a doctor (odds ratio 2.54, confidence interval 1.90-3.40). The odds of lifestyle changes were lower in the age groups 30-39 years and 60 years and over, compared to those aged 18-29 years (the reference group). Lifestyle changes were not associated with gender, education, or self-rated health.

CONCLUSIONS

Our findings indicate that health-care professionals can play an important role in lifestyle changes additional to health-advice found on the internet. This study underlines the importance of easily accessible high-quality online information, as well as the importance of making room for discussing lifestyle in the clinical encounter.

Factors affecting willingness to comply with public health measures during the pandemic among sub-Sahara Africans

Background

The unprecedented outbreak of coronavirus disease (COVID-19) drastically spread worldwide, resulting in extraordinary measures put in place in various countries including Sub Saharan Africa (SSA) countries.

Objective

To assess the factors associated with compliance with the public health measures imposed by various SSA countries.

Method

Cross sectional study using self-administered surveys distributed on social media platforms between April 18th and May 16th, 2020, corresponding with the mandatory lockdown period in most SSA countries. Multivariate analysis examined the associated factors.

Results

The prevalence of hand hygiene, quarantine, self isolation practices, wearing of face mask and attending large gatherings during COVID-19 were 94%, 39%, 31%, 64% and 14%, respectively. In multivariate models, older age 49+ years: adjusted OR 2.13, 95%CI 1.22,3.71), females (OR 1.41,95%CI 1.03,1.93), Central African countries (OR 3.73,95%CI 2.02,6.87) were associated with wearing face mask. Living alone (aOR 1.52,95%CI 1.04,2.24) during the lockdown was associated with avoiding large gatherings including religious events. Female respondents (aOR 1.61, 95%CI 1.30, 2.00), married (aOR 1.71,95%CI 1.33,2.21) and unemployed (aOR 1.62,95%CI 1.25,2.09) SSAs were more likely to practice self-quarantine measures.

Conclusion

The low prevalence of mitigation practices suggest the need for targeted education campaign programs to sensitise the population.

Patient-Reported Outcomes in a Nationally Representative Sample of Older Internet Users: Cross-sectional Survey

BACKGROUND

The rapid diffusion of the internet has decreased consumer reliance on health care providers for health information and facilitated the patients' ability to be an agent in control of their own health. However, empirical evidence is limited regarding the effects of health-related internet use among older adults, which is complicated by the proliferation of online health and medical sources of questionable scientific accuracy.

OBJECTIVE

We explore the effects of health-related internet use, education, and eHealth literacy on medical encounters and patient-reported outcomes. Patient-reported outcomes are categorized into two dimensions: (1) self-reported health problem and (2) affective distress (feeling worried and anxious) due to information obtained. We were particularly interested in whether education and eHealth literacy moderate the association between perceived strain in medical encounters and patient-reported outcomes.

METHODS

Our study sample consisted of online panel members who have used the internet as a resource for health information, randomly drawn from one of the largest probability-based online research panels. This paper specifically reports results obtained from older panel members (age≥60 years: n=194). First, we examined descriptive statistics and bivariate associations (Pearson correlations and independent samples t tests). We used hierarchical ordinary least squares regression analyses by running separate regressions for each patient-reported outcome. In model 1, we entered the main effects. In model 2, technology and medical encounter variables were included. Model 3 added the statistical interaction terms.

RESULTS

Age (β=-.17; P=.02), gender (β=-.22; P=.01), and medical satisfaction (β=-.28; P=.01) were significant predictors of self-reported health problems. Affective distress was positively predicted by gender (β=.13; P=.05) and satisfaction with medical encounters (β=.34; P<.001) but negatively predicted by education (β=-.18; P=.03) and eHealth literacy (β=-.32; P=.01). The association between experiencing a health problem in relation to health-related internet use and perception of strained medical encounters was greater among respondents with lower levels of education (β=-.55; P=.04). There was also a significant interaction between education and eHealth literacy in predicting the level of affective distress (β=-.60; P=.05), which indicated that higher levels of education predicted lower averages of feeling anxiety and worry despite lower eHealth literacy. Older women reported higher averages of affective distress (β=.13; P=.05), while older men reported higher averages of experiencing a self-reported health problem (β=-.22; P=.01).

CONCLUSIONS

This study provides evidence for the effect of health-related internet use on patient-reported outcomes with implications for medical encounters. The results could be used to guide educational and eHealth literacy interventions for older individuals.

Co-design of a digital dietary intervention for adults at risk of type 2 diabetes

Background

Co-design has the potential to create interventions that lead to sustainable health behaviour change. Evidence suggests application of co-design in various health domains has been growing; however, few public-facing digital interventions have been co-designed to specifically address the needs of adults at risk of Type 2 diabetes (T2D). This study aims to: (1) co-design, with key stakeholders, a digital dietary intervention to promote health behaviour change among adults at risk of T2D, and (2) evaluate the co-design process involved in developing the intervention prototype.

Methods

The co-design study was based on a partnership between nutrition researchers and designers experienced in co-design for health. Potential end-users (patients and health professionals) were recruited from an earlier stage of the study. Three online workshops were conducted to develop and review prototypes of an app for people at risk of T2D. Themes were inductively defined and aligned with persuasive design (PD) principles used to inform ideal app features and characteristics.

Results

Participants were predominantly female (range 58–100%), aged 38 to 63 years (median age = 59 years), consisting of a total of 20 end-users and four experts. Participants expressed the need for information from credible sources and to provide effective strategies to overcome social and environmental influences on eating behaviours. Preferred app features included tailoring to the individual’s unique characteristics, ability to track and monitor dietary behaviour, and tools to facilitate controlled social connectivity. Relevant persuasive design principles included social support, reduction (reducing effort needed to reach target behaviour), tunnelling (guiding users through a process that leads to target behaviour), praise, rewards, and self-monitoring. The most preferred prototype was the Choices concept, which focusses on the users’ journey of health behaviour change and recognises progress, successes, and failures in a supportive and encouraging manner. The workshops were rated successful, and feedback was positive.

Conclusions

The study’s co-design methods were successful in developing a functionally appealing and relevant digital health promotion intervention. Continuous engagement with stakeholders such as designers and end-users is needed to further develop a working prototype for testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12102-y.

Trends in Health Information Technology Use Among the US Population With and Without Cardiovascular Risk Factors, 2012-2018: Evidence From the National Health Interview Survey

Background

The COVID-19 pandemic has required clinicians to pivot to offering services via telehealth; however, it is unclear which patients (users of care) are equipped to use digital health. This is especially pertinent for adults managing chronic diseases, such as obesity, hypertension, and diabetes, which require regular follow-up, medication management, and self-monitoring.

Objective

The aim of this study is to measure the trends and assess factors affecting health information technology (HIT) use among members of the US population with and without cardiovascular risk factors.

Methods

We used serial cross-sectional data from the National Health Interview Survey for the years 2012-2018 to assess trends in HIT use among adults, stratified by age and cardiovascular risk factor status. We developed multivariate logistic regression models adjusted for age, sex, race, insurance status, marital status, geographic region, and perceived health status to assess the likelihood of HIT use among patients with and without cardiovascular disease risk factors.

Results

A total of 14,304 (44.6%) and 14,644 (58.7%) participants reported using HIT in 2012 and 2018, respectively. When comparing the rates of HIT use for the years 2012 and 2018, among participants without cardiovascular risk factors, the HIT use proportion increased from 51.1% to 65.8%; among those with one risk factor, it increased from 43.9% to 59%; and among those with more than one risk factor, it increased from 41.3% to 54.7%. Increasing trends in HIT use were highest among adults aged >65 years (annual percentage change [APC] 8.3%), who had more than one cardiovascular risk factor (APC 5%) and among those who did not graduate from high school (APC 8.8%). Likelihood of HIT use was significantly higher in individuals who were younger, female, and non-Hispanic White; had higher education and income; were married; and reported very good or excellent health status. In 2018, college graduates were 7.18 (95% CI 5.86-8.79), 6.25 (95% CI 5.02-7.78), or 7.80 (95% CI 5.87-10.36) times more likely to use HIT compared to adults without high school education among people with multiple cardiovascular risk factors, one cardiovascular risk factor, or no cardiovascular risk factors, respectively.

Conclusions

Over 2012-2018, HIT use increased nationally, with greater use noted among younger and higher educated US adults. Targeted strategies are needed to engage wider age, racial, education, and socioeconomic groups by lowering barriers to HIT access and use.

Internet-Based Health Care Communication Among Cancer Survivors, 2011-2018 National Health Interview Survey

Introduction

Understanding trends and associated factors in internet-based health care communication (IBHC) among cancer survivors is important for meeting patient needs because their reliance on telehealth is growing. We aimed to examine IBHC use among cancer survivors in the US.

Methods

We identified adult cancer survivors aged 18 to 64 (n = 8,029) and 65 or older (n = 11,087) from the National Health Interview Survey in 2011–2018. We calculated temporal trends of self-reported IBHC in the previous year (filled a prescription, scheduled a medical appointment, or communicated with a health care provider) and used multivariable logistic models to identify associated factors.

Results

Approximately 84% of survivors had been diagnosed 2 years or more before the survey. IBHC prevalence increased among cancer survivors aged 18 to 64, from 19.3% to 40.2%, and among those aged 65 or older, from 11.4% to 22.6%, from 2011 to 2018 (P for trend <.001). Among both age groups, lower educational attainment, lack of usual source of care, and current smoking were associated with less IBHC, whereas residing in the South or West, having 1 or more chronic conditions, and drinking any alcohol were associated with higher IBHC (all P < .05). Factors associated with less IBHC also included being non-Hispanic Black or Hispanic, lacking private insurance, and being 11 or more years postdiagnosis among survivors aged 18 to 64; among survivors aged 65 or older, factors were being an older age, not married, and non-US born (all P < .05).

Conclusion

IBHC among cancer survivors is common and increasing, with differences across sociodemographic and behavioral characteristics. As health care delivery continues adopting IBHC and other advanced telehealth techniques, disparities need to be addressed to ensure equitable access to care for all cancer survivors.

Benefits and barriers: a qualitative study on online social participation among widowed older adults in Southwest China

BACKGROUND

With the development of digital media, online activities are increasingly becoming part of the daily life of older adults. Widowed older adults generally would face changes in social interactions and activities due to widowhood; thus, the importance of online participation may be more prominent in this population. However, a detailed evidence on the experiences of online social participation among widowed older adults is relatively sparse. This study aimed to explore widowed older adults' perceptions regarding online social participation in southwestern China.

METHODS

This study adopted a qualitative approach. Semi-structured, in-depth individual interviews were conducted with 19 widowed older adults between September-December 2020. Thematic analysis was applied to analyse the data.

RESULTS

Two major themes, "benefits" and "barriers" were identified from the original data analysis. Subcategories concerning the theme "benefits" were "benefit perception (convenience, flexible time, supplementation)", "health promotion", "emotional comfort", and "social connection". Subcategories of "barriers" were "worries: personal economic loss", "concerns: security of digital device", "troubles: the diversity of online social participation", and "difficulties: using digital media".

CONCLUSIONS

Social participation of widowed older adults in southwestern China has begun to be integrated into the digital world; however, it remains at an early stage with the simple purpose of engagement. The older adults may face many challenges for online social participation. Although there are barriers and challenges in online social participation, widowed older adults can reap its benefits, which can be used as an important measure to facilitate a fulfilling life and successful ageing. There is no doubt that online social participation will become a trend within the foreseeable future. Family, friends and health care professionals should pay more attention to the needs of online social participation in widowed older adults and provide adequate support for them to achieve a meaningful life.

Coronavirus-related health literacy and perceived restrictiveness of protective measures among community-dwelling older persons in Finland

BACKGROUND

Older people with limited health literacy may encounter difficulties in finding relevant information on COVID-19, understanding its relevance, and complying with recommended protective measures. Complying with such recommendations has required older as well as younger persons to change their daily lives in ways that have reduced their opportunities for engaging in many activities meaningful to them.

AIMS

To find out from what sources older people have obtained information on protective measures, the level of their coronavirus-related health literacy (CHL), and whether CHL is associated with their perceptions of the restrictiveness of coronavirus-related protective measures.

METHODS

696 Finnish men and women aged over 77 answered a mailed questionnaire on their CHL, sources of information and perceptions of the restrictiveness of the recommended protective measures. The association of CHL with perceived restrictiveness was studied using multinomial logistic regression analysis.

RESULTS

Television and newspapers were the most frequently reported sources of information. Reporting high confidence in the ability to assess how one's behavior influences coronavirus infection risk was associated with higher odds of perceiving the protective measures to be highly restrictive, when controlling for age, gender, and difficulty in using digital devices (OR 3.21, 95% CI 1.09, 9.46).

DISCUSSION

Participants who reported being highly confident about their ability to appraise the influence of their behavior on their susceptibility to coronavirus infection were more likely to perceive that the recommended protective measures had restricted their daily lives.

CONCLUSIONS

Health literacy plays a role in complying with recommended restrictions.

Pattern of Use of Electronic Health Record (EHR) among the Chronically Ill: A Health Information National Trend Survey (HINTS) Analysis

Effective patient–provider communication is a cornerstone of patient-centered care. Patient portals provide an effective method for secure communication between patients or their proxies and their health care providers. With greater acceptability of patient portals in private practices, patients have a unique opportunity to manage their health care needs. However, studies have shown that less than 50% of patients reported accessing the electronic health record (EHR) in a 12-month period. We used HINTS 5 cycle 1 and cycle 2 to assess disparities among US residents 18 and older with any chronic condition regarding the use of EHR for secure direct messaging with providers, to request refills, to make clinical decisions, or to share medical records with another provider. The results indicate that respondents with multimorbidity are more likely to share their medical records with other providers. However, respondents who are 75 and older are less likely to share their medical records with another provider. Additionally, respondents who are 65 and older are less likely to use the EHR for secure direct messaging with their provider. Additional health care strategies and provider communication should be developed to encourage older patients with chronic conditions to leverage the use of patient portals for effective disease management.

A health literacy analysis of the consumer-oriented COVID-19 information produced by ten state health departments

Objective:

The COVID-19 pandemic highlights the public's need for quality health information that is understandable. This study aimed to identify (1) the extent to which COVID-19 messaging by state public health departments is understandable, actionable, and clear; (2) whether materials produced by public health departments are easily readable; (3) relationships between material type and understandability, actionability, clarity, and reading grade level; and (4) potential strategies to improve public health messaging around COVID-19.

Methods:

Based on US Centers for Disease Control and Prevention statistics from June 30, 2020, we identified the ten states with the most COVID-19 cases and selected forty-two materials (i.e., webpages, infographics, and videos) related to COVID-19 prevention according to predefined eligibility criteria. We applied three validated health literacy tools (i.e., Patient Education Materials Assessment Tool, CDC Clear Communication Index, and Flesch-Kincaid Grade Level) to assess material understandability, actionability, clarity, and readability. We also analyzed correlations between scores on the three health literacy tools and material types.

Results:

Overall, COVID-19 materials had high understandability and actionability but could be improved in terms of clarity and readability. Material type was significantly correlated with understandability, actionability, and clarity. Infographics and videos received higher scores on all tools.

Conclusions:

Based on our findings, we recommend public health entities apply a combination of these tools when developing health information materials to improve their understandability, actionability, and clarity. We also recommend using infographics and videos when possible, taking a human-centered approach to information design, and providing multiple modes and platforms for information delivery.

Digital Information Technology Use, Self-Rated Health, and Depression: Population-Based Analysis of a Survey Study on Older Migrants

BACKGROUND

Previous studies have found that in general, poor health is associated with a lower likelihood of internet use in older adults, but it is not well known how different indicators of health are associated with different types of digital information technology (DIT) use. Moreover, little is known about the relationship between health and the types of DIT use in older ethnic minority and migrant populations.

OBJECTIVE

The aim of this study is to examine the associations among depressive symptoms and self-rated health (SRH) with different dimensions of DIT use in older migrants.

METHODS

We analyzed data from the Care, Health and Ageing of Russian-speaking Minority (CHARM) study, which is based on a nationally representative sample of community-dwelling, Russian-speaking adults aged 50 years or older residing permanently in Finland (men: 616/1082, 56.93%; age: mean 63.2 years, SD 8.4 years; response rate: 1082/3000, 36.07%). Data were collected in 2019 using a postal survey. Health was measured using depressive symptoms (measured using the Center for Epidemiologic Studies Depression Scale) and SRH. Binary logistic regression analyses were used to investigate the associations between the two health indicators and the following six outcomes: daily internet use, smartphone ownership, the use of the internet for messages and calls, social media use, the use of the internet for personal health data, and obtaining health information from the internet. A number of sociodemographic and socioeconomic factors were controlled for in the logistic regression regression analysis. Analyses were performed with weights accounting for the survey design and nonresponse.

RESULTS

After adjusting for sociodemographic and socioeconomic factors, depressive symptoms (odds ratio [OR] 2.68, 95% CI 1.37-5.24; P=.004) and poor SRH (OR 7.90, 95% CI 1.88-33.11; P=.005) were associated with a higher likelihood of not using the internet daily. Depressive symptoms (OR 1.88, 95% CI 1.06-3.35; P=.03) and poor SRH (OR 5.05, 95% CI 1.58-16.19; P=.006) also increased the likelihood of smartphone nonuse. Depressive symptoms were additionally associated with a lower likelihood of social media use, and poor SRH was associated with a lower likelihood of using the internet for messaging and calling.

CONCLUSIONS

Poor SRH and depressive symptoms are associated with a lower likelihood of DIT use in older adults. Longitudinal studies are required to determine the directions of these relationships.

Feasibility and Adoption of a Focused Digital Wellness Program in Older Adults

Digital health programs offer numerous psychological and physical health benefits. To date, digital programs have been aimed broadly at younger participants, yet older individuals may also benefit. Our study sought to demonstrate user feasibility and satisfaction in a digital wellness program for older adults. We conducted a retrospective analysis of 140 participants in a digital health wellness application that integrated guided exercises, nutrition planning and health education. Primary outcomes were active participant retention, engagement in the mobile program and user satisfaction as operationalized by NPS scores. Among 140 participants, median age was 59.82 (50–80), 61% female, in a sample taken in the United States. Engagement was high and sustained, with more than 65% participants engaged, operationalized as at least completing one task activity a month over 17 weeks. Participants were also satisfied with the program, reporting NPS scores of 43 on day 30 of the program. Secondary health outcomes included 3.44 pound weight change during the first month. User feasibility and satisfaction was demonstrated in a sample of older participants for this novel digital health wellness program. Future work focused on older adult users may result in improvements in patient health outcomes and improved preventive medicine strategies.

Voices of Experience: What Do Low-Income Older Adults Tell Us About Mobility, Technology, and Social Participation?

Mobility and technology can facilitate in-person and virtual social participation to help reduce social isolation, but issues exist regarding older adults' access, feasibility, and motivation to use various forms of mobility and technology. This qualitative study explores how a diverse group of low-income, urban-living older adults use mobility and technology for social participation. We conducted six focus groups (N = 48), two each in English, Spanish, and Korean at a Los Angeles senior center. Three major themes emerged from thematic analysis: using technology for mobility; links between mobility and social participation; and technology-mediated social participation. Cost, perceived safety, (dis)ability, and support from family and friends were related to mobility and technology use. This study demonstrates the range of mobility and technology uses among older adults and associated barriers. The findings can help establish a pre-COVID-19 baseline on how to make mobility and technology more accessible for older adults at risk of isolation.

Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19

IMPORTANCE

The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits.

OBJECTIVE

To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021.

EXPOSURE

In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period.

MAIN OUTCOMES AND MEASURES

Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone).

RESULTS

This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits [39.1%] vs 25 474 COVID-era in-person visits [34.2%] vs 2562 COVID-era video visits [54.3%] vs 4264 COVID-era telephone visits [41.1%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits [42.6%] vs 31 359 COVID-era in-person visits [42.1%] vs 2006 COVID-era video visits [42.5%] vs 5181 COVID-era telephone visits [49.9%]; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits [16.4%] vs 10 488 COVID-era in-person visits [14.1%] vs 1172 COVID-era video visits [24.8%] vs 2674 COVID-era telephone visits [25.8%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio [OR], 0.62 [95% CI, 0.60-0.64], COVID-era video: OR, 0.22 [95% CI, 0.20-0.24]; COVID-era telephone: OR, 0.14 [95% CI, 0.13-0.15]) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 [95% CI, 0.58-0.62]; COVID-era video: OR, 0.03 [95% CI, 0.02-0.04]; COVID-era telephone: OR, 0.02 [95% CI, 0.01-0.03]) or echocardiograms (COVID-era in-person: OR, 1.21 [95% CI, 1.18-1.24]; COVID-era video: OR, 0.47 [95% CI, 0.42-0.52]; COVID-era telephone: OR, 0.28 [95% CI, 0.25-0.31]).

CONCLUSIONS AND RELEVANCE

Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.

Use of Passive Sensing in Psychotherapy Studies in Late Life: A Pilot Example, Opportunities and Challenges

Late-life depression is heterogenous and patients vary in disease course over time. Most psychotherapy studies measure activity levels and symptoms solely using self-report scales, administered periodically. These scales may not capture granular changes during treatment. We introduce the potential utility of passive sensing data collected with smartphone to assess fluctuations in daily functioning in real time during psychotherapy for late life depression in elder abuse victims. To our knowledge, this is the first investigation of passive sensing among depressed elder abuse victims. We present data from three victims who received a 9-week intervention as part of a pilot randomized controlled trial and showed a significant decrease in depressive symptoms (50% reduction). Using a smartphone, we tracked participants' daily number of smartphone unlocks, time spent at home, time spent in conversation, and step count over treatment. Independent assessment of depressive symptoms and behavioral activation were collected at intake, Weeks 6 and 9. Data revealed patient-level fluctuations in activity level over treatment, corresponding with self-reported behavioral activation. We demonstrate how passive sensing data could expand our understanding of heterogenous presentations of late-life depression among elder abuse. We illustrate how trajectories of change in activity levels as measured with passive sensing and subjective measures can be tracked concurrently over time. We outline challenges and potential solutions for application of passive sensing data collection in future studies with larger samples using novel advanced statistical modeling, such as artificial intelligence algorithms.

Multigenerational social support in the face of the COVID-19 pandemic

Research documents high levels of instrumental, financial, and expressive support exchanges within multigenerational families in the 21st century. The COVID-19 pandemic poses unique challenges to support exchanges between the generations; however, the pandemic may provide opportunities for greater solidarity within families. In this review, we draw from theoretical perspectives that have been used to study family relationships to understand the implications of the pandemic for multigenerational families: the life course perspective, the intergenerational solidarity model, and rational choice/social exchange theory. We review literature on multigenerational relationships in the United States and discuss how established social support patterns and processes may be altered by the COVID-19 pandemic. We reflect on how the impact of the COVID-19 pandemic on multigenerational relationships may vary by gender, race, ethnicity, and socioeconomic status. Finally, we provide directions for future researchers to pursue in order to understand the lasting impacts of the COVID-19 pandemic on multigenerational ties.

Internet Use in Old Age: Results of a German Population-Representative Survey

Background

The internet has the potential to foster healthy lifestyles and to support chronic disease management. Older adults could benefit from using the internet and other information and communication technology to access health-related information and interventions available online.

Objective

The aim of this study was to investigate factors influencing internet use in older and oldest age groups and to determine the frequency of internet use for health-related purposes.

Methods

Using data from a nationally representative telephone survey of older adults aged 75 years and over, a sample of 999 people was assessed using structured clinical interviews. Descriptive and binary logistic regression analyses were performed.

Results

Overall, 42.6% (418/999) of participants used the internet. Among those, 55.7% (233/417) searched the internet for health-related information. Regression analyses revealed that internet use was significantly associated with younger age (odds ratio [OR] 0.89, 95% CI 0.85-0.92; P<.001), male gender (OR 2.84, 95% CI 2.02-4.00; P<.001), higher education levels (OR 6.69, 95% CI 4.48-9.99; P<.001), a wider social network (OR 1.04, 95% CI 1.01-1.07; P=.01), higher health-related quality of life (OR 1.02, 95% CI 1.00-1.03; P=.006), lower levels of depressive symptoms (OR 0.89, 95% CI 0.80-0.99; P=.04), and higher rates of chronic illness (OR 1.12, 95% CI 1.04-1.21; P<.004).

Conclusions

This study provides population-representative data on internet use in old age in Germany. People in the older and oldest age groups participate in online activities. Understanding the factors that are associated with older adults internet use can contribute to developing tailored interventions and eHealth (electronic health) services to improve well-being in older adults.

Association of eHealth Use, Literacy, Informational Social Support, and Health-Promoting Behaviors: Mediation of Health Self-Efficacy

This descriptive, cross-sectional study identified the association of eHealth use, literacy, informational support, and health-promoting behaviors among older adults, as mediated by health self-efficacy. Convenience sampling was conducted at senior welfare centers in Chuncheon, in the Republic of Korea. Data analysis was performed using Pearson’s correlation and via path analyses. The findings showed that eHealth use had an indirect effect on health-promoting behaviors, as mediated by self-efficacy. Informational support was indirectly mediated by self-efficacy and had direct effects upon health-promoting behaviors. eHealth can facilitate self-efficacy and health management, despite not having direct effects upon health-promoting behaviors themselves. Thus, older adults need to be prepared for the increased use of eHealth. In addition, healthcare professionals should support older people in their use of eHealth and encourage informational support through comprehensive interventions so as to facilitate self-efficacy and health behaviors.

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums

Background

The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support.

Objective

The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively.

Methods

A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery.

Results

A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals.

Conclusions

Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.

Internet and Health Information Technology Use and Psychological Distress Among Older Adults With Self-Reported Vision Impairment: Case-Control Study

BACKGROUND

The number of older adults with vision impairment (VI) is growing. As health care services increasingly call for patients to use technology, it is important to examine internet/health information technology (HIT) use among older adults with VI.

OBJECTIVE

This study aimed to examine (1) the rates of internet/HIT use among older adults with VI compared with a matched sample of their peers without VI, (2) associations of VI with internet/HIT use, and (3) association of HIT use with psychological distress, assessed with the Kessler-6 screen.

METHODS

Data were obtained from the 2013 to 2018 US National Health Interview Survey. Older adults (aged ≥65 years) with self-reported VI were matched with older adults without VI, in a 1:1 ratio, based on age, sex, number of chronic medical conditions, and functional limitations (N=2866). Descriptive statistics and multivariable logistic regression models, with sociodemographic factors, health conditions, health insurance type, and health care service use as covariates, were used to examine the research questions.

RESULTS

In total, 3.28% of older adults (compared with 0.84% of those aged 18-64 years) reported VI, and 25.7% of them were aged ≥85 years. Those with VI were significantly more socioeconomically disadvantaged than those without VI and less likely to use the internet (adjusted odds ratio [aOR] 0.64, 95% CI0.49-0.83) and HIT (aOR 0.74, 95% CI 0.56-0.97). However, among internet users, VI was not associated with HIT use. HIT use was associated with lower odds of mild/moderate or serious psychological distress (aOR 0.62, 95% CI 0.43-0.90), whereas VI was associated with greater odds of mild/moderate or serious distress (aOR 1.84, 95% CI 1.36-2.49). Health care provider contacts were also associated with higher odds of internet or HIT use.

CONCLUSIONS

Compared with their matched age peers without VI, older adults with VI are less likely to use HIT because they are less likely to use the internet. Socioeconomically disadvantaged older adults experiencing a digital divide need help to access information and communication technologies through a fee waiver or subsidy to cover internet equipment and subscription and ensure continuous connectivity. Older adults with VI who do not know how to use the internet/HIT but want to learn should be provided instruction, with special attention to accessibility features and adaptive devices. Older adults with a low income also need better access to preventive eye care and treatment of VI as well as other health care services.

Mental Health Problems and Internet Access: Results From an Australian National Household Survey

BACKGROUND

Mental health support and interventions are increasingly delivered on the web, and stepped care systems of mental health services are embracing the notion of a digital gateway through which individuals can have access to information, assessment, and services and can be connected with more intensive services if needed. Although concerns have been raised over whether people with mental health problems are disadvantaged in terms of their access to the internet, there is a lack of representative data on this topic.

OBJECTIVE

This study aimed to examine the relationship between mental health and internet access, particularly lack of access because of affordability issues.

METHODS

Data from wave 14 of the Household, Income, and Labour Dynamics in Australia survey were used (n=15,596) in the analyses. Sample weights available in the survey were used to calculate the proportion of those with or without internet access for those with and without mental health problems and more severe long-term mental health conditions. These proportions were also calculated for those with and without internet access due, specifically, to affordability issues. Multinomial logistic regression analyses assessed the relationship between mental health status and internet access/affordability issues, adjusting for a range of covariates.

RESULTS

Access to the internet was poorer for those with mental health problems (87.8%) than those without mental health problems (92.2%), and the difference was greater when a measure of more severe mental health conditions was used (81.3% vs 92.2%). The regression models showed that even after adjusting for a broad range of covariates, people with mental ill health were significantly more likely to have no internet access because of unaffordability than those without mental ill health (mental health problems: relative risk ratio [RRR] 1.68; 95% CI 1.11-2.53 and severe mental health conditions: RRR 1.92; 95% CI 1.16-3.19).

CONCLUSIONS

As Australia and other nations increasingly deliver mental health services on the web, issues of equity and affordability need to be considered to ensure that those who most need support and assistance are not further disadvantaged.

Towards bridging the grey digital divide: changes in internet access and its predictors from 2002 to 2014 in Germany

The internet is an indispensable aspect of modern society. It facilitates long distance communication, access to information, health care interventions, as well as multiple opportunities for social participation. Despite increasing pervasiveness of this technology, persistent inequalities exist in who has access to the internet. In particular, older adults lag behind in having internet access, thus putting them at risk for social exclusion. In order to gain a better understanding about the determinants of this grey digital divide, the current study contrasts influencing factors of internet access, comparing samples from 2002 to 2014 across age groups (40 to 54 years, 55 to 69 years and 70 to 85 years) using data from the German Ageing Survey (DEAS). Logistic regression confirmed that the likelihood of having internet access was lower with higher age at both time points. However, the percentages of people with internet access grew primarily in the middle and older age groups between 2002 and 2014. Furthermore, being male and having a higher education were both associated with greater odds of internet access. However, gender and education differences in internet access were significantly less pronounced in 2014 in contrast to 2002. Finally, both greater income and cognitive ability were associated with greater odds of internet access, while providing care for a grandchild was significantly associated with internet access only among the oldest age group. In an attempt towards bridging the grey digital divide, the current study serves as a basis for identifying groups mostly affected by this increasingly important form of social inequality.

Characteristics of Patients Using Different Patient Portal Functions and the Impact on Primary Care Service Utilization and Appointment Adherence: Retrospective Observational Study

Background

Patient portals are now widely available and increasingly adopted by patients and providers. Despite the growing research interest in patient portal adoption, there is a lack of follow-up studies describing the following: whether patients use portals actively; how frequently they use distinct portal functions; and, consequently, what the effects of using them are, the understanding of which is paramount to maximizing the potential of patient portals to enhance care delivery.

Objective

To investigate the characteristics of primary care patients using different patient portal functions and the impact of various portal usage behaviors on patients’ primary care service utilization and appointment adherence.

Methods

A retrospective, observational study using a large dataset of 46,544 primary care patients from University of Florida Health was conducted. Patient portal users were defined as patients who adopted a portal, and adoption was defined as the status that a portal account was opened and kept activated during the study period. Then, users were further classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The intervention outcomes were the rates of primary care office visits categorized as arrived, telephone encounters, cancellations, and no-shows per quarter as the measures of primary care service utilization and appointment adherence. Generalized linear models with a panel difference-in-differences study design were then developed to estimate the rate ratios between the users and the matched nonusers of the four measurements with an observational window of up to 10 quarters after portal adoption.

Results

Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent use of portals. In particular, the number of active health problems one had was significantly negatively associated with portal adoption (odds ratios [ORs] 0.57-0.86, 95% CIs 0.51-0.94, all P<.001) but was positively associated with portal usage (ORs 1.37-1.76, 95% CIs 1.11-2.22, all P≤.01). The same was true for being enrolled in Medicare for portal adoption (OR 0.47, 95% CI 0.41-0.54, P<.001) and message usage (OR 1.44, 95% CI 1.03-2.03, P=.04). On the impact of portal usage, the effects were time-dependent and specific to the user subgroup. The most salient change was the improvement in appointment adherence, and patients who used messaging and laboratory functions more often exhibited a larger reduction in no-shows compared to other user subgroups.

Conclusions

Patients differ in their portal adoption and usage behaviors, and the portal usage effects are heterogeneous and dynamic. However, there exists a lack of match in the patient portal market where patients who benefit the most from patient portals are not active portal adopters. Our findings suggest that health care delivery planners and administrators should remove the barriers of adoption for the portal beneficiaries; in addition, they should incorporate the impact of portal usage into care coordination and workflow design, ultimately aligning patients’ and providers’ needs and functionalities to effectively deliver patient-centric care.

From Online to Offline and Vice Versa: Change in Internet Use in Later Life Across Europe

The internet can be a valuable source of social participation in modern society. Although increasing numbers of older adults are using the internet, numerous older adults also cease using the internet and become "offliners." The question of which factors in usage change (i.e., switching from onliner to offliner, and vice versa) are most influential remains unclear. This study investigates changes in internet use among the older European population using two waves of representative panel data for 13 countries from the Survey of Health, Aging and Retirement in Europe (SHARE). The analyses were based on 34,149 respondents aged 50 years and older. In general, the results indicate a positive trend by a slight (2%) increase in usage, from 51% in 2013 to 53% in 2015. However, the results also show that a total of 6% had not recently used the internet, although they had done so in the past. Our multilevel results suggest that both the onset of and cessation of internet usage are primarily driven by changes in socioeconomic resources (income and occupation), health resources (subjective health and grip strength), living situation (via relocation), and social factors (partnership and distance to children) as well as contextual factors such as country-specific wealth and social indexes and internet infrastructure. The study underlines the importance of investigating the influencing factors for commencing internet usage and of determining which factors lead to its increase.

Key methodological considerations for usability testing of electronic patient-reported outcome (ePRO) systems

INTRODUCTION

Recent advances in information technology and improved access to the internet have led to a rapid increase in the adoption and ownership of electronic devices such as touch screen smartphones and tablet computers. This has also led to a renewed interest in the field of digital health also referred to as telehealth or electronic health (eHealth). There is now a drive to collect these PROs electronically using ePRO systems.

METHOD

However, the user interfaces of ePRO systems need to be adequately assessed to ensure they are not only fit for purpose but also acceptable to patients who are the end users. Usability testing is a technique that involves the testing of systems, products or websites with participants drawn from the target population. Usability testing can assist ePRO developers in the evaluation of ePRO user interface. The complexity of ePRO systems; stage of development; metrics to measure; and the use of scenarios, moderators and appropriate sample sizes are key methodological issues to consider when planning usability tests.

CONCLUSION

The findings from usability testing may facilitate the improvement of ePRO systems making them more usable and acceptable to end users. This may in turn improve the adoption of ePRO systems post-implementation. This article highlights the key methodological issues to consider and address when planning usability testing of ePRO systems.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.

Assessment of eHealth behaviors in national surveys: a systematic review of instruments

Objectives

To conduct a systematic review of instruments used in national surveys of eHealth behaviors.

Materials and Methods

Major databases and websites of federal agencies were searched with pre-determined inclusion and exclusion criteria. National surveys with measures of eHealth behaviors were identified. The survey instruments were retrieved, and their measures of eHealth behaviors were categorized and critiqued.

Results

We located 13 national surveys containing eHealth behavior assessment questions that were administered from 1999 to 2017. Most surveys were conducted annually or biennially and typically covered topics on searching health information, obtaining social support, communicating with healthcare providers, and buying medicine online; recent surveys included items related to personal health management and use of mobile tools. There were redundant measures of searching health information online but insufficient measures of use of mobile apps, social media, and wearable devices.

Discussion

Future assessment of eHealth behaviors should reflect the growing varieties of behaviors enabled by technology development and reflect the current mobile ownership patterns in diverse social groups. More studies also need to include longitudinal surveys, integrative and standardized measures, and better designs to allow data linkage and comparison.

Conclusion

The existing survey instruments covering eHealth behaviors are rather limited compared to fast technological progress. We call for more national surveys on eHealth behaviors that are more responsive to technology development; we also advocate for more analysis and dissemination of existing national data on eHealth behaviors for evidence-based health policies.

What information can the lay public find about osteoporosis treatment? A descriptive study coding the content and quality of bisphosphonate information on the internet

Despite its effectiveness, bisphosphonate use for osteoporosis is low. We assessed bisphosphonate information on the internet and found the most commonly listed benefits/risks were bone density loss, gastrointestinal issues, and jaw necrosis, that risk quantification was rare, and information quality varied. Findings underscore the importance of clinical communication about bisphosphonates.

INTRODUCTION

The US Preventative Services Task Force recommends osteoporosis screening and treatment with bisphosphonates in high-risk populations. However, bisphosphonate use among individuals with osteoporosis remains low. The content and quality of information from outside sources may influence individuals' bisphosphonate decisions. Therefore, we sought to assess the content and quality of osteoporosis treatment information available to the public by conducting an internet search and coding available bisphosphonate information.

METHODS

Eleven search terms about osteoporosis and bisphosphonates were entered into four search engines. Two raters assessed websites for information about bisphosphonates, whether and how benefits and side effects were described and quantified, contraindications, and dosing instructions. Coders also assessed website interface and slant/balance of information.

RESULTS

One thousand four hundred seventy-three websites were identified. Two hundred twenty-seven websites met inclusion criteria and were coded. The most common bisphosphonate benefit described was prevention of bone density loss (77.1% of websites). The most common side effects described were gastrointestinal problems (66.1%) and jaw osteonecrosis (58.6%). Most websites did not quantify bisphosphonate benefits (78.0%) or side effects (82.4%). Complementary/integrative health websites (p < .001) and pharmaceutical litigation websites (p < .001) were more often slanted against taking bisphosphonates, compared to all websites coded. General medical knowledge websites were more balanced than other websites (p = .023).

CONCLUSIONS

The quality of bisphosphonate information on the internet varies substantially. Providers counseling patients about osteoporosis treatment should inquire about patients' baseline bisphosphonate knowledge. Providers can complement accurate information and address potential bisphosphonate misconceptions.

Growing Disparities in Patient-Provider Messaging: Trend Analysis Before and After Supportive Policy

BACKGROUND

Public policy introduced since 2011 has supported provider adoption of electronic medical records (EMRs) and patient-provider messaging, primarily through financial incentives. It is unclear how disparities in patients' use of incentivized electronic health (eHealth) tools, like patient-provider messaging, have changed over time relative to disparities in use of eHealth tools that were not directly incentivized.

OBJECTIVE

This study examines trends in eHealth disparities before and after the introduction of US federal financial incentives. We compare rates of patient-provider messaging, which was directly incentivized, with rates of looking for health information on the Web, which was not directly incentivized.

METHODS

We used nationally representative Health Information National Trends Survey data from 2003 to 2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information on the Web. We first reported the percentage of individuals across education and racial and ethnic groups who reported using these tools in each survey year and compared changes in unadjusted disparities during preincentive (2003-2011) and postincentive (2011-2018) periods. Using multivariable linear probability models, we then examined adjusted effects of education and race and ethnicity in 3 periods-preincentive (2003-2005), early incentive (2011-2013), and postincentive (2017-2018)-controlling for sociodemographic and health factors. In the postincentive period, an additional model tested whether internet adoption, provider access, or providers' use of EMRs explained disparities.

RESULTS

From 2003 to 2018, overall rates of provider messaging increased from 4% to 36%. The gap in provider messaging between the highest and lowest education groups increased by 10 percentage points preincentive (P<.001) and 22 additional points postincentive (P<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points preincentive (P=.42) and 11 additional points postincentive (P=.01). Trends for blacks resembled those for Hispanics, whereas trends for Asians resembled those for non-Hispanic whites. In contrast, education-based disparities in looking for health information on the Web (which was not directly incentivized) did not significantly change in preincentive or postincentive periods, whereas racial disparities narrowed by 15 percentage points preincentive (P=.008) and did not significantly change postincentive. After adjusting for other sociodemographic and health factors, observed associations were similar to unadjusted associations, though smaller in magnitude. Including internet adoption, provider access, and providers' use of EMRs in the postincentive model attenuated, but did not eliminate, education-based disparities in provider messaging and looking for health information on the Web. Racial and ethnic disparities were no longer statistically significant in adjusted models.

CONCLUSIONS

Disparities in provider messaging widened over time, particularly following federal financial incentives. Meanwhile, disparities in looking for health information on the Web remained stable or narrowed. Incentives may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations to adopt messaging capabilities and encouraging patients' use of messaging.

Web-Based Tobacco Cessation Interventions and Digital Inequality across US Racial/Ethnic Groups

Introduction

Internet-based tobacco cessation programs have increased in use and popularity in recent years. To examine evidence for racial/ethnic digital inequality in web-only tobacco cessation services offered by US tobacco quitlines, we conducted an analysis of quitline enrollees in five states. We hypothesized that racial/ethnic minorities would demonstrate lower enrollment and utilization of a web-only tobacco cessation program.

Methods

The sample includes enrollees into five state quitlines whose service options included a web-only program in 2015 (N=32,989). Outcomes included web-entry into the quitline, web-only enrollment, establishment of a web account, and the number of times users logged into the program. Regression models tested associations with race/ethnicity.

Results

Compared with Whites, African Americans, Hispanics, American Indians/Alaska Natives, and "others" were less likely to enter the quitline via the web (Ps<.01) and enroll in a web-only (vs counseling) program (Ps<.01). Among web-only program enrollees, all racial/ethnic minority groups were significantly less likely than Whites to establish an online account (Ps<.03), and African Americans were less likely than Whites to log in to the web-only service (P<.01).

Conclusions

This study suggests that digital inequalities exist in web-based tobacco cessation services. Findings have implications for the development and implementation of digital tobacco interventions for racial/ethnic minority communities. The proliferation of digital tobacco interventions could increase disparities, as members of racial/ethnic minority groups may not engage in these interventions.

Implications

The proliferation of digital interventions has the potential to increase tobacco-related disparities, as members of racial/ethnic minority groups may not enroll in, or engage in, such interventions. As the field moves to digitize tobacco interventions, we must remain cognizant of persistent digital inequalities and the potential for widening racial/ethnic tobacco cessation disparities.

Inequalities in the Use of eHealth Between Socioeconomic Groups Among Patients With Type 1 and Type 2 Diabetes: Cross-Sectional Study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. People with diabetes need frequent monitoring and follow-up of health parameters, and eHealth services can be highly valuable. However, little is known about the use of eHealth in different socioeconomic groups among people with diabetes.

OBJECTIVE

The aim of this study was to investigate the use of 4 different eHealth platforms (apps, search engines, video services, and social media sites) and the association with socioeconomic status (SES) among people diagnosed with type 1 and type 2 diabetes mellitus (T1D and T2D, respectively).

METHODS

We used email survey data from 1250 members of the Norwegian Diabetes Association (aged 18-89 years), collected in 2018. Eligible for analyses were the 1063 respondents having T1D (n=523) and T2D (n=545). 5 respondents reported having both diabetes types and thus entered into both groups. Using descriptive statistics, we estimated the use of the different types of eHealth. By logistic regressions, we studied the associations between the use of these types of eHealth and SES (education and household income), adjusted for gender, age, and self-rated health.

RESULTS

We found that 87.0% (447/514) of people with T1D and 77.7% (421/542) of people with T2D had used 1 or more forms of eHealth sometimes or often during the previous year. The proportion of people using search engines was the largest in both diagnostic groups, followed by apps, social media, and video services. We found a strong association between a high level of education and the use of search engines, whereas there were no educational differences for the use of apps, social media, or video services. In both diagnostic groups, high income was associated with the use of apps. In people with T1D, lower income was associated with the use of video services.

CONCLUSIONS

This paper indicates a digital divide among people with diabetes in Norway, with consequences that may contribute to sustaining and shaping inequalities in health outcomes. The strong relationship between higher education and the use of search engines, along with the finding that the use of apps, social media, and video services was not associated with education, indicates that adequate communication strategies for audiences with varying education levels should be a focus in future efforts to reduce inequalities in health outcomes.