WYZ: a pilot study protocol for designing and developing a mobile health application for engagement in HIV care and medication adherence in youth and young adults living with HIV

Developing an mHealth program to improve HIV care continuum outcomes among young Black gay and bisexual men

BACKGROUND

Young Black gay and bisexual men (YBGBM) in the United States face significant disparities in HIV care outcomes. Mobile health (mHealth) interventions have shown promise with improving outcomes for YBGBM across the HIV care continuum.

METHODS

We developed an mHealth application using human-centered design (HCD) from 2019-2021 in collaboration with YBGBM living with HIV and with HIV service providers. Our HCD process began with six focus groups with 50 YBGBM and interviews with 12 providers. These insights were used to inform rapid prototyping, which involved iterative testing and refining of program features and content, with 31 YBGBM and 12 providers. We then collected user feedback via an online survey with 200 YBGBM nationwide and usability testing of a functional prototype with 21 YBGBM.

RESULTS

Focus groups and interviews illuminated challenges faced by YBGBM living with HIV, including coping with an HIV diagnosis, stigma, need for social support, and a dearth of suitable information sources. YBGBM desired a holistic approach that could meet the needs of those newly diagnosed as well as those who have been living with HIV for many years. Program preferences included video-based content where users could learn from peers and experts, a range of topics, a community of people living with HIV, and tools to support their health and well-being. Providers expressed enthusiasm for an mHealth program to improve HIV care outcomes and help them serve clients. Rapid prototyping resulted in a list of content topics, resources, video characteristics, community features, and mHealth tools to support adherence, retention, goal setting, and laboratory results tracking, as well as tools to help organization staff to support clients. Online survey and usability testing confirmed the feasibility, acceptability, and usability of the content, tools, and features.

CONCLUSIONS

This study demonstrates the potential of a video-based mHealth program to address the unique needs of YBGBM living with HIV, offering support and comprehensive information through a user-friendly interface and videos of peers living with HIV and of experts. The HCD approach allowed for continuous improvements to the concept to maximize cultural appropriateness, utility, and potential effectiveness for both YBGBM and HIV service organizations.

iVY: protocol for a randomised clinical trial to test the effect of a technology-based intervention to improve virological suppression among young adults with HIV in the USA

INTRODUCTION

Young adults with HIV (YWH) experience worse clinical outcomes than adults and have high rates of substance use (SU) and mental illness that impact their engagement in care and adherence to antiretroviral therapy (ART). The intervention for Virologic Suppression in Youth (iVY) aims to address treatment engagement/adherence, mental health (MH) and SU in a tailored manner using a differentiated care approach that is youth friendly. Findings will provide information about the impact of iVY on HIV virological suppression, MH and SU among YWH who are disproportionately impacted by HIV and at elevated risk for poor health outcomes.

METHODS AND ANALYSIS

The iVY study will test the effect of a technology-based intervention with differing levels of resource requirements (ie, financial and personnel time) in a randomised clinical trial with an adaptive treatment strategy among 200 YWH (18-29 years old). The primary outcome is HIV virological suppression measured via dried blood spot. This piloted and protocolised intervention combines: (1) brief weekly sessions with a counsellor via a video-chat platform (video-counselling) to discuss MH, SU, HIV care engagement/adherence and other barriers to care; and (2) a mobile health app to address barriers such as ART forgetfulness, and social isolation. iVY has the potential to address important, distinct and changing barriers to HIV care engagement (eg, MH, SU) to increase virological suppression among YWH at elevated risk for poor health outcomes.

ETHICS AND DISSEMINATION

This study and its protocols have been approved by the University of California, San Francisco Institutional Review Board. Study staff will work with a Youth Advisory Panel to disseminate results to YWH, participants and the academic community.

TRIAL REGISTRATION NUMBER

NCT05877729.

Design, development, utility and usability testing of the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians and patients with metabolic syndrome

Objective

This study aimed to design, develop, assess and refine the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians (PCP) and patients with metabolic syndrome (MetS) in primary care.

Methodology

Using the software-development-life-cycle (SDLC) iterative model, storyboard and wireframe were drafted; and a mock prototype was designed to illustrate the content and function graphically. Subsequently, a working prototype was developed. Qualitative studies using the 'think-aloud' and cognitive-task-analysis methods were conducted for the utility and usability testing. Topic guide was based on the 10-Nielsen's-Heuristic-Principles. Utility testing was conducted among PCP in which they 'thought-aloud' while performing tasks using the mobile app. Usability testing was conducted among MetS patients after they were given the app for 3 weeks. They 'thought-aloud' while performing tasks using the app. Interviews were audio- and video-recorded, and transcribed verbatim. Thematic content analysis was performed.

Result

Seven PCP and nine patients participated in the utility and usability testing, respectively. Six themes (efficiency of use, user control and freedom, appearance and aesthetic features, clinical content, error prevention, and help and documentation) emerged. PCP found the mobile app attractive and relevant sections were easy to find. They suggested adding 'zoom/swipe' functions and some parts needed bigger fonts. Patients commented that the app was user-friendly, has nice interface, and straightforward language. It helped them understand their health better. Based on these findings, the mobile app was refined.

Conclusion

This app was produced using a robust SDLC method to increase users' satisfaction and sustainability of its use. It could potentially improve self-management behaviour among MetS patients in primary care.

Intersection of Health Informatics Tools and Community Engagement in Health-Related Research to Reduce Health Inequities: Scoping Review

Background

The exponential growth of health information technology has the potential to facilitate community engagement in research. However, little is known about the use of health information technology in community-engaged research, such as which types of health information technology are used, which populations are engaged, and what are the research outcomes.

Objective

The objectives of this scoping review were to examine studies that used health information technology for community engagement and to assess (1) the types of populations, (2) community engagement strategies, (3) types of health information technology tools, and (4) outcomes of interest.

Methods

We searched PubMed and PCORI Literature Explorer using terms related to health information technology, health informatics, community engagement, and stakeholder involvement. This search process yielded 967 papers for screening. After inclusion and exclusion criteria were applied, a total of 37 papers were analyzed for key themes and for approaches relevant to health information technology and community engagement research.

Results

This analysis revealed that the communities engaged were generally underrepresented populations in health-related research, including racial or ethnic minority communities such as Black/African American, American Indian/Alaska Native, Latino ethnicity, and communities from low socioeconomic backgrounds. The studies focused on various age groups, ranging from preschoolers to older adults. The studies were also geographically spread across the United States and the world. Community engagement strategies included collaborative development of health information technology tools and partnerships to promote use (encompassing collaborative development, use of community advisory boards, and focus groups for eliciting information needs) and use of health information technology to engage communities in research (eg, through citizen science). The types of technology varied across studies, with mobile or tablet-based apps being the most common platform. Outcomes measured included eliciting user needs and requirements, assessing health information technology tools and prototypes with participants, measuring knowledge, and advocating for community change.

Conclusions

This study illustrates the current landscape at the intersection of health information technology tools and community-engaged research approaches. It highlights studies in which various community-engaged research approaches were used to design culturally centered health information technology tools, to promote health information technology uptake, or for engagement in health research and advocacy. Our findings can serve as a platform for generating future research upon which to expand the scope of health information technology tools and their use for meaningful stakeholder engagement. Studies that incorporate community context and needs have a greater chance of cocreating culturally centered health information technology tools and better knowledge to promote action and improve health outcomes.

A Mobile Health App (WYZ) for Engagement in Care and Antiretroviral Therapy Adherence Among Youth and Young Adults Living With HIV: Single-Arm Pilot Intervention Study

BACKGROUND

Youth are globally recognized as being vulnerable to HIV. Younger age has been correlated with worse health outcomes. Mobile health (mHealth) interventions have the potential to interact with youth where they are, using a device they already access.

OBJECTIVE

Using predefined benchmarks, we sought to evaluate the feasibility and acceptability of WYZ, an mHealth app, for improved engagement in care and antiretroviral therapy (ART) adherence among youth and young adults living with HIV. WYZ was designed and developed with input from youth and young adults living with HIV using a human-centered design approach and was based on the information, motivation, and behavioral skills framework to address common barriers to care and ART adherence among youth and young adults living with HIV.

METHODS

We recruited youth and young adults living with HIV (18-29 years old) from the San Francisco Bay Area to take part in a 6-month pilot trial. Their participation included completing baseline and exit surveys, and participating in seven phone check-ins about their use of WYZ.

RESULTS

Youth and young adults living with HIV (N=79) reported high levels of feasibility and acceptability with WYZ use. We met predefined benchmarks for recruitment (79/84, 94%), mean logins per week (5.3), tracking ART adherence (5442/9393, 57.9%), posting chat topics per week (4.8), and app crashes reported per week (0.24). The ease of app download, install, and setup, and comfort with security, privacy, and anonymity were highly rated (all over 91%). Additionally, participants reported high satisfaction for a research project that was remotely conducted. Participants used the app for shorter timeframes compared to the predefined benchmark.

CONCLUSIONS

We noted high feasibility and acceptability with WYZ. Further research to examine the efficacy of WYZ will enable youth and young adults living with HIV and their providers to make informed decisions when using, recommending, and prescribing the app for improved engagement in HIV care and ART adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03587857; https://clinicaltrials.gov/ct2/show/NCT03587857.

A Review of Recent HIV Prevention Interventions and Future Considerations for Nursing Science

ABSTRACT

As our knowledge of HIV evolved over the decades, so have the approaches taken to prevent its transmission. Public health scholars and practitioners have engaged in four key strategies for HIV prevention: behavioral-, technological-, biomedical-, and structural/community-level interventions. We reviewed recent literature in these areas to provide an overview of current advances in HIV prevention science in the United States. Building on classical approaches, current HIV prevention models leverage intimate partners, families, social media, emerging technologies, medication therapy, and policy modifications to effect change. Although much progress has been made, additional work is needed to achieve the national goal of ending the HIV epidemic by 2030. Nurses are in a prime position to advance HIV prevention science in partnership with transdisciplinary experts from other fields (e.g., psychology, informatics, and social work). Future considerations for nursing science include leveraging transdisciplinary collaborations and consider social and structural challenges for individual-level interventions.

Development of the Mobile Technology Vulnerability Scale among Youth and Young Adults Living with HIV

Introduction: Youth and young adults living with HIV (YLWH) in the US have the lowest viral suppression percentage. Lack of sufficient technology access may be correlated with HIV health outcomes in this population. Methods: We developed a Mobile Technology Vulnerability Scale (MTVS; 18 items) among 18–29-year-olds. Exploratory factor analysis (EFA) was performed on baseline data (N = 79), followed by a confirmatory factor analysis (CFA) of 6-month follow-up data (N = 69). Cronbach’s alpha for internal consistency and test-retest reliability were examined. We also correlated the scale with self-report antiretroviral therapy (ART) adherence. Results: EFA yielded a single-factor solution at baseline after dropping one item. CFA at follow-up corroborated the single-factor. Cronbach’s alpha was high and MTVS was correlated with ART adherence at both time points. MTVS at baseline and 6 months were correlated. Conclusion: The 17-item MTVS scale was found to be valid and reliable and related to ART adherence.

A mobile health intervention in HIV primary care: supporting patients at risk for ART non-adherence

Mobile health (mHealth) interventions that are integrated in HIV clinical settings to facilitate ongoing patient-provider communication between primary care visits are garnering evidence for their potential in improving HIV outcomes. Rango is an mHealth intervention to support engagement in HIV care and treatment adherence. This study used a single-arm prospective design with baseline and 6-month assessments for pre-post comparisons, as well as a matched patient sample for between-group comparisons to test Rango's preliminary efficacy in increasing viral suppression. The Rango sample (n = 406) was predominantly 50 years of age or older (63%; M = 50.67; SD = 10.97, 23-82), Black/African-American (44%) or Hispanic/Latinx (38%), and male (59%). At baseline, 18% reported missing at least one dose of ART in the prior three days and chart reviews of recent VL showed that nearly 82% of participants were virally suppressed. Overall 95% of the patients enrolled in Rango returned for a medical follow-up visit. Of the 65 unsuppressed patients at baseline who returned for a medical visit, 38 (59%) achieved viral suppression and only 5% of the suppressed group at baseline had an increase in viral load at 6 months despite being at risk for ART non-adherence. While viral suppression was similar between Rango participants and patients receiving treatment as usual over the same time period, it is unknown whether those patients were similarly at risk for non-adherence. Our findings support efforts to formally test this innovative approach in addressing ART non-adherence and viral suppression particularly to reach HIV treatment goals.

Human-Centered Design Lessons for Implementation Science: Improving the Implementation of a Patient-Centered Care Intervention

Supplemental Digital Content is Available in the Text.

Evidence-based HIV interventions often fail to reach anticipated impact due to insufficient utilization in real-world health systems. Human-centered design (HCD) represents a novel approach in tailoring innovations to fit end-users, narrowing the gap between efficacious interventions and impact at scale.

Ethical Considerations in HIV eHealth Intervention Research: Implications for Informational Risk in Recruitment, Data Maintenance, and Consent Procedures

PURPOSE OF REVIEW

Along with the benefits of eHealth HIV interventions are challenges to participant privacy and confidentiality inherent in the use of online strategies. This paper reviews current guidelines and recent publications to identify ethical issues and suggested solutions in recruitment, data management, and informed consent.

RECENT FINDINGS

Across eHealth HIV research, recruitment, data collection, and storage efforts to protect informational risk highlight the tension between the investigators' ability to protect participant confidentiality and the evolving informational risk posed by the online platforms on which they are operating. Adequately addressing these challenges requires updating technical competencies and educating participants on their own responsibilities to guard against privacy violations. Additional protections are required when interventions involve peer or community support, especially with minors. The rapid progression of technology presents challenges in solidifying best practices for future interventions. This article draws on published works describing investigator experiences to contribute to the ongoing development of guidance in this area.

"Positive Peers": Function and Content Development of a Mobile App for Engaging and Retaining Young Adults in HIV Care

BACKGROUND

Although treatment for HIV infection is widely available and well tolerated, less than 30% of adolescents and young adults living with HIV infection achieve stable viral suppression. Mobile technology affords increased opportunities for young people living with HIV to engage with information, health management tools, and social connections that can support adherence to treatment recommendations and medication. Although mobile apps are increasingly prevalent, few are informed by the target population.

OBJECTIVE

The objective of this study was to describe the "Positive Peers" app, a mobile app currently being evaluated in a public hospital in the Midwestern United States. Formative development, key development strategies, user recruitment, and lessons learned are discussed in this paper.

METHODS

"Positive Peers" was developed in collaboration with a community advisory board (CAB) comprising in-care young adults living with HIV and a multidisciplinary project team. Mobile app functions and features were developed over iterative collaborative sessions that were tailored to the CAB members. In turn, the CAB built rapport with the project team and revealed unique information that was used in app development.

RESULTS

The study was funded on September 1, 2015; approved by the MetroHealth Institutional Review Board on August 31, 2016; and implemented from October 11, 2016, to May 31, 2019. The "Positive Peers" mobile app study has enrolled 128 users who reflect priority disparity population subgroups. The app administrator had frequent contact with users across app administration and study-related activities. Key lessons learned from the study include changing privacy concerns, data tracking reliability, and user barriers. Intermediate and outcome variable evaluation is expected in October 2019.

CONCLUSIONS

Successful development of the "Positive Peers" mobile app was supported by multidisciplinary expertise, an enthusiastic CAB, and a multifaceted, proactive administrator.

Evaluation of smartphone APP-based case-management services among antiretroviral treatment-naïve HIV-positive men who have sex with men: a randomized controlled trial protocol

Background

Men who have sex with men (MSM) are disproportionally affected by HIV in China. ‘Treatment as Prevention’ is a promising strategy for HIV prevention but requires adequate adherence. Mobile health (mHealth) may be an acceptable and feasible approach for service delivery, but there is little evidence supporting mHealth intervention for improving antiretroviral treatment adherence among HIV-infected MSM in low- and middle-income countries, including China. This study will aim to develop a smartphone application-based case-management service and compare its efficacy to standard care with regards to adherence, CD4, HIV viral load and psychosocial outcomes among MSM patients in Guangzhou, China.

Methods

A non-blinded 1:1 parallel-group randomised controlled trial will be conducted in Guangzhou Eighth People’s Hospital, with 300 MSM enrolled in each arm. Eligible MSM who are newly initiating ART will be randomly assigned to an intervention group (standard-of-care case management plus mHealth intervention) or a control group (standard-of-care case management). The development of the mHealth intervention will be based on the information–motivation–behavioural skills theory of ART adherence, and comprise four components: educational articles, one-to-one online communication with case managers, support-service information and hospital-visit reminders. Outcome measures will be collected at baseline and at months 1, 3, 6, and 12. The primary outcomes will be ART adherence and CD4 count at month 6. Secondary outcomes include HIV RNA, sexual behaviours, mental health status, illness perceptions, and quality of life. χ² test and t-test will be used for between-group comparisons. Intervention effects will be evaluated using General estimating equation performed by SAS 9.0, on the principle of intention-to-treat. Structural equation modelling will be used to test potential mechanisms of intervention effect.

Discussion

This study is the first to explore the efficacy of mHealth intervention in the case management services targeted at HIV-infected MSM in low-and middle-income countries. Once proven effective, the innovative mHealth service could be integrated into the routine case management of PLWH. as well as be tailored to the patient management service for other chronic conditions.

Trial registration

ClinicalTrial.gov: NCT03860116; Registered on 1 March 2019.

We are family: designing and developing a mobile health application for the San Francisco bay area House Ball and Gay Family communities

BACKGROUND

The House Ball community (HBC) and its affiliated Gay Families (GFs) consist of predominantly African American and Latinx sexual, gender, and ethnic minorities (SGEM), who form chosen families often as a way to provide support, and in the case of the HBC, to constitute houses that then compete in performative categories in balls. Members of both communities are disproportionately impacted by HIV. Although public health professionals have engaged with the HBC and GFs to improve HIV testing and clinical care, most intervention activities have relied on in-person modes of outreach and delivery. Little research has been conducted with the members of the HBC and GFs to develop and produce culturally-informed mobile health (mHealth) applications that would enable them to increase HIV-related knowledge, connect to HIV-related resources, receive HIV health support, and to celebrate their unique identities and communities in a safe space.

METHODS

We conducted 45 in-depth interviews with HBC and GF members who attended balls. Topics included HIV-related health needs, suggestions for mHealth components, current usage of apps and desirable features, and wishes around privacy and security. Following analysis of the interview data, we convened a series of four workshops with N=15 participants who were split into two groups. The purpose of the workshops was to co-design a digital tool to help provide information, reduce HIV-related stigma, and locate HIV resources for participants. Each group attended two workshops. Data were analyzed by a team of social scientists, community members, and mobile health experts. Findings were used to design an mHealth app related to HIV prevention and care.

RESULTS

Participants requested an app that clearly reflected the community. The desired features of the app included accurate information and education on HIV transmission; links to resources such as HIV testing, lube and condoms, PrEP, and other health-related services; and the ability to rate and review local resources. In workshops, participants proposed several design elements and functions for the app. It had to be 'Mobile and Modern', 'Relatable, Raw, and "Reflective of Me"', 'Positive and Fun', feature community-generated content, and provide a safe space for users. Using these clear directives, the team designed an mHealth tool to be fielded as part of the larger "We Are Family" intervention that would provide HIV-specific information, resources, and support in a platform that was congruent with community norms and expectations.

CONCLUSIONS

Designing and fielding an mHealth app as part of a larger HIV prevention intervention that reflects the social support and relationships within existing House Ball and Gay Family communities allows those youth most at risk for HIV-related health disparities to gain access to HIV testing, or link and re-engage young people to care.