Can mHealth and eHealth improve management of diabetes and hypertension in a hard-to-reach population? -lessons learned from a process evaluation of digital health to support a peer educator model in Cambodia using the RE-AIM framework

Advancing mHealth Research in Low-Resource Settings: Young Women's Insights and Implementation Challenges with Wearable Smartwatch Devices in Uganda

In many regions globally, including low-resource settings, there is a growing trend towards using mHealth technology, such as wearable sensors, to enhance health behaviors and outcomes. However, adoption of such devices in research conducted in low-resource settings lags behind use in high-resource areas. Moreover, there is a scarcity of research that specifically examines the user experience, readiness for and challenges of integrating wearable sensors into health research and community interventions in low-resource settings specifically. This study summarizes the reactions and experiences of young women (N = 57), ages 18 to 24 years, living in poverty in Kampala, Uganda, who wore Garmin vívoactive 3 smartwatches for five days for a research project. Data collected from the Garmins included participant location, sleep, and heart rate. Through six focus group discussions, we gathered insights about the participants' experiences and perceptions of the wearable devices. Overall, the wearable devices were met with great interest and enthusiasm by participants. The findings were organized across 10 domains to highlight reactions and experiences pertaining to device settings, challenges encountered with the device, reports of discomfort/comfort, satisfaction, changes in daily activities, changes to sleep, speculative device usage, community reactions, community dynamics and curiosity, and general device comfort. The study sheds light on the introduction of new technology in a low-resource setting and also on the complex interplay between technology and culture in Kampala's slums. We also learned some insights into how wearable devices and perceptions may influence behaviors and social dynamics. These practical insights are shared to benefit future research and applications by health practitioners and clinicians to advance and enhance the implementation and effectiveness of wearable devices in similar contexts and populations. These insights and user experiences, if incorporated, may enhance device acceptance and data quality for those conducting research in similar settings or seeking to address population-specific needs and health issues.

How to design equitable digital health tools: A narrative review of design tactics, case studies, and opportunities

With a renewed focus on health equity in the United States driven by national crises and legislation to improve digital healthcare innovation, there is a need for the designers of digital health tools to take deliberate steps to design for equity in their work. A concrete toolkit of methods to design for health equity is needed to support digital health practitioners in this aim. This narrative review summarizes several health equity frameworks to help digital health practitioners conceptualize the equity dimensions of importance for their work, and then provides design approaches that accommodate an equity focus. Specifically, the Double Diamond Model, the IDEAS framework and toolkit, and community collaboration techniques such as participatory design are explored as mechanisms for practitioners to solicit input from members of underserved groups and better design digital health tools that serve their needs. Each of these design methods requires a deliberate effort by practitioners to infuse health equity into the approach. A series of case studies that use different methods to build in equity considerations are offered to provide examples of how this can be accomplished and demonstrate the range of applications available depending on resources, budget, product maturity, and other factors. We conclude with a call for shared rigor around designing digital health tools that deliver equitable outcomes for members of underserved populations.

eHealth tools to assess the neurological function for research, in absence of the neurologist - a systematic review, part I (software)

BACKGROUND

Neurological disorders remain a worldwide concern due to their increasing prevalence and mortality, combined with the lack of available treatment, in most cases. Exploring protective and risk factors associated with the development of neurological disorders will allow for improving prevention strategies. However, ascertaining neurological outcomes in population-based studies can be both complex and costly. The application of eHealth tools in research may contribute to lowering the costs and increase accessibility. The aim of this systematic review is to map existing eHealth tools assessing neurological signs and/or symptoms for epidemiological research.

METHODS

Four search engines (PubMed, Web of Science, Scopus & EBSCOHost) were used to retrieve articles on the development, validation, or implementation of eHealth tools to assess neurological signs and/or symptoms. The clinical and technical properties of the software tools were summarised. Due to high numbers, only software tools are presented here.

FINDINGS

A total of 42 tools were retrieved. These captured signs and/or symptoms belonging to four neurological domains: cognitive function, motor function, cranial nerves, and gait and coordination. An additional fifth category of composite tools was added. Most of the tools were available in English and were developed for smartphone device, with the remaining tools being available as web-based platforms. Less than half of the captured tools were fully validated, and only approximately half were still active at the time of data collection.

INTERPRETATION

The identified tools often presented limitations either due to language barriers or lack of proper validation. Maintenance and durability of most tools were low. The present mapping exercise offers a detailed guide for epidemiologists to identify the most appropriate eHealth tool for their research.

FUNDING

The current study was funded by a PhD position at the University of Groningen. No additional funding was acquired.

A RE-AIM Analysis of a Mental Health App for Undergraduate and Medical Students during the COVID-19 Pandemic: A Retrospective Cross-Sectional Study

OBJECTIVE

The purpose of this study was to use the RE-AIM framework to evaluate the implementation of a mental health app designed for undergraduate and medical students during the COVID-19 pandemic.

PARTICIPANTS

Medical (n = 270) and undergraduate students (n = 1386) from five universities in the Appalachian region in the United States participated in this study.

METHODS

Universities from the United States were recruited to deploy the Sharpen app for medical and undergraduate students. The Sharpen app provided psychoeducational modules in mental health literacy, social-emotional learning, mindfulness-based stress reduction, and suicide prevention to promote protective factors for students. The utilization of the Sharpen app was analyzed using the RE-AIM framework using a retrospective, cross-sectional design.

RESULTS

Reach: A total of 12.72% of medical students and 6.00% of undergraduate students participated in the study.

EFFICACY

Medical students viewed significantly more pages, had a significantly higher unique page view average, and a statistically significant exit percentage when compared to undergraduate students. Adoption: A total of 100% of the universities that were recruited participated in the study.

IMPLEMENTATION

Five out of six implementation criteria were included, indicating high implementation. Maintenance: All of the universities continued using the Sharpen app following the end of data collection, resulting in a 100% maintenance rate.

CONCLUSIONS

The RE-AIM framework indicated usability and maintenance by medical and undergraduate students. Future research needs to implement a more rigorous design to determine the impact of the Sharpen app on mental health outcomes in medical and undergraduate students.

The facilitators and barriers of mHealth adoption and use among people with a low socio-economic position: A scoping review

Background

Despite the fact that 95% of the global population has a mobile phone, the adoption of mHealth lags among people with a low socio-economic position (SEP). As they face health risks and many barriers in the traditional offline healthcare system, mHealth has an important role. Therefore, it is important to understand the factors that promote and impede mHealth adoption among people with a lower SEP.

Objective

The current study aims to provide an overview of what is known about the facilitators and barriers to the adoption and use of autonomous mHealth applications among people with low SEP.

Methods

A PRISMA scoping review in which the scientific databases PubMed, Web of Science, PsychInfo and SocINDEX were searched in the period of March 2017 to March 2022.

Results

Of the 1827 indexed papers, 13 papers were included in the review. In these papers, 30 factors have been identified as promoting or hindering the adoption of autonomous mHealth applications among low SEP people.

Conclusions

Thirty factors were found to facilitate or impede mHealth adoption among people with a low SEP, categorised into intrapersonal, interpersonal, community, ecological and app specific levels. Factors are assumed to be interrelated. The relationship between traditional (offline) care and digital care appeared to be of particular interest as the current study revealed that face-to-face contact is a prerequisite of mHealth adoption among people with low SEP. Therefore, a well-structured cosmopolitan system of stakeholders has been recommended.

Trial registration

This study was registered in OSF (https://doi.org/10.17605/OSF.IO/ATU9D).

Digital Health Technologies Applied by the Pharmaceutical Industry to Improve Access to Noncommunicable Disease Care in Low- and Middle-Income Countries

BACKGROUND

There is limited research on how digital health technologies (DHTs) are used to promote access to care for patients with noncommunicable diseases (NCDs), particularly in low- and middle-income countries (LMICs). We describe the use of DHTs in pharmaceutical industry-led access programs aimed at improving access to NCD care in LMICs.

METHODS

The Access Observatory is the largest publicly available repository containing detailed information about pharmaceutical industry-led access programs targeting NCDs. The repository includes 101 access program reports submitted by 19 pharmaceutical companies. From each report, we extracted data relating to geographic location, disease area, beneficiary population, use of DHTs, partnerships, strategies, and activities. Data were analyzed descriptively using SAS Statistical Software and categorized according to the World Health Organization Digital Health Classification Framework.

RESULTS

A total of 43 access programs (42.6%) included DHTs. The majority of programs using DHTs were clustered across sub-Saharan Africa (72.1%) and targeted cancer (60.5%) followed by metabolic disorders (39.5%). The applied DHTs mostly related to program strategies on health service strengthening (74.4%) and community awareness (41.9%) and were largely directed toward health providers, followed by data services and clients. Only a few DHTs were used for health system management. To promote access, most DHTs focused on improving data collection, management, and use (51.1%); building health provider capacity through training (37.2%); and providing targeted patient information (34.8%).

CONCLUSION

The range of DHTs applied by the pharmaceutical industry offers opportunities for more effective access to NCD care. Transparent reporting on DHT use and its contributions to access programs' achievements may reduce duplicative and redundant efforts and provide learnings for private and public stakeholders that may contribute to greater access to NCD care in LMICs.

The impact of community-based non-pharmacological interventions on cardiovascular and kidney disease outcomes in remote dwelling Indigenous communities: A scoping review protocol

Introduction

Indigenous people represent approximately 5% of the world’s population. However, they often have a disproportionately higher burden of cardiovascular disease (CVD) risk and chronic kidney disease (CKD) than their equivalent general population. Several non-pharmacological interventions (e.g., educational) have been used to reduce CVD and kidney disease risk factors in Indigenous groups. The aim of this paper is to describe the protocol for a scoping review that will assess the impact of non-pharmacological interventions carried out in Indigenous and remote dwelling populations to reduce CVD risk factors and CKD.

Materials and methods

This scoping review will be guided by the methodological framework for conducting scoping studies developed by Arksey and O’Malley. Both empirical (Medline, Embase, Cochrane Library, CINAHL, ISI Web of Science and PsycINFO) and grey literature references will be assessed if they focused on interventions targeted at reducing CVD or CKD among Indigenous groups. Two reviewers will independently screen references in consecutive stages of title/abstract screening and then full-text screening. Impact of interventions used will be assessed using the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework. A descriptive overview, tabular summaries, and content analysis will be carried out on the extracted data.

Ethics and dissemination

This review will collect and analyse evidence on the impact of interventions of research carried out to reduce CVD and CKD among Indigenous populations. Such evidence will be disseminated using traditional approaches that includes open-access peer-reviewed publication, scientific presentations, and a report. Also, we will disseminate our findings to the government and Indigenous leaders. Ethical approval will not be required for this scoping review as the data used will be extracted from already published studies with publicly accessible data.

Effects of a Novel Blood Glucose Forecasting Feature on Glycemic Management and Logging in Adults With Type 2 Diabetes Using One Drop: Retrospective Cohort Study

Background

Personalized feedback is an effective behavior change technique frequently incorporated into mobile health (mHealth) apps. Innovations in data science create opportunities for leveraging the wealth of user data accumulated by mHealth apps to generate personalized health forecasts. One Drop’s digital program is one of the first to implement blood glucose forecasts for people with type 2 diabetes. The impact of these forecasts on behavior and glycemic management has not been evaluated to date.

Objective

This study sought to evaluate the impact of exposure to blood glucose forecasts on blood glucose logging behavior, average blood glucose, and percentage of glucose points in range.

Methods

This retrospective cohort study examined people with type 2 diabetes who first began using One Drop to record their blood glucose between 2019 and 2021. Cohorts included those who received blood glucose forecasts and those who did not receive forecasts. The cohorts were compared to evaluate the effect of exposure to blood glucose forecasts on logging activity, average glucose, and percentage of glucose readings in range, after controlling for potential confounding factors. Data were analyzed using analysis of covariance (ANCOVA) and regression analyses.

Results

Data from a total of 1411 One Drop users with type 2 diabetes and elevated baseline glucose were analyzed. Participants (60.6% male, 795/1311; mean age 50.2 years, SD 11.8) had diabetes for 7.1 years on average (SD 7.9). After controlling for potential confounding factors, blood glucose forecasts were associated with more frequent blood glucose logging (P=.004), lower average blood glucose (P<.001), and a higher percentage of readings in range (P=.03) after 12 weeks. Blood glucose logging partially mediated the relationship between exposure to forecasts and average glucose.

Conclusions

Individuals who received blood glucose forecasts had significantly lower average glucose, with a greater amount of glucose measurements in a healthy range after 12 weeks compared to those who did not receive forecasts. Glucose logging was identified as a partial mediator of the relationship between forecast exposure and week-12 average glucose, highlighting a potential mechanism through which glucose forecasts exert their effect. When administered as a part of a comprehensive mHealth program, blood glucose forecasts may significantly improve glycemic management among people living with type 2 diabetes.

Clinical and patient-centered implementation outcomes of mHealth interventions for type 2 diabetes in low-and-middle income countries: a systematic review

BACKGROUND

The prevalence of Type 2 Diabetes is rising in Low- and Middle-Income Countries (LMICs), affecting all age categories and resulting in huge socioeconomic implications. Mobile health (mHealth) is a potential high-impact approach to improve clinical and patient-centered outcomes despite the barriers of cost, language, literacy, and internet connectivity. Therefore, it is valuable to examine the clinical and implementation outcomes of mHealth interventions for Type 2 Diabetes in LMICs.

METHODS

The Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines were applied in framing and reporting the review criteria. A systematic search of Cochrane Library, Web of Science, PubMed, Scopus, and Ovid databases was performed through a combination of search terms. Randomized Controlled Trials (RCTs) and cohort studies published in English between January 2010 and August 2021 were included. Risk of bias for missing results in the included studies was assessed using the Cochrane risk-of-bias tool for randomized trials (RoB 2). Quantitative and qualitative methods were used to synthesize the results.

RESULTS

The search identified a total of 1161 articles. Thirty studies from 14 LMICs met the eligibility criteria. On clinical outcomes, 12 and 9 studies reported on glycated hemoglobin (HbA1c )and fasting blood glucose (FBG) respectively. Text messages was the most commonly applied mHealth approach, used in 19 out of the 30 studies. Ten out of the 12 studies (83.3%) that reported on HbA1c had a percentage difference of <0.3% between the mHealth intervention and the comparison group. Additionally, studies with longer intervention periods had higher effect size and percentage difference on HbA1c (1.52 to 2.92%). Patient-centred implementation outcomes were reported variedly, where feasibility was reported in all studies. Acceptability was reported in nine studies, appropriateness in six studies and cost in four studies. mHealth evidence reporting and assessment (mERA) guidelines were not applied in all the studies in this review.   CONCLUSION: mHealth interventions in LMICs are associated with clinically significant effectiveness on HbA1 but have low effectiveness on FBG. The application of mERA guidelines may standardize reporting of patient-centered implementation outcomes in LMICs.

TRIAL REGISTRATION

PROSPERO: Registration ID 154209.

World Heart Federation Roadmap for Digital Health in Cardiology

More than 500 million people worldwide live with cardiovascular disease (CVD). Health systems today face fundamental challenges in delivering optimal care due to ageing populations, healthcare workforce constraints, financing, availability and affordability of CVD medicine, and service delivery. Digital health technologies can help address these challenges. They may be a tool to reach Sustainable Development Goal 3.4 and reduce premature mortality from non-communicable diseases (NCDs) by a third by 2030. Yet, a range of fundamental barriers prevents implementation and access to such technologies. Health system governance, health provider, patient and technological factors can prevent or distort their implementation. World Heart Federation (WHF) roadmaps aim to identify essential roadblocks on the pathway to effective prevention, detection, and treatment of CVD. Further, they aim to provide actionable solutions and implementation frameworks for local adaptation. This WHF Roadmap for digital health in cardiology identifies barriers to implementing digital health technologies for CVD and provides recommendations for overcoming them.