The Management of Diabetes in Everyday Life (MODEL) program: development of a tailored text message intervention to improve diabetes self-care activities among underserved African-American adults

Development of pictogram-based content of self-management health information for Korean patients with chronic obstructive pulmonary disease

BACKGROUND

Adherence to self-management greatly impacts patients with chronic obstructive pulmonary disease (COPD) patients. However, most patients with COPD have a limitation in understanding text-based self-management plans owing to low health literacy. Thus, strategies to improve self-management in patients with COPD should be developed.

OBJECTIVES

This study aimed to develop pictogram-based content comprising self-management health information for patients with COPD.

METHODS

Items for COPD self-management health information were selected based on in-depth interviews with patients and text network analysis conducted in our previous study and a systematic literature review to develop preliminary pictogram-based content. Then, 30 patients with COPD and 10 healthcare professionals (HCPs) were recruited to evaluate the preliminary content using a client satisfaction questionnaire with a maximum score of 32.

RESULTS

Content was developed with one item related to disease knowledge while the other 20 concerned self-management. Patients (28.70 ± 2.94) and HCPs (27.40 ± 2.84) evaluated the content as high quality with adjustments made to increase the size of the letters and shorten the number of items for readability. Twenty-one items were collated in the final booklet, while 14 of the 21 items were incorporated into a poster.

CONCLUSIONS

This study indicates that the pictogram-based content was sufficiently well designed and received good evaluations from both patients with COPD and HCPs. Therefore, it may have prospects for enhancing self-management in patients with COPD. However, the effect of the content on the outcomes of older patients with COPD and low health literacy will need to be validated in future research.

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study

BACKGROUND

Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated.

OBJECTIVE

This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care.

METHODS

This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed.

RESULTS

In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.

CONCLUSIONS

The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19488.

Integrating Lay Health Coaches Into Primary Care: Acceptability, Credibility, and Effectiveness From the Provider Perspective

The purpose of this mixed-methods, cross-sectional study was to assess the acceptability, effectiveness, and credibility of lay health coaches from the perspective of primary care personnel during coach integration into primary care teams through the Management of Diabetes in Everyday Life (MODEL) study. Surveys of 46 primary care clinic personnel were conducted in June 2017 and July 2017 to assess the acceptability, effectiveness, and credibility of lay health coaches in the clinics. Clinic personnel rated coach acceptability, impact, and credibility on a five-point Likert scale as 3.78, 3.76-4.04, and 3.71-3.95, respectively. Additionally, interviews revealed support for a team-based approach and recognition of the potential of coaches to enhance care. In the interviews clinic personnel also reported a lack of provider time to counsel patients as well as a need for improved provider-coach communication.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

BACKGROUND

Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities.

OBJECTIVE

This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities.

METHODS

A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study.

RESULTS

PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information.

CONCLUSIONS

Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

Trends and gaps in precision health research: a scoping review

OBJECTIVE

To determine progress and gaps in global precision health research, examining whether precision health studies integrate multiple types of information for health promotion or restoration.

DESIGN

Scoping review.

DATA SOURCES

Searches in Medline (OVID), PsycINFO (OVID), Embase, Scopus, Web of Science and grey literature (Google Scholar) were carried out in June 2020.

ELIGIBILITY CRITERIA

Studies should describe original precision health research; involve human participants, datasets or samples; and collect health-related information. Reviews, editorial articles, conference abstracts or posters, dissertations and articles not published in English were excluded.

DATA EXTRACTION AND SYNTHESIS

The following data were extracted in independent duplicate: author details, study objectives, technology developed, study design, health conditions addressed, precision health focus, data collected for personalisation, participant characteristics and sentence defining 'precision health'. Quantitative and qualitative data were summarised narratively in text and presented in tables and graphs.

RESULTS

After screening 8053 articles, 225 studies were reviewed. Almost half (105/225, 46.7%) of the studies focused on developing an intervention, primarily digital health promotion tools (80/225, 35.6%). Only 28.9% (65/225) of the studies used at least four types of participant data for tailoring, with personalisation usually based on behavioural (108/225, 48%), sociodemographic (100/225, 44.4%) and/or clinical (98/225, 43.6%) information. Participant median age was 48 years old (IQR 28-61), and the top three health conditions addressed were metabolic disorders (35/225, 15.6%), cardiovascular disease (29/225, 12.9%) and cancer (26/225, 11.6%). Only 68% of the studies (153/225) reported participants' gender, 38.7% (87/225) provided participants' race/ethnicity, and 20.4% (46/225) included people from socioeconomically disadvantaged backgrounds. More than 57% of the articles (130/225) have authors from only one discipline.

CONCLUSIONS

Although there is a growing number of precision health studies that test or develop interventions, there is a significant gap in the integration of multiple data types, systematic intervention assessment using randomised controlled trials and reporting of participant gender and ethnicity. Greater interdisciplinary collaboration is needed to gather multiple data types; collectively analyse big and complex data; and provide interventions that restore, maintain and/or promote good health for all, from birth to old age.

Design Features for Improving Mobile Health Intervention User Engagement: Systematic Review and Thematic Analysis

Background

Well-designed mobile health (mHealth) interventions support a positive user experience; however, a high rate of disengagement has been reported as a common concern regarding mHealth interventions. To address this issue, it is necessary to summarize the design features that improve user engagement based on research over the past 10 years, during which time the popularity of mHealth interventions has rapidly increased due to the use of smartphones.

Objective

The aim of this review was to answer the question “Which design features improve user engagement with mHealth interventions?” by summarizing published literature with the purpose of guiding the design of future mHealth interventions.

Methods

This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Databases, namely, PubMed, Web of Science, Cochrane Library, Ovid EMBASE, and Ovid PsycINFO, were searched for English and Chinese language papers published from January 2009 to June 2019. Thematic analysis was undertaken to assess the design features in eligible studies. The Mixed Methods Appraisal Tool was used to assess study quality.

Results

A total of 35 articles were included. The investigated mHealth interventions were mainly used in unhealthy lifestyle (n=17) and chronic disease (n=10) prevention programs. Mobile phone apps (n=24) were the most common delivery method. Qualitative (n=22) and mixed methods (n=9) designs were widely represented. We identified the following 7 themes that influenced user engagement: personalization (n=29), reinforcement (n=23), communication (n=20), navigation (n=17), credibility (n=16), message presentation (n=16), and interface aesthetics (n=7). A checklist was developed that contained these 7 design features and 29 corresponding specific implementations derived from the studies.

Conclusions

This systematic review and thematic synthesis identified useful design features that make an mHealth intervention more user friendly. We generated a checklist with evidence-based items to enable developers to use our findings easily. Future evaluations should use more robust quantitative approaches to elucidate the relationships between design features and user engagement.

The management of diabetes in everyday life study: Design and methods for a pragmatic randomized controlled trial comparing the effectiveness of text messaging versus health coaching

Background African American patients with uncontrolled diabetes living in medically underserved areas need effective clinic-based interventions to improve self-care behaviors. Text messaging (TM) and health coaching (HC) are among the most promising low-cost population-based approaches, but little is known about their comparative effectiveness in real-world clinical settings. Objective Use a pragmatic randomized controlled trial design to determine the comparative effectiveness of TM and HC with enhanced usual care (EC) in African American adults with uncontrolled diabetes and multiple chronic health conditions. Methods/design The Management of Diabetes in Everyday Life (MODEL) study is randomizing 646 patients (n = 581with anticipated 90% retention) to 3 intervention arms: TM, HC, and EC. Participants are African American adults living in medically underserved areas of the Mid-South, age ≥ 18, with uncontrolled diabetes (A1c ≥ 8), one or more additional chronic conditions, and who have a phone with texting and voicemail capability. Primary outcome measures: the general diet, exercise, and medication adherence subscales of the revised Summary of Diabetes Self-Care Activities questionnaire assessed at one year. Secondary outcomes: diabetes-specific quality of life, primary care engagement, and average blood sugar (A1c). The study will also assess heterogeneity of treatment effects by six key baseline participant characteristics. Conclusions We describe the design and methods of the MODEL study along with design revisions required during implementation in a pragmatic setting. This trial, upon its conclusion, will allow us to compare the effectiveness of two promising low-cost primary care-based strategies for supporting self-care behaviors among African Americans individuals with uncontrolled diabetes. ClinicalTrials.gov registration number: NCT02957513.

Development, implementation and participant evaluation of combining text messaging and peer group support in a weight management programme for African-American women

Background

Development of highly accessible interventions that are effective in reducing body weight, preventing weight gain, and maintaining weight loss is urgently needed to solve the current obesity epidemic, especially among African-American women.

Aims

The purpose of this paper is to describe the development, implementation, and participant evaluation processes of a combined text messaging and peer support group programme to enhance weight management skills among African-American women.

Methods

The programme's conceptual framework and operational model were developed to enhance the research design and protocol to support the study rationale and to lay a solid theoretical base for programme implementation. The programme curriculum and schedule were established and embedded into the programme protocol.

Results

The 16-week text messaging and peer support group intervention was implemented from September 2014 to March 2015. In total, 2089 messages were sent using an online text messaging application. Eight support group sessions were held in the participant's community centre or community church bi-weekly for approximately one hour.

Conclusions

This paper provides a blueprint of the methodological aspects and insights from participants' evaluation of a combined weight management intervention that can be used or adapted by public health nurses and other community health professionals in their work to develop weight management skills among African-American women.