Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies

Needs-Assessment for an Artificial Intelligence-Based Chatbot for Pharmacists in HIV Care: Results from a Knowledge-Attitudes-Practices Survey

BACKGROUND

Pharmacists need up-to-date knowledge and decision-making support in HIV care. We aim to develop MARVIN-Pharma, an adapted artificial intelligence-based chatbot initially for people with HIV, to assist pharmacists in considering evidence-based needs.

METHODS

From December 2022 to December 2023, an online needs-assessment survey evaluated Québec pharmacists' knowledge, attitudes, involvement, and barriers relative to HIV care, alongside perceptions relevant to the usability of MARVIN-Pharma. Recruitment involved convenience and snowball sampling, targeting National HIV and Hepatitis Mentoring Program affiliates.

RESULTS

Forty-one pharmacists (28 community, 13 hospital-based) across 15 Québec municipalities participated. Participants perceived their HIV knowledge as moderate (M = 3.74/6). They held largely favorable attitudes towards providing HIV care (M = 4.02/6). They reported a "little" involvement in the delivery of HIV care services (M = 2.08/5), most often ART adherence counseling, refilling, and monitoring. The most common barriers reported to HIV care delivery were a lack of time, staff resources, clinical tools, and HIV information/training, with pharmacists at least somewhat agreeing that they experienced each (M ≥ 4.00/6). On average, MARVIN-Pharma's acceptability and compatibility were in the 'undecided' range (M = 4.34, M = 4.13/7, respectively), while pharmacists agreed to their self-efficacy to use online health services (M = 5.6/7).

CONCLUSION

MARVIN-Pharma might help address pharmacists' knowledge gaps and barriers to HIV treatment and care, but pharmacist engagement in the chatbot's development seems vital for its future uptake and usability.

Analyzing the barriers and enablers to internet hospital implementation: a qualitative study of a tertiary hospital using TDF and COM-B framework

Background

Internet hospitals have become an important way to improve the accessibility of medical services and promote medical equity in China. However, there is still lack of research on the behavior of medical personnel during the process of using Internet medical services, and the elements of behavior that motivate doctors to actively use or resist the use of Internet hospitals are still not fully analyzed. The study applied the Theoretical Domains Framework to examine the factors affecting the engagement of medical personnel in Internet hospitals, with the aim of guiding the design of intervention to enhance Internet hospital participation.

Methods

This study utilized qualitative analysis. Semi-structured questionnaires based on the Theoretical Domains Framework (TDF) and Capability-Opportunity-Motivation-Behavior (COM-B) model was developed and administered to 40 doctors and nurses at a Grade A tertiary hospital in Guangdong Province. Data was coded and analyzed using qualitative methods including Nvivo software.

Results

The research displayed 19 barriers and 7 enablers for the implementation of Internet hospitals, all 14 TDF domains impacted participation with motivation cited most frequently. Despite challenges, medical personnel exhibited a generally optimistic stance towards utilization of the Internet hospital. Major barriers include the higher requirement of diagnostic ability, objective difficulties brought by online consultation to the decision-making process, limitation of time and other resources, not ideal technological and institutional environment, lack of self-efficacy and negative expectation of results in online consultation. Key enablers include patient needs and the positive impact of online care on the medical process and patient experience.

Discussion

This qualitative study identified a range of barriers and enablers to Internet hospital participation according to medical personnel, providing an conceptual framework to guide further research evaluating implementation strategies. Expanded research and targeted interventions design can help optimize participation in this evolving healthcare delivery model.

Telerehabilitation of Developmental Dyslexia: Critical Considerations on Intervention Methods and Their Effectiveness

Paper-based or IT tools can be used in telerehabilitation mode to improve the skills of children with developmental dyslexia (DD), seeking to increase reading speed and reduce errors. Telerehabilitation is the provision of remote treatments in which the patient works autonomously in a familiar environment under the remote monitoring, through telecommunication means, of an expert operator. Through telerehabilitation, children with DD can receive treatments outside the specialist clinic, at home or school, via internet connections, and through advanced technological platforms. These procedures allow adequate communication with the family, intensity of treatment, self-adaptivity of exercises, and child engagement; these factors are crucial for a high intervention efficacy. Recent studies have supported the effectiveness of the telerehabilitation of reading in children with DD, with some studies reporting no differences in efficacy between remote and in-person methods. Nevertheless, many points remain to be clarified about the procedures and methods required by telerehabilitation, the variables linked to its effectiveness (e.g., the impact of the intensity of the training and the neuropsychological profile of the child), and the comparative validity of different tele-treatment paths. These aspects are discussed in the present paper.

Exploring Older Adults' Perceptions of Using Digital Health Platforms for Self-Managing Musculoskeletal Health Conditions: Focus Group Study

BACKGROUND

Digital technologies can assist and optimize health care processes. This is increasingly the case in the musculoskeletal health domain, where digital platforms can be used to support the self-management of musculoskeletal conditions, as well as access to services. However, given a large proportion of the population with musculoskeletal conditions are older adults (aged ≥60 years), it is important to consider the acceptability of such platforms within this demographic.

OBJECTIVE

This study aims to explore participants' opinions and perceptions on the use of digital platforms for supporting the self-management of musculoskeletal conditions within older adult (aged ≥60 years) populations and to gather their opinions on real examples.

METHODS

A total of 2 focus groups (focus group 1: 6/15, 40%; focus group 2: 9/15, 60%) were conducted, in which participants answered questions about their thoughts on using digital health platforms to prevent or manage musculoskeletal conditions. Participants were further presented with 2 example scenarios, which were then discussed. Interviews were audio recorded, transcribed, and analyzed thematically. Participants were aged ≥60 years and with or without current musculoskeletal conditions. Prior experience of using smartphone apps or other digital health platforms for musculoskeletal conditions was not required. Focus groups took place virtually using the Teams (Microsoft Corp) platform.

RESULTS

A total of 6 themes were identified across both focus groups: "experiences of digital health platforms," "preference for human contact," "barriers to accessing clinical services," "individual differences and digital literacy," "trust in technology," and "features and benefits of digital health technologies." Each theme is discussed in detail based on the interview responses. The findings revealed that most participants had some existing experience with digital health platforms for preventing or managing musculoskeletal conditions. Overall, there was a lack of trust in and low expectations of quality for digital platforms for musculoskeletal health within this age group. While there was some concern about the use of digital platforms in place of in-person health consultations, several benefits were also identified.

CONCLUSIONS

Results highlighted the need for better communication on the benefits of using digital platforms to support the self-management of musculoskeletal conditions, without the platforms replacing the role of the health care professionals. The concerns about which apps are of suitable quality and trustworthiness lead us to recommend raising public awareness around the role of organizations that verify and assess the quality of digital health platforms.

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

CONCLUSION

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

PATIENT OR PUBLIC CONTRIBUTION

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

Young People's Barriers and Facilitators of Engagement with Web-Based Mental Health Interventions for Anxiety and Depression: A Qualitative Study

BACKGROUND

The prevalence of anxiety and depressive symptoms in young people have increased in many countries around the world. Web-based mental health interventions (or W-MHIs) have the potential to reduce anxiety and depression symptoms for young people. Although W-MHIs have become more widely used by young people since the coronavirus disease 2019 (COVID-19) pandemic, real-world engagement in these W-MHIs has remained low compared with engagement reported in research studies. Moreover, there are limited studies examining factors influencing engagement with W-MHIs in the post-COVID-19 pandemic years.

OBJECTIVE

This study aims to explore barriers and facilitators of engagement with W-MHIs for anxiety and depression among young people.

METHOD

Seventeen semi-structured interviews and one focus group with three participants were conducted online via Zoom between February and March 2023. Participants were young people aged 18-25 years who had self-reported experience of anxiety and/or depression in the past 6 months, lived in Australia, and considered using W-MHIs to manage their anxiety and/or depression symptoms. Inductive thematic analysis was performed to understand the key barriers and facilitators of young people's engagement with W-MHIs.

RESULTS

Both individual- and intervention-related factors influenced young people's engagement with W-MHIs. Facilitators of engagement included personal trust and beliefs in W-MHIs, ability to contact a health professional, programme suitability (e.g., affordability, content aligning with user needs), programme usability (e.g., user interface), and accessibility of the online platform. Barriers included concerns about online security, lack of human interaction and immediate responses from health professionals (if any), and negative experience with mental health programmes. Participants expressed greater willingness to pay if they could contact health professionals during the programme.

CONCLUSION

Better promotion strategies for mental health and W-MHI awareness are needed to increase the perceived importance and priority of mental health interventions among young people. Young people should be involved in the W-MHI co-design to enhance the programme suitability and usability for young people, fostering their engagement with W-MHIs.

Caregiver Experiences With an Internet-Delivered Insomnia Intervention: SHUTi-CARE Trial Primary Qualitative Analysis

BACKGROUND

Digital health interventions show potential to increase caregivers' access to psychosocial care; however, it is unclear to what extent existing interventions may need to be tailored to meet caregivers' unique needs.

PURPOSE

This study aimed to determine whether-and if so, how-an efficacious Internet-delivered insomnia program should be modified for caregivers. The generalizability of these findings beyond the tested program was also examined.

METHODS

Higher-intensity family caregivers (N = 100; age M = 52.82 [SD = 13.10], 75% non-Hispanic White, 66% ≥college degree) received access to an Internet-based cognitive-behavioral therapy for insomnia (CBT-I) program. Participants who completed one or more intervention "Cores" provided open-ended feedback on their experience; nonusers (completed no Cores) shared their barriers.

RESULTS

Most caregivers who used the program (n = 82, 82%) found it feasible, citing its user-friendly, fully automated online format. Many reported that CBT-I strategies were helpful, although some faced challenges in implementing these strategies due to the unpredictability of their caregiving responsibilities. Opinions were divided on the utility of tailoring the program for caregivers. Nonusers (n = 18, 18%) primarily cited concerns about time burden and lifestyle compatibility as usage barriers.

CONCLUSIONS

Delivering fully automated behavioral interventions through the Internet appears suitable for many caregivers. Extensive tailoring may not be required for most caregivers to benefit from an existing online CBT-I program, although additional guidance on integrating CBT-I strategies in the context of challenging sleep schedules and environments may help a subset of caregivers. Future research should explore how such tailoring may enhance digital health intervention uptake and effectiveness for caregivers.

Acceptability of data linkage to identify women at risk of postnatal complication for the development of digital risk prediction tools and interventions to better optimise postnatal care, a qualitative descriptive study design

BACKGROUND

Pregnancy acts as a cardiovascular stress test. Although many complications resolve following birth, women with hypertensive disorder of pregnancy have an increased risk of developing cardiovascular disease (CVD) long-term. Monitoring postnatal health can reduce this risk but requires better methods to identity high-risk women for timely interventions.

METHODS

Employing a qualitative descriptive study design, focus groups and/or interviews were conducted, separately engaging public contributors and clinical professionals. Diverse participants were recruited through social media convenience sampling. Semi-structured, facilitator-led discussions explored perspectives of current postnatal assessment and attitudes towards linking patient electronic healthcare data to develop digital tools for identifying postpartum women at risk of CVD. Participant perspectives were gathered using post-it notes or a facilitator scribe and analysed thematically.

RESULTS

From 27 public and seven clinical contributors, five themes regarding postnatal check expectations versus reality were developed, including 'limited resources', 'low maternal health priority', 'lack of knowledge', 'ineffective systems' and 'new mum syndrome'. Despite some concerns, all supported data linkage to identify women postnatally, targeting intervention to those at greater risk of CVD. Participants outlined potential benefits of digitalisation and risk prediction, highlighting design and communication needs for diverse communities.

CONCLUSIONS

Current health system constraints in England contribute to suboptimal postnatal care. Integrating data linkage and improving education on data and digital tools for maternal healthcare shows promise for enhanced monitoring and improved future health. Recognised for streamlining processes and risk prediction, digital tools may enable more person-centred care plans, addressing the gaps in current postnatal care practice.

eHealth Literacy and the Use of NHS 111 Online Urgent Care Service in England: Cross-Sectional Survey

BACKGROUND

Many health care systems have used digital technologies to support care delivery, a trend amplified by the COVID-19 pandemic. "Digital first" may exacerbate health inequalities due to variations in eHealth literacy. The relationship between eHealth literacy and web-based urgent care service use is unknown.

OBJECTIVE

This study aims to measure the association between eHealth literacy and the use of NHS (National Health Service) 111 online urgent care service.

METHODS

A cross-sectional sequential convenience sample survey was conducted with 2754 adults (October 2020-July 2021) from primary, urgent, or emergency care; third sector organizations; and the NHS 111 online website. The survey included the eHealth Literacy Questionnaire (eHLQ), questions about use, preferences for using NHS 111 online, and sociodemographic characteristics.

RESULTS

Across almost all dimensions of the eHLQ, NHS 111 online users had higher mean digital literacy scores than nonusers (P<.001). Four eHLQ dimensions were significant predictors of use, and the most highly significant dimensions were eHLQ1 (using technology to process health information) and eHLQ3 (ability to actively engage with digital services), with odds ratios (ORs) of 1.86 (95% CI 1.46-2.38) and 1.51 (95% CI 1.22-1.88), respectively. Respondents reporting a long-term health condition had lower eHLQ scores. People younger than 25 years (OR 3.24, 95% CI 1.87-5.62) and those with formal qualifications (OR 0.74, 95% CI 0.55-0.99) were more likely to use NHS 111 online. Users and nonusers were likely to use NHS 111 online for a range of symptoms, including chest pain symptoms (n=1743, 70.4%) or for illness in children (n=1117, 79%). The users of NHS 111 online were more likely to have also used other health services, particularly the 111 telephone service (χ12=138.57; P<.001).

CONCLUSIONS

These differences in eHealth literacy scores amplify perennial concerns about digital exclusion and access to care for those impacted by intersecting forms of disadvantage, including long-term illness. Although many appear willing to use NHS 111 online for a range of health scenarios, indicating broad acceptability, not all are able or likely to do this. Despite a policy ambition for NHS 111 online to substitute for other services, it appears to be used alongside other urgent care services and thus may not reduce demand.

Barriers and facilitators to engaging with a digital self-management programme for painful distal upper limb musculoskeletal disorders: A qualitative exploratory study

INTRODUCTION

People living with a painful distal upper limb musculoskeletal disorder (DUL-MSD) often experience pain, difficulty in doing everyday tasks and a reduced quality of life. Currently, there are challenges in the treatment of DUL-MSDs, highlighting the need to develop innovative approaches to rehabilitation. A potential solution is to develop and implement a digital self-management rehabilitation programme focussing on optimising recovery, improving function and reducing pain. Before developing this programme, we aimed to identify the barriers and facilitators to using a digital health intervention (DHI) for self-management of DUL-MSDs.

OBJECTIVE

This study aimed to investigate the potential barriers and facilitators to using a DHI with people living with DUL-MSDs and healthcare professionals (HCPs).

METHODS

A qualitative exploratory study was carried out with purposely selected participants consisting of 15 participants with DUL-MSDs and 13 HCPs. Three focus groups (FGs) and four semistructured interviews with DUL-MSD participants and semistructured interviews with 13 HCPs were conducted. FGs and interviews were digitally recorded, transcribed and analysed using reflexive thematic analysis.

RESULTS

To address challenges in the care and management of DUL-MSDs, both HCPs and people living with a DUL-MSD welcomed the development of a DHI. This study identified several barriers and facilitators that would influence engagement with a digital intervention. Findings suggest that in developing a DHI, attention needs to be paid to digital design features, usability, tailoring, personalisation and consideration of how well usual care could be replicated digitally without direct HCP involvement.

CONCLUSION

The identified digital design features of importance to participants will inform the design of a digital self-management rehabilitation programme for people living with DUL-MSDs. Addressing the barriers and facilitators to engagement with a DHI is essential in ensuring its relevance and acceptability to those who will use it.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement and Engagement (PPIE) was integral throughout the study. PPIE members contributed to the development and planning of this study, checked and confirmed the relevance of the findings and are involved in the dissemination plans.

Using virtual reality to improve verbal episodic memory in schizophrenia: A proof-of-concept trial

Background

Schizophrenia is associated with impairments in verbal episodic memory. Strategy for Semantic Association Memory (SESAME) training represents a promising cognitive remediation program to improve verbal episodic memory. Virtual reality (VR) may be a novel tool to increase the ecological validity and transfer of learned skills of traditional cognitive remediation programs. The present proof-of-concept study aimed to assess the feasibility, acceptability, and preliminary efficacy of a VR-based cognitive remediation module inspired by SESAME principles to improve the use of verbal episodic memory strategies in schizophrenia.

Methods

Thirty individuals with schizophrenia/schizoaffective disorder completed this study. Participants were randomized to either a VR-based verbal episodic memory training condition inspired by SESAME principles (intervention group) or an active control condition (control group). In the training condition, a coach taught semantic encoding strategies (active rehearsal and semantic clustering) to help participants remember restaurant orders in VR. In the active control condition, participants completed visuospatial puzzles in VR. Attrition rate, participant experience ratings, and cybersickness questionnaires were used to assess feasibility and acceptability. Trial 1 of the Hopkins Verbal Learning Test - Revised was administered pre- and post-intervention to assess preliminary efficacy.

Results

Feasibility was demonstrated by a low attrition rate (5.88 %), and acceptability was demonstrated by limited cybersickness and high levels of enjoyment. Although the increase in the number of semantic clusters used following the module did not reach conventional levels of statistical significance in the intervention group, it demonstrated a notable trend with a medium effect size (t = 1.48, p = 0.15, d = 0.54), in contrast to the control group where it remained stable (t = 0.36, p = 0.72, d = 0.13). These findings were similar for the semantic clustering ratio in the intervention (t = 1.61, p = 0.12, d = 0.59) and control (t = 0.36, p = 0.72, d = 0.13) groups. There was no significant change in the number of recalled words in either group following VR immersion.

Discussion

This VR intervention was feasible, acceptable, and may be useful for improving the use of semantic encoding strategies. These findings support the use of more ecological approaches for the treatment of cognitive impairments in schizophrenia, such as VR-based cognitive remediation.

Exploring the digital divide: results of a survey informing mobile application development

Introduction

Mobile health apps risk widening health disparities if they overlook digital inclusion. The digital divide, encompassing access, familiarity, and readiness, poses a significant barrier to medical interventions. Existing literature lacks exploration of the digital divide's contributing factors. Hence, data are needed to comprehend the challenges in developing inclusive health apps.

Methods

We created a survey to gauge internet and smartphone access, smartphone familiarity, and readiness for using mobile health apps among caregivers of pediatric patients in tertiary care. Open-ended questions solicited feedback and suggestions on mobile health applications. Responses were categorized by similarity and compared. Developed with patient partners, the survey underwent cognitive testing and piloting for accuracy.

Results

Data from 209 respondents showed that 23% were affected by the digital divide, mainly due to unfamiliarity with digital skills. Among 49 short text responses about health app concerns, 31 mentioned security and confidentiality, with 7 mentioning the impersonal nature of such apps. Desired features included messaging healthcare providers, scheduling, task reminders, and simplicity.

Conclusions

This study underscores a digital divide among caregivers of pediatric patients, with nearly a quarter affected primarily due to a lack of digital comfort. Respondents emphasized user-friendliness and online security for health apps. Future apps should prioritize digital inclusion by addressing the significant barriers and carefully considering patient and family concerns.

Predictors of participation in online self-management programs: A longitudinal observational study

PURPOSE/OBJECTIVE

Lack of patient participation and engagement remains a barrier to implementing effective online self-management and behavioral health interventions. Identifying patient characteristics associated with engagement rates may lead to interventions that improve engagement in traditional and online self-management programs. In this study, two online self-management and recovery programs were evaluated to identify factors that predict patient engagement.

RESEARCH METHOD/DESIGN

Predictors were collected in a questionnaire at baseline before 435 participants started either of the two interventions. One or two online lessons were completed per week with seven or eight total lessons to complete in each program, and each lesson took about 20-30 min to finish. Full patient engagement was defined as completing all lessons and assessments in the program and partial engagement as attempting at least one lesson or assessment.

RESULTS

Predictors of full patient engagement were self-rated confidence in completing the program or being over 60 years of age. Predictors of at least partial patient engagement were experienced ordering online or being over 50 years of age.

CONCLUSIONS/IMPLICATIONS

Identifying profiles of individuals who predict poor engagement may improve implementation and the health outcomes of intervention programs. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Remote Symptom Monitoring Using Patient-Reported Outcomes in Patients With Chronic Kidney Disease: Process Evaluation of a Randomized Controlled Trial

BACKGROUND

In Denmark, outpatient follow-up for patients with chronic kidney disease (CKD) is changing from in-hospital visits toward more remote health care delivery. The nonuse of remote patient-reported outcomes (PROs) is a well-known challenge, and it can be difficult to explain which mechanisms of interventions influence the outcome. Process evaluation may, therefore, be used to answer important questions on how and why interventions work, aiming to enhance the implications for clinical practice.

OBJECTIVE

This study aimed to provide insight into the intervention process by evaluating (1) the representativity of the study population, (2) patient and physician use patterns, (3) patient adherence to the intervention, and (4) clinical engagement.

METHODS

A process evaluation determining the reach, dose, fidelity, and clinical engagement was carried out, alongside a multicenter randomized controlled trial (RCT). We developed and implemented an intervention using PRO measures to monitor outpatients remotely. Data were collected for the PRO intervention arms in the RCT from 4 sources: (1) PRO data from the participants to determine personal factors, (2) the web-based PRO system to identify key usage intervention patterns, (3) medical records to identify clinical factors relating to the use of the intervention, and (4) semistructured interviews conducted with involved physicians.

RESULTS

Of the 320 patients invited, 152 (47.5%) accepted to participate. The study population reflected the target population. The mean adherence rate to the PRO intervention arms was 82% (95% CI 76-87). The questionnaire response rate was 539/544 (99.1%). A minority of 13 (12.9%) of 101 patients needed assistance to complete study procedures. Physicians assessed 477/539 (88.5%) of the questionnaires. Contact was established in 417/539 (77.4%) of the cases, and 122/539 (22.6%) of the patients did not have contact. Physicians initiated 288/417 (69.1%) and patients requested 129/417 (30.9%) of all the contacts. The primary causes of contact were clinical data (242/417, 58%), PRO data (92/417, 22.1%), and medication concerns and precautionary reasons (83/417, 19.9%). Physicians found the use of PRO measures in remote follow-up beneficial for assessing the patient's health. The inclusion of self-reported clinical data in the questionnaire motivated physicians to assess patient responses. However, some barriers were emphasized, such as loss of a personal relationship with the patient and the risk of missing important symptoms in the absence of a face-to-face assessment.

CONCLUSIONS

This study demonstrates the importance and practical use of remote monitoring among patients with CKD. Overall, the intervention was implemented as intended. We observed high patient adherence rates, and the physicians managed most questionnaires. Some physicians worried that distance from the patients made it unfeasible to use their "clinical glance," posing a potential risk of overlooking crucial patients' symptoms. These findings underscore key considerations for the implementation of remote follow-up. Introducing a hybrid approach combining remote and face-to-face consultations may address these concerns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03847766; https://clinicaltrials.gov/study/NCT03847766.

Exploring behavioral intention to use telemedicine services post COVID-19: a cross sectional study in Saudi Arabia

Introduction

While telemedicine offers significant benefits, there remain substantial knowledge gaps in the literature, particularly regarding its use in Saudi Arabia. This study aims to explore health consumers' behavioral intention to use telemedicine examining the associated factors such as eHealth literacy and attitudes toward telemedicine services.

Methods

A cross-sectional observational study was conducted to collect data on demographics, health status, internet skills, attitudes toward telemedicine, and eHealth literacy. An online survey was administered at two large public gatherings in Riyadh. The eHEALS-Pl scale was used to measure perceived eHealth literacy levels, and data analysis was performed using SPSS (IBM Corp. United States).

Results

There were 385 participants, with an equal distribution of genders. The largest age group was 18-20 years old (57%). Nearly half of the participants were neither employed nor students, while 43% had access to governmental hospitals through employment. 71% reported proficiency in using the internet. Health-wise, 47% rated their health as excellent, and 56% did not have medical insurance. 87% expressed a high likelihood of using telemedicine if offered by a provider. Participants were categorized based on their eHealth Literacy scores, with 54% scoring low and 46% scoring high. Overall, participants showed positive attitudes toward telemedicine, with 82% agreeing that it saves time, money, and provides access to specialized care. About half of the participants perceived the process of seeing a doctor through telemedicine video as complex. Both eHealth Literacy and attitudes toward telemedicine showed a statistically significant association with the intention to use telemedicine (p < 0.001). There was a positive and significant correlation between eHealth Literacy and attitudes (ρ =0.460; p < 0.001). Multivariate ordinal regression analysis revealed that the odds for a high likelihood of intention to use telemedicine significantly increased with positive attitudes (p < 0.001). Mediation analysis confirmed the significant mediating role of attitudes toward telemedicine in the relationship between eHealth Literacy and the intention to use telemedicine.

Conclusion

The findings underline the importance of enhancing health literacy and consumer attitudes toward telemedicine, particularly during the healthcare digital transformation we are experiencing globally. This is crucial for promoting increased acceptance and utilization of telemedicine services beyond the COVID-19 pandemic.

A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial

Introduction

Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support.

Objectives

We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering.

Methods

In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy.

Results

Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4.

Conclusion

First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.

Well-being and dignity in innovative digitally-led healthcare for aged adults

Dignity is a central value in care for aged adults, and it must be protected and respected. With demographic changes leading to an aging population, health ministries are increasingly investing in digitalization. However, using unfamiliar digital technology can be challenging and thus impact aged adults' dignity and well-being. The INNOVATEDIGNITY project aims to research new, dignified ways of engaging with aged adults to shape digital developments in care delivery. This qualitative study aimed to explore how innovative digitally-led healthcare have influenced aged adults' well-being and dignity through three studies conducted as part of the INNOVATEDIGNITY project: a scoping review, an empirical study and a policy analysis. The three documents were analysed to uncover meanings relevant to the research problem revealing four main themes: the advantages of new technologies in facilitating aged adults' well-being, the rupture of dignity due to bewilderment in the digital world, aged adults' dignity is affected by their worries about human face of care being replaced by technology and preserving aged adults' dignity in digitally-led healthcare. Digitalization in healthcare impacts aged adults' well-being as providing new opportunities for care, but preserving aged adults' dignity when working with unfamiliar digital innovations is challenging. Aged adults need to be informed about the use of technology in their care and supported to develop the necessary digital skills to better adapt to digitally-led healthcare. The circumstances, conditions and needs of individuals should remain central when implementing new technologies in healthcare settings in a dignified way.

Impact of digital services on healthcare and social welfare: An umbrella review

BACKGROUND

Digital services can be effective and cost-efficient options for treating non-communicable diseases, but generalizability is limited due to heterogeneous treatment effects. This umbrella review aims to evaluate the impact of digital services on population health, costs, and patient and healthcare professional satisfaction, and to identify facilitators and barriers to using digital services in healthcare and social welfare.

METHODS

The protocol of the study was registered on the 4th of September 2022 to the International Prospective Register of Systematic Reviews, PROSPERO (CRD42022355635). The review was performed using the Centre for Reviews and Dissemination, Cochrane, Ovid Medline, Scopus, and Web of Science in June 2022. The methodological quality of the included reviews was assessed. The impact of digital services was categorized as no evidence, no dominance, and mixed and positive effect. Inductive content analysis was used to identify facilitators and barriers.

RESULTS

A total of 66 studies were included in the review, 64 % of which were evaluated as high quality. Studies on the impact of digital services in social welfare were not identified. Sixty-five percent of reviews evaluated the impact of digital services on population health with mixed effects; 21 % were on costs with mixed effects; 27 % were on patient satisfaction with positive effects; and 7.6 % were on healthcare professionals' satisfaction with mixed effects. Various features, allocation, end-user support, organized services, and service development facilitated the use of digital services. Correspondingly, barriers were related to service limitations, digital competency, funding- and service strategies, resources and change management.

CONCLUSIONS

Compared to usual care, digital services had a mixed impact on population health and costs with high satisfaction in patients. Mixed healthcare professionals' satisfaction was associated with the use of digital services, and it was less studied. To ensure successful implementation and sustainability of digital services, attention must be paid to address barriers and supporting facilitators at all levels.

College student interest in teletherapy and self-guided mental health supports during the COVID-19 pandemic

Objective The COVID-19 pandemic has worsened college students' mental health while simultaneously creating new barriers to traditional in-person care. Teletherapy and online self-guided mental health supports are two potential avenues for addressing unmet mental health needs when face-to-face services are less accessible, but little is known about factors that shape interest in these supports. Participants: 1,224 U.S. undergraduate students (mean age = 20.7; 73% female; 40% White) participated. Methods: Students completed an online questionnaire assessing interest in teletherapy and self-guided supports. Predictors included age, sex, race/ethnicity, sexual minority status, and anxiety and depression symptomatology. Results: Interest rates were 20% and 25% for at-cost supports (teletherapy and online self-help, respectively) and 70% and 72% for free supports (teletherapy and online self-help, respectively). Patterns emerged by age, anxiety symptom severity, and race/ethnicity. Conclusions: Results may inform universities' efforts to optimize students' engagement with nontraditional, digital mental health supports, including teletherapy and self-guided programs.

The SARS-CoV2 (COVID-19) pandemic has taken a severe toll on public health, with effects reaching far beyond unprecedented illness and mortality. Levels of mental health difficulties appear to be rising broadly as the pandemic has progressed, both in the general U.S. population and among college students specifically.1,2 The COVID-19 pandemic and its repercussions may undermine college student mental health in myriad ways.2 Concurrently, students now face the potential for serious illness, loss of loved ones, financial strain, social isolation, loss of on-campus resources, and sudden disruption of routines-creating a "perfect storm" for the emergence or exacerbation of psychological distress.

Digital health technologies for high-risk pregnancy management: three case studies using Digilego framework

Objective

High-risk pregnancy (HRP) conditions such as gestational diabetes mellitus (GDM), hypertension (HTN), and peripartum depression (PPD) affect maternal and neonatal health. Patient engagement is critical for effective HRP management (HRPM). While digital technologies and analytics hold promise, emerging research indicates limited and suboptimal support offered by the highly prevalent pregnancy digital solutions within the commercial marketplace. In this article, we describe our efforts to develop a portfolio of digital products leveraging advances in social computing, data science, and digital health.

Methods

We describe three studies that leverage core methods from Digilego digital health development framework to (1) conduct large-scale social media analysis (n = 55 301 posts) to understand population-level patterns in women's needs, (2) architect a digital repository to enable women curate HRP related information, and (3) develop a digital platform to support PPD prevention. We applied a combination of qualitative coding, machine learning, theory-mapping, and programmatic implementation of theory-linked digital features. Further, we conducted preliminary testing of the resulting products for acceptance with sample of pregnant women for GDM/HTN information management (n = 10) and PPD prevention (n = 30).

Results

Scalable social computing models using deep learning classifiers with reasonable accuracy have allowed us to capture and examine psychosociobehavioral drivers associated with HRPM. Our work resulted in two digital health solutions, MyPregnancyChart and MomMind are developed. Initial evaluation of both tools indicates positive acceptance from potential end users. Further evaluation with MomMind revealed statistically significant improvements (P < .05) in PPD recognition and knowledge on how to seek PPD information.

Discussion

Digilego framework provides an integrative methodological lens to gain micro-macro perspective on women's needs, theory integration, engagement optimization, as well as subsequent feature and content engineering, which can be organized into core and specialized digital pathways for women engagement in disease management.

Conclusion

Future works should focus on implementation and testing of digital solutions that facilitate women to capture, aggregate, preserve, and utilize, otherwise siloed, prenatal information artifacts for enhanced self-management of their high-risk conditions, ultimately leading to improved health outcomes.

Designing mHealth Apps to Incorporate Evidence-Based Techniques for Prolonging User Engagement

Maintaining user engagement with mobile health (mHealth) apps can be a challenge. Previously, we developed a conceptual model to optimize patient engagement in mHealth apps by incorporating multiple evidence-based methods, including increasing health literacy, enhancing technical competence, and improving feelings about participation in clinical trials. This viewpoint aims to report on a series of exploratory mini-experiments demonstrating the feasibility of testing our previously published engagement conceptual model. We collected data from 6 participants using an app that showed a series of educational videos and obtained additional data via questionnaires to illustrate and pilot the approach. The videos addressed 3 elements shown to relate to engagement in health care app use: increasing health literacy, enhancing technical competence, and improving positive feelings about participation in clinical trials. We measured changes in participants' knowledge and feelings, collected feedback on the videos and content, made revisions based on this feedback, and conducted participant reassessments. The findings support the feasibility of an iterative approach to creating and refining engagement enhancements in mHealth apps. Systematically identifying the key evidence-based elements intended to be included in an app's design and then systematically testing the implantation of each element separately until a satisfactory level of positive impact is achieved is feasible and should be incorporated into standard app design. While mHealth apps have shown promise, participants are more likely to drop out than to be retained. This viewpoint highlights the potential for mHealth researchers to test and refine mHealth apps using approaches to better engage users.

Using a Novel Gameplay Intervention to Target Intrusive Memories After Work-Related Trauma: Iterative Qualitative Analysis of Intensive Care Unit Staff Experiences

BACKGROUND

Many intensive care unit (ICU) staff experience intrusive memories following work-related traumatic events, which can lead to long-term mental health outcomes and impact work functioning. There is a need for interventions that target intrusive memories in this population; however, factors such as mental health stigma and difficulty in fitting interventions into busy schedules can pose barriers. The Brief Gameplay Intervention For National Health Service Intensive Care Unit Staff Affected By COVID-19 Trauma (GAINS) study tested a brief, digital imagery-competing task intervention (including computer gameplay) with the aim of reducing the recurrence of intrusive memories, which holds promise for overcoming some of these barriers.

OBJECTIVE

This substudy aims to explore barriers and facilitators to the uptake and practical use of the intervention by ICU staff, along with its acceptability, and iteratively explore the impact of intervention optimizations to further refine the intervention.

METHODS

The GAINS study is a randomized controlled trial comparing access to a brief digital imagery-competing task intervention for 4 weeks with usual care followed by delayed access to the intervention. The participants were ICU staff who worked during the COVID-19 pandemic and experienced intrusive memories. All participants were sent a questionnaire at 4 weeks to gather data about intervention acceptability. Nested within the randomized controlled trial, a subset of 16 participants was interviewed, and data were analyzed using thematic analysis drawing from a framework approach.

RESULTS

Both quantitative and qualitative data indicated high acceptability of the intervention. Intervention use data show that, on average, staff were able to target approximately 73% (3.64/4.88) of their intrusive memories and engaged with the Tetris component for the full 20 minutes per session. Overall, on the acceptability questionnaire, staff found the intervention easy to use, helpful, and highly acceptable. The interviews generated four themes: approach to the intervention, positives of the intervention, negatives of the intervention, and improvements and optimizations. Findings highlighted barriers that ICU staff experienced: stigma, feeling weak for seeking help, not wanting colleagues to know they were struggling, and skepticism. However, they provided suggestions on how barriers could be overcome and discussed the advantages of the intervention when compared with other treatments. Although participants described many positive aspects of the intervention, such as being easy to use, enjoyable, and leading to a reduction in the frequency or intensity of intrusive memories, they also raised practical issues for implementation.

CONCLUSIONS

The intervention has the potential to overcome stigma and reduce the frequency of intrusive memories after traumatic events among ICU staff. Further refinement is needed to improve the adoption and reach of this intervention. A limitation is that we could not interview the National Health Service staff who were unable or unwilling to take part in the trial.

Barriers to and facilitators of user engagement with web-based mental health interventions in young people: a systematic review

Many young people (YP) are diagnosed with mental illnesses and require support. Web-based mental health interventions (W-MHIs) have been increasingly utilized by YP, healthcare providers, and parents due to reasons including convenience and anonymity. W-MHIs are effective in improving mental health in YP. However, real-world engagement with W-MHIs remains low. Therefore, understanding barriers/facilitators of user engagement with W-MHIs is necessary to promote W-MHIs and help users gain optimal benefits through higher engagement. This review aims to identify barriers/facilitators of user engagement with W-MHIs in YP aged 10-24 years. A systematic search of five databases for English language, peer-reviewed publications was conducted between January 2010 and February 2023. Studies examining factors influencing user engagement with W-MHIs, described as barriers or facilitators, were included. Study quality was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis was performed. Of 4088 articles identified, 69 studies were included. Barriers/facilitators were reported by young people (63 studies), providers (17 studies), and parents/caregivers (8 studies). YP perceived that usefulness and connectedness were the most common facilitators, whereas low-perceived need was the most reported barrier. Both providers and parents reported that perceived usefulness for YP was the most common facilitator, whereas concerns about program effectiveness and privacy were noted as barriers. This review found that program- and individual-related factors were important determinants of engagement with W-MHIs. This review provides guidance on the future design and development of new interventions, narrowing the gap between existing W-MHIs and unmet needs of users.

Determining the feasibility of a codesigned and personalised intervention (Veg4Me) to improve vegetable intake in young adults living in rural Australian communities: protocol for a randomised controlled trial

INTRODUCTION

Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control).

METHODS AND ANALYSIS

A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18-35 years; eat<5 serves of vegetables/day; have an internet connected mobile device/computer) living in Loddon Campaspe or Colac Otway Shire in Victoria, Australia, will be randomised to receive 12 weeks of personalised (intervention) or non-personalised (control) support to increase vegetable intake via a free web application (app; Veg4Me). The primary outcome is feasibility (recruitment, participation and retention rates). Secondary outcomes are user engagement, usability and experience, as well as vegetable intake, eating habits and digital health equity. Process evaluation will be conducted in a subsample of participants using semistructured interviews. Descriptive statistics will be presented for the personalised and non-personalised groups at baseline and 12 weeks. Generalised linear models will be used to evaluate group differences in outcomes. Interviews will be transcribed and analysed thematically.

ETHICS AND DISSEMINATION

All procedures involving human subjects were approved by Deakin University's Human Ethics Advisory Group-Health (HEAG-H 06_2023) on 6 March 2023. Dissemination events will be held in the City of Greater Bendigo and the Colac Otway Shire. Summaries of the results will be disseminated to participants via email. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry, ACTRN12623000179639p, prospectively registered on 21 February 2023, according to the World Health Organizational Trial Registration Data Set. Universal Trial Number U1111-1284-9027.

Co-design of a personalised digital intervention to improve vegetable intake in adults living in Australian rural communities

BACKGROUND

Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas. This paper describes the co-design of a digital intervention to improve vegetable intake with rural community members and research partners.

METHODS

Active participants in the co-design process were adults ≥ 18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population. Eight online workshops and a community survey were conducted between July and December 2021. The MoSCoW prioritisation method was used to help participants identify the 'Must-have, Should-have, Could-have, and Won't-have or will not have right now' features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community.

RESULTS

Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on (i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, (ii) access to personalisation options and behaviour change support, and (iii) improving the community food environment by providing information on and access to local food initiatives.

CONCLUSIONS

Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This research will inform the development of the prototyping (evaluation phase) and feasibility testing (post-design phase) of this intervention.

The development and internal pilot trial of a digital physical activity and emotional well-being intervention (Kidney BEAM) for people with chronic kidney disease

This trial assessed the feasibility and acceptability of Kidney BEAM, a physical activity and emotional well-being self-management digital health intervention (DHI) for people with chronic kidney disease (CKD), which offers live and on-demand physical activity sessions, educational blogs and videos, and peer support. In this mixed-methods, multicentre randomised waitlist-controlled internal pilot, adults with established CKD were recruited from five NHS hospitals and randomised 1:1 to Kidney BEAM or waitlist control. Feasibility outcomes were based upon a priori progression criteria. Acceptability was primarily explored via individual semi-structured interviews (n = 15). Of 763 individuals screened, n = 519 (68%, 95% CI 65 to 71%) were eligible. Of those eligible, n = 303 (58%, 95% CI 54-63%) did not respond to an invitation to participate by the end of the pilot period. Of the 216 responders, 50 (23%, 95% CI 18-29%) consented. Of the 42 randomised, n = 22 (10 (45%) male; 49 ± 16 years; 14 (64%) White British) were allocated to Kidney BEAM and n = 20 (12 (55%) male; 56 ± 11 years; 15 (68%) White British) to the waitlist control group. Overall, n = 15 (30%, 95% CI 18-45%) withdrew during the pilot phase. Participants completed a median of 14 (IQR 5-21) sessions. At baseline, 90-100% of outcome data (patient reported outcome measures and a remotely conducted physical function test) were completed and 62-83% completed at 12 weeks follow-up. Interview data revealed that remote trial procedures were acceptable. Participants' reported that Kidney BEAM increased their opportunity and motivation to be physically active, however, lack of time remained an ongoing barrier to engagement with the DHI. An randomised controlled trial of Kidney BEAM is feasible and acceptable, with adaptations to increase recruitment, retention and engagement.Trial registration NCT04872933. Date of first registration 05/05/2021.

Challenges in implementing cultural adaptations of digital health interventions

Differences in the access and use of digital health interventions are driven by culture, in addition to economic and physical factors. To avoid the systematic exclusion of traditionally underserved cultural groups, creating inclusive digital health interventions is essential. One way to achieve this is through cultural adaptations, defined as the systematic modification of an existing intervention that aligns with a target audience's cultural norms, beliefs, and values. In theory, cultural adaptations can potentially increase the reach and engagement of digital health interventions. However, the evidence of whether and how that is achieved is limited. Justifying, planning, and implementing an adaptation comes with various challenges and takes time and money. This perspective provides a critical overview of the field's current state and emphasizes the need for technology-specific frameworks that address when and how to culturally adapt digital health interventions.

Feasibility of a mobile health app-based self-management program for Chinese patients with breast cancer receiving chemotherapy: A randomized controlled pilot study

Objective

There are currently an increasing number of mobile health (mHealth) programs offered to patients with breast cancer undergoing chemotherapy, but their rate of adherence to app usage has remained low. This study aimed to examine the feasibility of an mHealth app-based program such as the adherence rate of app usage and determine the preliminary effects on self-efficacy, quality of life, symptom burden and healthcare utilization in these patients.

Methods

We conducted a randomized controlled pilot trial. Ninety-six participants were randomly allocated into either an intervention group or a control group (routine care plus a placebo app). The intervention group engaged in a 6-week self-regulation activity and received nurse-led social support via the app. The intention-to-treat principle was adopted. The generalized estimating equation was utilized to analyze the between-group, within-group and interaction effectiveness of this program.

Results

Totally 96 participants were enrolled from 16 May to 23 August 2022. The average rate of adherence to app usage increased from 4.8% at week 3 to 51.2% at week 6. There was a statistically significant reduction in the physiological efficacy scores of the intervention (p < .001) and control groups (p < .001) at week 6, compared with the baseline. At week 6, the intervention group reported a significantly lower symptom burden (p = .042) and significantly better physical well-being than the control group (p = .024).

Conclusions

It is feasible to perform an mHealth app-based self-management program for patients with breast cancer receiving chemotherapy. Nurses can utilize this program to facilitate patient self-management of symptoms during chemotherapy.

Registration

Clinicaltrials.gov, https://clinicaltrials.gov, (NCT05192525).

Implementation and evaluation of participatory advisory boards in mental health research: a research protocol of the 'PART-Beirat' project

BACKGROUND

The use of participatory research approaches in the field of dementia and forensic mental health research has been on the rise. Advisory board structures, involving people with lived experience (PWLE), have frequently been used for guiding and leading research. Yet, there has been limited guidance on the establishment, retention and use of advisory boards in the field of dementia and forensic mental health research.

OBJECTIVE

This project outlined in this research protocol will investigate the benefits and challenges of establishing three patient advisory boards, involving PWLE, practitioners and researchers with the purpose to guide research. Data will be used to develop guidelines for best practice in involving PWLE in dementia and forensic mental health research through advisory boards.

METHODS

The research project will be divided into three phases: Phase I will involve two topic-specific systematic reviews on the use of participatory research with PWLE, followed by an initial study exploring PWLE's, practitioners' and researchers' expectations on research involvement. Phase II will consist of the establishment of three advisory boards, one focusing on dementia, one on forensic mental health and one overarching coordinating advisory board, which will involve PWLE from both fields. Phase III, will consist of interviews and focus groups with advisory board members, exploring any challenges and benefits of involving PWLE and practitioners in advisory boards for guiding research. To capture the impact of involving PWLE in different research phases and tasks, interviews and focus groups will be conducted at four different points of time (0, 6, 12, 18 months). Reflexive thematic analysis will be used for the analysis of data.

DISCUSSION

The project aims to explore the involvement of PWLE and practitioners in guiding research and aims to develop guidelines for best practice in establishing and using patient advisory boards in dementia and forensic mental health research and involving PWLE and practitioners in research.

Patients' perspectives on digital health tools

Objective

Digital technology has changed the way healthcare is delivered and accessed. However, the focus is mostly on technology and clinical aspects. This review aimed to integrate and critically analyse the available knowledge regarding patients' perspectives on digital health tools and identify facilitators and barriers to their uptake.

Methods

A narrative review was conducted using the Scopus and Google Scholar databases. Information related to facilitators and barriers to uptake was synthesised and interpreted using thematic and content analyses, respectively.

Results

Seventy-one out of 1722 articles identified were eligible for inclusion. Patient empowerment, self-management, and personalisation were identified as the main factors that contributed to patient uptake in using digital health tools. Digital literacy, health literacy, and privacy concerns were identified as barriers to the uptake of digital health technology.

Conclusion

Digital health technologies have changed the way healthcare is experienced by patients. Research highlights the disconnect between the development and implementation of digital health tools and the patients they are created for. This review may serve as the foundation for future research incorporating patients' perspectives to help increase patients' engagement with emerging technologies.

Innovation

Participatory design approaches have the potential to support the creation of patient-centred digital health tools.

An integrative review of adult cancer patients' experiences of nursing telephone and virtual triage systems for symptom management

PURPOSE

Telephone and virtual triage services are becoming increasingly common in ambulatory oncology settings. Few studies have evaluated their implementation from the perspective of service users. This study aims to evaluate the experiences of engaging with nurse-delivered telephone and virtual triage systems for symptom management among people undergoing cancer treatment.

METHODS

An integrative review was undertaken. MEDLINE, CINAHL, PsycInfo, Academic Search Complete and Scopus were systematically searched. Twelve publications met the inclusion criteria, and data related to cancer patients' perceptions of the triage process were extracted and analysed.

RESULTS

Telephone-based (n=7), app-based (n=5) and video-based teleconferencing (n=2) triage systems were evaluated positively overall, enhancing ease of health system navigation, avoidance of emergency department for consultation, and the information, reassurance and support provided to support self-management of symptoms. However, several factors influenced the users' engagement with triage services, including confidence to articulate symptoms, limited opening hours, waiting times for initial triage or follow-up and digital literacy. Collectively, these factors contributed to delayed reporting or under-reporting of symptoms, undermining the potential impact of services. Studies included variable reporting of intervention characteristics, including the qualification of nurses delivering and leading services.

CONCLUSIONS

Future evaluations of triage services must give greater consideration to the characterisation of interventions to ensure transferability, including nursing roles and qualifications. To ensure effective intervention and optimal supportive care for symptom management, patients must be prepared to engage triage services early. Future evaluations must ensure the impact of digital literacy on engagement with, and experience of, virtual triage is investigated.

Therapeutic games to reduce anxiety and depression in young people: A systematic review and exploratory meta-analysis of their use and effectiveness

OBJECTIVE

The development of serious games for mental wellbeing is a topic of growing interest. The increase in acceptance of games as a mainstream entertainment medium combined with the immersive qualities of games provides opportunities for meaningful support and intervention in mental wellbeing.

METHOD

We conducted a systematic review and exploratory meta-analysis to examine if aspects of the interventions influenced outcomes as measured via overall effect sizes. We employed a multilevel meta-analytic approach to accommodate the interdependency of effect sizes (18 effect sizes from 14 studies, with 2027 participants).

RESULTS

Overall, the main effect for gaming interventions on any outcome variable was small to medium sized, d = .35 (confidence interval [.23, 47], p < .001). Results revealed that the only significant moderator was the nature of the intervention. Specifically, only interventions that included a rational emotional behavioural focus significantly predicted an improvement in depression and/or anxiety in participants.

CONCLUSION

The findings reveal promising effects for therapeutic games for mental health, but replications are needed, alongside the addressing of methodological and procedural concerns.

Evaluating a Remote Monitoring Program for Respiratory Diseases: Prospective Observational Study

BACKGROUND

Patients with chronic respiratory diseases and those in the postdischarge period following hospitalization because of COVID-19 are particularly vulnerable, and little is known about the changes in their symptoms and physiological parameters. Continuous remote monitoring of physiological parameters and symptom changes offers the potential for timely intervention, improved patient outcomes, and reduced health care costs.

OBJECTIVE

This study investigated whether a real-time multimodal program using commercially available wearable technology, home-based Bluetooth-enabled spirometers, finger pulse oximeters, and smartphone apps is feasible and acceptable for patients with chronic respiratory diseases, as well as the value of low-burden, long-term passive data collection.

METHODS

In a 3-arm prospective observational cohort feasibility study, we recruited 60 patients from the Royal Free Hospital and University College Hospital. These patients had been diagnosed with interstitial lung disease, chronic obstructive pulmonary disease, or post-COVID-19 condition (n=20 per group) and were followed for 180 days. This study used a comprehensive remote monitoring system designed to provide real-time and relevant data for both patients and clinicians. Data were collected using REDCap (Research Electronic Data Capture; Vanderbilt University) periodic surveys, Remote Assessment of Disease and Relapses-base active app questionnaires, wearables, finger pulse oximeters, smartphone apps, and Bluetooth home-based spirometry. The feasibility of remote monitoring was measured through adherence to the protocol, engagement during the follow-up period, retention rate, acceptability, and data integrity.

RESULTS

Lowest-burden passive data collection methods, via wearables, demonstrated superior adherence, engagement, and retention compared with active data collection methods, with an average wearable use of 18.66 (SD 4.69) hours daily (77.8% of the day), 123.91 (SD 33.73) hours weekly (72.6% of the week), and 463.82 (SD 156.70) hours monthly (64.4% of the month). Highest-burden spirometry tasks and high-burden active app tasks had the lowest adherence, engagement, and retention, followed by low-burden questionnaires. Spirometry and active questionnaires had the lowest retention at 0.5 survival probability, indicating that they were the most burdensome. Adherence to and quality of home spirometry were analyzed; of the 7200 sessions requested, 4248 (59%) were performed. Of these, 90.3% (3836/4248) were of acceptable quality according to American Thoracic Society grading. Inclusion of protocol holidays improved retention measures. The technologies used were generally well received.

CONCLUSIONS

Our findings provide evidence supporting the feasibility and acceptability of remote monitoring for capturing both subjective and objective data from various sources for respiratory diseases. The high engagement level observed with passively collected data suggests the potential of wearables for long-term, user-friendly remote monitoring in respiratory disease management. The unique piloting of certain features such as protocol holidays, alert notifications for missing data, and flexible support from the study team provides a reference for future studies in this field.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/28873.

A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Personalization in digital health interventions for older adults with cancer: A scoping review

INTRODUCTION

Digital health interventions (DHIs) are promising to support older adults with cancer in managing their conditions and improving their health outcomes. However, there is a lack of overall understanding of various DHIs for the aging population with cancer. Specifically, it is unclear how personalization components are included in those DHIs to promote engagement in the interventions among older adults with cancer. This study aimed to provide a comprehensive overview of existing DHIs for older adults with cancer and identify the intervention components, especially personalized features, and effectiveness of these DHIs for improving self-management and psychosocial health.

MATERIALS AND METHODS

A scoping review was conducted following Joanna Briggs Institute guidelines, focusing on older adults diagnosed with cancer who participated in DHIs to improve self-management and psychosocial health. Studies using an experimental design and published from 2000 to January 2023 were retrieved from four databases: PubMed, Embase, CINAHL, and Scopus. After primary data extraction of study characteristics, participants, interventions, and outcomes, DHIs were categorized according to personalized features.

RESULTS

Out of 9,750 articles, 20 were eligible for this scoping review. The main personalized features of DHIs were categorized into four domains: goal setting, adjusting the plan, data-driven approaches, and motivating behavioral changes. Self-management outcomes were focused on physical activity, diet, and symptom management. Quality of life, depression, and anxiety were addressed as psychosocial health-related outcomes. Although no consistent results were reported on the effectiveness, DHIs with a combination of multiple personalized features, more than three domains, were likely to be more effective in improving self-management outcomes.

DISCUSSION

This review enhances the understanding of personalized DHIs for older adults with cancer by identifying intervention components, personalized features, and effectiveness on self-management and psychosocial health. Several gaps were identified, including the absence of targeted studies exclusively focusing on older adults, a relative scarcity of personalized features for improving patient engagement, a lack of understanding of the mechanism of effective personalized features, and the necessity for more experimental studies. Addressing these gaps can contribute to improving health outcomes and the quality of care for older adults with cancer by providing the direction for developing effective DHIs.

Supporting translation of research evidence into practice-the use of Normalisation Process Theory to assess and inform implementation within randomised controlled trials: a systematic review

BACKGROUND

The status of randomised controlled trials (RCTs) as the 'gold standard' for evaluating efficacy in healthcare interventions is increasingly debated among the research community, due to often insufficient consideration for implementation. Normalisation Process Theory (NPT), which focuses on the work required to embed processes into practice, offers a potentially useful framework for addressing these concerns. While the theory has been deployed in numerous RCTs to date, more work is needed to consolidate understanding of if, and how, NPT may aid implementation planning and processes within RCTs. Therefore, this review seeks to understand how NPT contributes to understanding the dynamics of implementation processes within RCTs. Specifically, this review will identify and characterise NPT operationalisation, benefits and reported challenges and limitations in RCTs.

METHODS

A qualitative systematic review with narrative synthesis of peer-reviewed journal articles from eight databases was conducted. Studies were eligible for inclusion if they reported sufficient detail on the use of NPT within RCTs in a healthcare domain. A pre-specified data extraction template was developed based on the research questions of this review. A narrative synthesis was performed to identify recurrent findings.

RESULTS

Searches identified 48 articles reporting 42 studies eligible for inclusion. Findings suggest that NPT is primarily operationalised prospectively during the data collection stage, with limited sub-construct utilisation overall. NPT is beneficial in understanding implementation processes by aiding the identification and analysis of key factors, such as understanding intervention fidelity in real-world settings. Nearly three-quarters of studies failed to report the challenges and limitations of utilising NPT, though coding difficulties and data falling outside the NPT framework are most common.

CONCLUSIONS

NPT appears to be a consistent and generalisable framework for explaining the dynamics of implementation processes within RCTs. However, operationalisation of the theory to its full extent is necessary to improve its use in practice, as it is currently deployed in varying capacities. Recommendations for future research include investigation of NPT alongside other frameworks, as well as earlier operationalisation and greater use of NPT sub-constructs.

TRIAL REGISTRATION

The protocol for this systematic review was accepted for public registration on PROSPERO (registration number: CRD42022345427) on 26 July 2022.

Determinants of motivation and adherence to a web application for health behaviour change: A qualitative study with cancer survivors

BACKGROUND

Given the increasing number of cancer survivors, eHealth may be an effective means to improve lifestyle-related behaviours. Limited data are available on the use of eHealth by post-cancer patients. The present study aimed to analyse the contexts of use to identify the determinants of cancer survivors' adherence and motivation to use a web application offering nutrition and physical activity coaching.

METHODS

Individual semi-structured interviews were conducted with cancer survivors who participated in an 8-week online program for health behaviour change. The interviews were analysed using thematic analysis.

RESULTS

Fifteen patients with a mean (SD) age of 62 (4.2) years completed the interview. Four themes relating to the environment and context of use were identified: digital use, social relations, health, and digital health interventions. Participants were familiar with digital tools through their professional work. Their motivation and adherence to the program improved through social relations; notably, a supportive family in addition to a trusted prescriber, continuity in the care pathway, and an appropriate choice of design features in the digital health intervention. With cancer survivorship, individuals no longer define themselves as sick but still need support to envisage the future more serenely.

CONCLUSIONS

Cancer survivorship plays a special role in people's adherence to online interventions for health behaviour change in addition to the influence of their social relations and health environment.

Barriers and facilitators to utilizing digital health technologies by healthcare professionals

Digital technologies change the healthcare environment, with several studies suggesting barriers and facilitators to using digital interventions by healthcare professionals (HPs). We consolidated the evidence from existing systematic reviews mentioning barriers and facilitators for the use of digital health technologies by HP. Electronic searches were performed in five databases (Cochrane Database of Systematic Reviews, Embase®, Epistemonikos, MEDLINE®, and Scopus) from inception to March 2023. We included reviews that reported barriers or facilitators factors to use technology solutions among HP. We performed data abstraction, methodological assessment, and certainty of the evidence appraisal by at least two authors. Overall, we included 108 reviews involving physicians, pharmacists, and nurses were included. High-quality evidence suggested that infrastructure and technical barriers (Relative Frequency Occurrence [RFO] 6.4% [95% CI 2.9-14.1]), psychological and personal issues (RFO 5.3% [95% CI 2.2-12.7]), and concerns of increasing working hours or workload (RFO 3.9% [95% CI 1.5-10.1]) were common concerns reported by HPs. Likewise, high-quality evidence supports that training/educational programs, multisector incentives, and the perception of technology effectiveness facilitate the adoption of digital technologies by HPs (RFO 3.8% [95% CI 1.8-7.9]). Our findings showed that infrastructure and technical issues, psychological barriers, and workload-related concerns are relevant barriers to comprehensively and holistically adopting digital health technologies by HPs. Conversely, deploying training, evaluating HP's perception of usefulness and willingness to use, and multi-stakeholders incentives are vital enablers to enhance the HP adoption of digital interventions.

Digital intervention for public health: searching for implementing characteristics, concepts and recommendations: scoping review

Studying the impact of digital interventions on public health can help ensure that the offered services produce the desired results. In order to address these factors, the subsequent study uses a scope review to evaluate the state of the field while concentrating on ideas and suggestions that represent factors that have been crucial in the management of digital intervention for public health. To shed light on the traits, ideas and suggestions related to public health digital intervention, a scoping review was carried out. Five electronic databases were used to locate pertinent research that were published before February 2022. All texts were examined, and study abstracts were scrutinized to determine their eligibility. The last analysis of this study included fifteen publications; five reviews, four qualitative studies, two quantitative studies, one viewpoint study, one mixed-method study, one perspective study, and one interventional study. The key ideas for digital interventions in population management and health studies are presented in this overview. Many concepts, implementation characteristics and recommendations have been raised which highlight the future role of these interventions to enhance public engagement and health equity.

Potential associations between behavior change techniques and engagement with mobile health apps: a systematic review

Introduction

Lack of engagement is a common challenge for digital health interventions. To achieve their potential, it is necessary to understand how best to support users' engagement with interventions and target health behaviors. The aim of this systematic review was to identify the behavioral theories and behavior change techniques being incorporated into mobile health apps and how they are associated with the different components of engagement.

Methods

The review was structured using the PRISMA and PICOS frameworks and searched six databases in July 2022: PubMed, Embase, CINAHL, APA PsycArticles, ScienceDirect, and Web of Science. Risk of bias was evaluated using the Cochrane Collaboration Risk of Bias 2 and the Mixed Methods Appraisal Tools.

Analysis

A descriptive analysis provided an overview of study and app characteristics and evidence for potential associations between Behavior Change Techniques (BCTs) and engagement was examined.

Results

The final analysis included 28 studies. Six BCTs were repeatedly associated with user engagement: goal setting, self-monitoring of behavior, feedback on behavior, prompts/cues, rewards, and social support. There was insufficient data reported to examine associations with specific components of engagement, but the analysis indicated that the different components were being captured by various measures.

Conclusion

This review provides further evidence supporting the use of common BCTs in mobile health apps. To enable developers to leverage BCTs and other app features to optimize engagement in specific contexts and individual characteristics, we need a better understanding of how BCTs are associated with different components of engagement.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022312596.

Do age, gender, and education modify the effectiveness of app-delivered and tailored self-management support among adults with low back pain?-Secondary analysis of the selfBACK randomised controlled trial

selfBACK is an artificial intelligence based self-management app for low back pain (LBP) recently reported to reduce LBP-related disability. The aim of this study was to examine if age, gender, or education modify the effectiveness of the selfBACK intervention using secondary analysis of the selfBACK randomized controlled trial. Persons seeking care for LBP were recruited from primary care in Denmark and Norway and an outpatient clinic (Denmark). The intervention group (n = 232) received the selfBACK app adjunct to usual care. The control group (n = 229) received usual care only. Analyses were stratified by age (18-34, 35-64, ≥65 years), gender (male, female), and education (≤12, >12 years) to investigate differences in effect at three and nine months follow-up on LBP-related disability (Roland-Morris Disability Questionnaire [RMDQ]), LBP intensity and pain self-efficacy. Overall, there was no effect modification for any of the sociodemographic factors. However, data on LBP-related disability suggest that the effect of the intervention was somewhat more beneficial in older than in younger participants. The difference between the intervention and control group due to interaction was 2.6 (95% CI: 0.4 to 4.9) RMDQ points for those aged ≥65 years as compared to those aged 35-64 years. In conclusion, age, gender, or education did not influence the effect of the selfBACK intervention on LBP-related disability. However, older participants may have an additional long-term positive effect compared to younger participants. Trial registration: ClinicalTrials.gov Identifier: NCT03798288.

Novel behaviour change frameworks for digital health interventions: A critical review

Digital health interventions - interventions delivered over digital media to support the health of users - are becoming increasingly prevalent. Utilising an intervention development framework can increase the efficacy of digital interventions for health-related behaviours. This critical review aims to outline and review novel behaviour change frameworks that guide digital health intervention development. Our comprehensive search for preprints and publications used PubMed, PsycINFO, Scopus, Web of Science and the Open Science Framework repository. Articles were included if they: (1) were peer-reviewed; (2) proposed a behaviour change framework to guide digital health intervention development; (3) were written in English; (4) were published between 1/1/19 and 1/8/2021; and (5) were applicable to chronic diseases. Intervention development frameworks considered the user, intervention elements and theoretical foundations. However, the timing and policy of interventions are not consistently addressed across frameworks. Researchers should deeply consider the digital applicability of behaviour change frameworks to improve intervention success.

Patients' Individualized Care Perceptions and Health Literacy Using an Interactive App During Breast and Prostate Cancer Treatment: Two Parallel Randomized Controlled Trials

The use of symptom management mobile apps can reduce patients' symptom burden during cancer treatment, but the evidence is lacking about their effect on care. Moreover, if patients' health literacy can be improved, it needs to be more rigorously tested. This study aimed to evaluate patients' perceptions of individualized care and health literacy using an interactive app in two randomized trials. Patients undergoing neoadjuvant chemotherapy for breast cancer (N = 149) and radiotherapy for prostate cancer (N = 150) were consecutively included and randomized into one intervention or control group. Outcome measures were Individualized Care Scale, Swedish Functional Health Literacy Scale, and Swedish Communicative and Critical Health Literacy Scale. In the breast cancer trial, no group differences were observed regarding individualized care or health literacy. Most patients had sufficient health literacy levels. In the prostate cancer trial, intervention group patients rated higher perceived individualized care regarding decision control at follow-up than the control group. Less than half had sufficient health literacy levels and intervention group patients significantly improved their ability to seek, understand, and communicate health information. Education level explained significant variance in health literacy in both trials. Using an interactive app can positively affect individualization in care and health literacy skills among patients treated for prostate cancer, although further research is warranted.

Effectiveness and Process Evaluation of Using Digital Health Technologies in Pharmaceutical Care in Low- and Middle-Income Countries: A Systematic Review of Quantitative and Qualitative Studies

Introduction: Digital health technology (DHT) has the potential to enhance remote health care delivery. However, little is known about the effectiveness of DHTs and factors that contribute to the limited uptake of DHTs in low- and middle-income countries (LMICs). Therefore, the objective of this study was to systematically review the effectiveness and evaluation process concerning the use of DHTs in pharmaceutical care in LMICs. Methods: A literature search on PubMed and Embase was conducted to identify experimental, descriptive, qualitative, and mixed-method studies that focused on the use of DHTs in pharmaceutical care as the main intervention, reported on the effects and/or the process of the DHT intervention, were performed by pharmacists, were conducted in LMICs, and had been published in English. Two reviewers independently conducted the study selection process. A qualitative narrative review of the effectiveness of using DHTs was conducted evaluating the population, intervention, comparators, and outcomes. We summarized the content and identified themes of the evaluation process under two categories-challenges and opportunities. Results: The search produced 589 studies, of which 16 met the eligibility criteria. The most common type of DHT was mobile health application (mHealth app; n = 8), followed by mobile phone call (n = 6) and mobile video call (n = 2). Eight studies assessed the effectiveness of using DHTs in pharmaceutical care. mHealth app, mobile phone call, mobile video call, text messages, home telemonitoring, and internet-based drug information centers improved some health-related outcomes. Two of these eight studies, however, did not find significant effects of a phone call or an mHealth app on certain health-related outcomes. Of the seven quantitative studies conducting a process evaluation, all showed that patients were satisfied with the use of DHTs in pharmaceutical care provided by pharmacists. Of the two mixed-methods and one qualitative study assessing the process evaluation concerning DHT usage, three distinct themes of challenges (patient-, DHT-, and health care system-related challenges) and opportunities (patient-, DHT-, and pharmacist-related opportunities) were identified. Conclusions: DHT is a promising approach in pharmaceutical care toward improving health-related outcomes in LMICs, despite the variable intervention effects. The challenges and opportunities identified are important considerations when developing and implementing DHTs in pharmaceutical care in LMICs.

The Constrained-Disorder Principle Assists in Overcoming Significant Challenges in Digital Health: Moving from "Nice to Have" to Mandatory Systems

The success of artificial intelligence depends on whether it can penetrate the boundaries of evidence-based medicine, the lack of policies, and the resistance of medical professionals to its use. The failure of digital health to meet expectations requires rethinking some of the challenges faced. We discuss some of the most significant challenges faced by patients, physicians, payers, pharmaceutical companies, and health systems in the digital world. The goal of healthcare systems is to improve outcomes. Assisting in diagnosing, collecting data, and simplifying processes is a "nice to have" tool, but it is not essential. Many of these systems have yet to be shown to improve outcomes. Current outcome-based expectations and economic constraints make "nice to have," "assists," and "ease processes" insufficient. Complex biological systems are defined by their inherent disorder, bounded by dynamic boundaries, as described by the constrained disorder principle (CDP). It provides a platform for correcting systems' malfunctions by regulating their degree of variability. A CDP-based second-generation artificial intelligence system provides solutions to some challenges digital health faces. Therapeutic interventions are held to improve outcomes with these systems. In addition to improving clinically meaningful endpoints, CDP-based second-generation algorithms ensure patient and physician engagement and reduce the health system's costs.

Improving Predictability and Effectiveness in Preventive Digital Health Interventions: Scoping Review

BACKGROUND

Lifestyle-related diseases caused by inadequate diet and physical activity cause premature death, loss of healthy life years, and increased health care costs. Randomized controlled trial (RCT) studies indicate that preventive digital health interventions (P-DHIs) can be effective in preventing these health problems, but the results of these studies are mixed. Adoption studies have identified multiple factors related to individuals and the context in which they live that complicate the transfer of positive results from RCT studies to practical use. Implementation studies have revealed barriers to the large-scale implementation of mobile health (mHealth) solutions in general. Consequently, there is no clear path to delivering predictable outcomes from P-DHIs and achieving effectiveness when scaling up interventions to reduce health problems in society.

OBJECTIVE

This research aimed to expand our understanding of how to increase the outcome predictability of P-DHIs by focusing on physical activity and diet behaviors and amplify our understanding of how to improve effectiveness in large-scale implementations.

METHODS

The research objective was pursued through a multidisciplinary scoping review. This scoping review used the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) as a guide. A comprehensive search of Web of Science and PubMed limited to English-language journal articles published before January 2022 was conducted. Google Scholar was used for hand searches. Information systems theory was used to identify key constructs influencing outcomes of IT in general. Public health and mHealth literature were used to identify factors influencing the adoption of, outcomes from, and implementation of P-DHIs. Finally, the P-DHI investment model was developed based on information systems constructs and factors from the public health and mHealth literature.

RESULTS

In total, 203 articles met the eligibility criteria. The included studies used a variety of methodologies, including literature reviews, interviews, surveys, and RCT studies. The P-DHI investment model suggests which constructs and related factors should be emphasized to increase the predictability of P-DHI outcomes and improve the effectiveness of large-scale implementations.

CONCLUSIONS

The research suggests that outcome predictability could be improved by including descriptions of the constructs and factors in the P-DHI investment model when reporting from empirical studies. Doing so would increase our understanding of when and why P-DHIs succeed or fail. The effectiveness of large-scale implementations may be improved by using the P-DHI investment model to evaluate potential difficulties and possibilities in implementing P-DHIs to create better environments for their use before investing in them and when designing and implementing them. The cost-effectiveness of large-scale implementations is unknown; implementations are far more complicated than just downloading and using apps, and there is uncertainty accompanying implementations given the lack of coordinated control over the constructs and factors that influence the outcome.

The Geras virtual frailty rehabilitation program to build resilience in older adults with frailty during COVID-19: a randomized feasibility trial

BACKGROUND

The Coronavirus (COVID-19) pandemic has exacerbated the risk for poor physical and mental health outcomes among vulnerable older adults. Multicomponent interventions could potentially prevent or reduce the risk of becoming frail; however, there is limited evidence about utilizing alternative modes of delivery where access to in-person care may be challenging. This randomized feasibility trial aimed to understand how a multicomponent rehabilitation program can be delivered remotely to vulnerable older adults with frailty during the pandemic.

METHODS

Participants were randomized to either a multimodal or socialization arm. Over a 12-week intervention period, the multimodal group received virtual care at home, which included twice-weekly exercise in small group physiotherapy-led live-streamed sessions, nutrition counselling and protein supplementation, medication consultation via a videoconference app, and once-weekly phone calls from student volunteers, while the socialization group received only once-weekly phone calls from the volunteers. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate the feasibility of the program. The main clinical outcomes were change in the 5-times sit-to-stand test (5 × STS) and Depression, Anxiety and Stress Scale (DASS-21) scores. The feasibility outcomes were analyzed using descriptive statistics and expressed as frequencies and mean percent with corresponding confidence intervals (CI). Analysis of covariance (ANCOVA) was used for the effectiveness component.

RESULTS

The program enrolled 33% (n = 72) of referrals to the study (n = 220), of whom 70 were randomized. Adoption rates from different referral sources were community self-referrals (60%), community organizations (33%), and healthcare providers (25%). At the provider level, implementation rates varied from 75 to 100% for different aspects of program delivery. Participant's adherence levels included virtual exercise sessions 81% (95% CI: 75-88%), home-based exercise 50% (95% CI: 38-62%), protein supplements consumption 68% (95% CI: 55-80%), and medication optimization 38% (95% CI: 21-59%). Most participants (85%) were satisfied with the program. There were no significant changes in clinical outcomes between the two arms.

CONCLUSION

The GERAS virtual frailty rehabilitation study for community-dwelling older adults living with frailty was feasible in terms of reach of participants, adoption across referral settings, adherence to implementation, and participant's intention to maintain the program. This program could be feasibly delivered to improve access to socially isolated older adults where barriers to in-person participation exist. However, trials with larger samples and longer follow-up are required to demonstrate effectiveness and sustained behavior change.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04500366. Registered August 5, 2020, https://clinicaltrials.gov/ct2/show/NCT04500366.

Persuasive features for patient engagement through mHealth applications in managing chronic conditions: A systematic literature review and meta-analysis

Patient engagement is currently considered the cornerstone of a revolution in healthcare for its positive impact on health outcomes, health behaviors and healthcare costs. Patient engagement is focused on personalized care to consumers through providing knowledge, skills and confidence. Mobile health (mHealth) applications are an innovative means to facilitate patient engagement. Nevertheless, the extent to which the current mHealth applications are designed to engage patients in managing their chronic diseases is unclear. This paper aims to identify the Persuasive System Design (PSD) features present in current mHealth applications that increased the engagement of patients with chronic diseases. This review also aims to identify patient engagement-related outcomes of these features. This paper conducted a systematic literature review and meta-analysis to find relevant studies published from all years up to 2020 through six databases: PubMed, Scopus, Web of Science, Cinahl plus with full text, MEDLINE with full text, and Cochrane Library (Central register of controlled trials). The database search returned 4939 articles; after applying the inclusion and exclusion criteria, the number of included articles for the final review was 13. A qualitative content analysis was performed to identify PSD model features and their patient engagement-related outcomes. The quality assessment has been done through the Cochrane Risk of Bias tool for RCTs. The systematic literature review and meta-analysis identified eleven PSD features that can increase patient engagement through using mHealth applications. The identified PSD features have been shown to have various patient engagement-related outcomes. Behavior Change Techniques (BCTs) were combined with the identified PSD features. This paper identified persuasive features of mHealth application design that influence the engagement of patients with chronic diseases toward changing their behavior. The impact of these features is also analyzed in this review. The results show that an mHealth technology-mediated patient engagement model is needed.

Keeping Active with Texting after Stroke (KATS): development of a text message intervention to promote physical activity and exercise after stroke

BACKGROUND

Post-stroke physical activity reduces disability and risk of further stroke. When stroke rehabilitation ends, some people feel abandoned by services and struggle to undertake physical activities that support recovery and health. The aim of this study was to codesign a novel text message intervention to promote physical activity among people with stroke and provide support when formal rehabilitation ends. This manuscript describes the intervention development processes that will inform future pilot and feasibility studies.

METHODS

The planned intervention was a series of text messages to be sent in a predetermined sequence to people with stroke at the end of rehabilitation. The intervention, underpinned by behaviour change theory and using salient behaviour change techniques, would provide daily messages offering encouragement and support for the uptake and maintenance of physical activity following stroke. The intervention was codesigned by a Collaborative Working Group, comprised of people with stroke, rehabilitation therapists, representatives from stroke charities and academics. A four-step framework was used to design the intervention: formative research on physical activity post-stroke, creation of the behaviour change text message intervention, pre-testing and refinement. Formative research included a review of the scientific evidence and interviews with community-dwelling people with stroke. Data generated were used by the Collaborative Working Group to identify topics to be addressed in the intervention. These were mapped to constructs of the Health Action Process Approach, and salient behaviour change techniques to deliver the intervention were identified. The intervention was rendered into a series of text messages to be delivered over 12 weeks. The draft intervention was revised and refined through an iterative process including review by people with stroke, their spouses, rehabilitation therapists and experts in the field of stroke. The messages encourage regular physical activity but do not prescribe exercise or provide reminders to exercise at specific times. They use conversational language to encourage engagement, and some are personalised for participants. Quotes from people with stroke provide encouragement and support and model key behaviour change techniques such as goal setting and coping planning.

DISCUSSION

Co-design processes were critical in systematically developing this theory and evidence-based intervention. People with stroke and rehabilitation therapists provided insights into perceived barriers post-rehabilitation and identified strategies to overcome them. The structured multistep approach highlighted areas for improvement through successive rounds of review. The intervention will be tested for acceptability, feasibility and effectiveness in future studies. This co-design approach could be used for interventions for other heath behaviours and with different populations.

Optimising engagement in a digital parenting intervention to prevent violence against adolescents in Tanzania: protocol for a cluster randomised factorial trial

BACKGROUND

Violence against adolescents is a universal reality, with severe individual and societal costs. There is a critical need for scalable and effective violence prevention strategies such as parenting programmes, particularly in low- and middle-income countries where rates of maltreatment are highest. Digital interventions may be a scalable and cost-effective alternative to in-person delivery, yet maximising caregiver engagement is a substantial challenge. This trial employs a cluster randomised factorial experiment and a novel mixed-methods analytic approach to assess the effectiveness, cost-effectiveness, and feasibility of intervention components designed to optimise engagement in an open-source parenting app, ParentApp for Teens. The app is based on the evidence-based Parenting for Lifelong Health for Teens programme, developed collaboratively by academic institutions in the Global South and North, the WHO, and UNICEF.

METHODS/DESIGN

Sixteen neighbourhoods, i.e., clusters, will be randomised to one of eight experimental conditions which consist of any combination of three components (Support: self-guided/moderated WhatsApp groups; App Design: sequential workshops/non-sequential modules; Digital Literacy Training: on/off). The study will be conducted in low-income communities in Tanzania, targeting socioeconomically vulnerable caregivers of adolescents aged 10 to 17 years (16 clusters, 8 conditions, 640 caregivers, 80 per condition). The primary objective of this trial is to estimate the main effects of the three components on engagement. Secondary objectives are to explore the interactions between components, the effects of the components on caregiver behavioural outcomes, moderators and mediators of programme engagement and impact, and the cost-effectiveness of components. The study will also assess enablers and barriers to engagement qualitatively via interviews with a subset of low, medium, and high engaging participants. We will combine quantitative and qualitative data to develop an optimised ParentApp for Teens delivery package.

DISCUSSION

This is the first known cluster randomised factorial trial for the optimisation of engagement in a digital parenting intervention in a low- and middle-income country. Findings will be used to inform the evaluation of the optimised app in a subsequent randomised controlled trial.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, PACTR202210657553944. Registered 11 October 2022, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051 .