Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study

The ethical dimension of personal health monitoring in the armed forces: a scoping review

BACKGROUND

Personal Health Monitoring (PHM) has the potential to enhance soldier health outcomes. To promote morally responsible development, implementation, and use of PHM in the armed forces, it is important to be aware of the inherent ethical dimension of PHM. In order to improve the understanding of the ethical dimension, a scoping review of the existing academic literature on the ethical dimension of PHM was conducted.

METHODS

Four bibliographical databases (Ovid/Medline, Embase.com, Clarivate Analytics/Web of Science Core Collection, and Elsevier/SCOPUS) were searched for relevant literature from their inception to June 1, 2023. Studies were included if they sufficiently addressed the ethical dimension of PHM and were related to or claimed relevance for the military. After selection and extraction, the data was analysed using a qualitative thematic approach.

RESULTS

A total of 9,071 references were screened. After eligibility screening, 19 articles were included for this review. The review identifies and describes three categories reflecting the ethical dimension of PHM in the military: (1) utilitarian considerations, (2) value-based considerations, and (3) regulatory responsibilities. The four main values that have been identified as being of concern are those of privacy, security, trust, and autonomy.

CONCLUSIONS

This review demonstrates that PHM in the armed forces is primarily approached from a utilitarian perspective, with a focus on its benefits, without explicit critical deliberation on PHM's potential moral downsides. Also, the review highlights a significant research gap with a specific lack of empirical studies focussing specifically on the ethical dimension of PHM. Awareness of the inherent ethical dimension of PHM in the military, including value conflicts and how to balance them, can help to contribute to a morally responsible development, implementation, and use of PHM in the armed forces.

Exploring User Perspectives on Brief Reflective Questioning Activities for Stress Management: Mixed Methods Study

BACKGROUND

Current online interventions dedicated to assisting individuals in managing stress and negative emotions often necessitate substantial time commitments. This can be burdensome for users, leading to high dropout rates and reducing the effectiveness of these interventions. This highlights an urgent need for concise digital activities that individuals can swiftly access during instances of negative emotions or stress in their daily lives.

OBJECTIVE

The primary aim of this study was to investigate the viability of using a brief digital exercise, specifically a reflective questioning activity (RQA), to help people reflect on their thoughts and emotions about a troubling situation. The RQA is designed to be quick, applicable to the general public, and scalable without requiring a significant support structure.

METHODS

We conducted 3 simultaneous studies. In the first study, we recruited 48 participants who completed the RQA and provided qualitative feedback on its design through surveys and semistructured interviews. In the second study, which involved 215 participants from Amazon Mechanical Turk, we used a between-participants design to compare the RQA with a single-question activity. Our hypotheses posited that the RQA would yield greater immediate stress relief and higher perceived utility, while not significantly altering the perception of time commitment. To assess these, we measured survey completion times and gathered multiple self-reported scores. In the third study, we assessed the RQA's real-world impact as a periodic intervention, exploring engagement via platforms such as email and SMS text messaging, complemented by follow-up interviews with participants.

RESULTS

In our first study, participants appreciated the RQA for facilitating structured reflection, enabling expression through writing, and promoting problem-solving. However, some of the participants experienced confusion and frustration, particularly when they were unable to find solutions or alternative perspectives on their thoughts. In the second study, the RQA condition resulted in significantly higher ratings (P=.003) for the utility of the activity and a statistically significant decrease (P<.001) in perceived stress rating compared with the single-question activity. Although the RQA required significantly more time to be completed (P<.001), there was no statistically significant difference in participants' subjective perceived time commitment (P=.37). Deploying the RQA over 2 weeks in the third study identified some potential challenges to consider for such activities, such as the monotony of doing the same activity several times, the limited affordances of mobile phones, and the importance of having the prompts align with the occurrence of new troubling situations.

CONCLUSIONS

This paper describes the design and evaluation of a brief online self-reflection activity based on cognitive behavioral therapy principles. Our findings can inform practitioners and researchers in the design and exploration of formats for brief interventions to help people with everyday struggles.

Acceptability of workplace choice architecture modification for healthy behaviours

BACKGROUND

Altering the choice architecture of decision contexts can assist behaviour change, but the acceptability of this approach has sparked debate. Considering hypothetical interventions, people generally welcome the approach for promoting health, but little evidence exists on acceptance in the real world. Furthermore, research has yet to explore the implementers' perspective, acknowledging the multidimensionality of the acceptability construct. Addressing these knowledge gaps, this study evaluated the acceptability of a quasi-experimental implementation-effectiveness trial that modified the worksite choice architecture for healthy eating and daily physical activity.

METHODS

Fifty-three worksites participated in the 12-month intervention and implemented altogether 23 choice architecture strategies (Mdn 3/site), including point-of-choice prompts and changes to choice availability or accessibility. Retrospective acceptability evaluation built on deductive qualitative content analysis of implementer interviews (n = 65) and quantitative analysis of an employee questionnaire (n = 1124). Qualitative analysis examined implementers' thoughts and observations of the intervention and its implementation, considering six domains of the Theoretical Framework of Acceptability: ethicality, affective attitude, burden, intervention coherence, opportunity costs, and perceived effectiveness. Quantitative analysis examined employees' acceptance (7-point Likert scale) of eight specific intervention strategies using Friedman test and mixed-effects logistic regression.

RESULTS

Implementers considered the choice architecture approach ethical for workplace health promotion, reported mostly positive affective attitudes to and little burden because of the intervention. Intervention coherence supported acceptance through increased interest in implementation, whereas low perceived utility and high intensity of implementation reduced cost acceptance. Perceived effectiveness was mixed and varied along factors related to the implementer, social/physical work environment, employer, and employee. Employees showed overall high acceptance of evaluated strategies (Mdn 7, IQR 6.4-7), though strategies replacing unhealthy foods with healthier alternatives appeared less supported than providing information or enhancing healthy option availability or accessibility (p-values < 0.02). Greater proportion of male employees per site predicted lower overall acceptance (OR 4.4, 95% CI 1.2-16.5).

CONCLUSIONS

Work communities appear to approve workplace choice architecture interventions for healthy eating and physical activity, but numerous factors influence acceptance and warrant consideration in future interventions. The study contributes with a theory-based, multidimensional evaluation that considered the perspectives of implementers and influenced individuals across heterogeneous real-world settings.

Sensory Appeal and Routines Beat Health Messages and Visibility Enhancements: Mixed-Methods Analysis of a Choice-Architecture Intervention in a Workplace Cafeteria

Easier recognition and enhanced visibility of healthy options supposedly increase healthy choices, but real-world evidence remains scarce. Addressing this knowledge gap, we promoted nutritionally favourable foods in a workplace cafeteria with three choice-architectural strategies-priming posters, point-of-choice nutrition labels, and improved product placement-and assessed their effects on visual attention, food choices, and food consumption. Additionally, we developed a method for analysing real-world eye-tracking data. The study followed a pretest-posttest design whereby control and intervention condition lasted five days each. We monitored visual attention (i.e., total number and duration of fixations) and food choices with eye tracking, interviewed customers about perceived influences on food choices, and measured cafeteria-level food consumption (g). Individual-level data represents 22 control and 19 intervention participants recruited at the cafeteria entrance. Cafeteria-level data represents food consumption during the trial (556/589 meals sold). Results indicated that the posters and labels captured participants' visual attention (~13% of fixations on defined areas of interest before food choices), but the intervention had insignificant effects on visual attention to foods, on food choices, and on food consumption. Interviews revealed 17 perceived influences on food choices, the most common being sensory appeal, healthiness, and familiarity. To conclude, the intervention appeared capable of attracting visual attention, yet ineffective in increasing healthier eating. The developed method enabled a rigorous analysis of visual attention and food choices in a natural choice setting. We discuss ways to boost the impact of the intervention on behaviour, considering target groups' motives. The work contributes with a unique, mixed-methods approach and a real-world setting that enabled a multi-dimensional effects evaluation with high external validity.

Veteran and Staff Experience from a Pilot Program of Health Care System-Distributed Wearable Devices and Data Sharing

OBJECTIVE

 The growing trend to use wearable devices to track activity and health data has the potential to positively impact the patient experience with their health care at home and with their care team. As part of a pilot program, the U.S. Department of Veterans Affairs (VA) distributed Fitbits to Veterans through four VA medical centers. Our objective was to assess the program from both Veterans' and clinicians' viewpoints. Specifically, we aimed to understand barriers to Fitbit setup and use for Veterans, including syncing devices with a VA mobile application (app) to share data, and assess the perceived value of the device functions and ability to share information from the Fitbit with their care team. In addition, we explored the clinicians' perspective, including how they expected to use the patient-generated health data (PGHD).

METHODS

 We performed semi-structured interviews with 26 Veterans and 16 VA clinicians to assess the program. Responses to each question were summarized in order of frequency of occurrence across participants and audited by an independent analyst for accuracy.

RESULTS

 Our findings reveal that despite setup challenges, there is support for the use of Fitbits to engage Veterans and help manage their health. Clinicians believed there were benefits for having Veterans use the Fitbits and expected to use the PGHD in a variety of ways as part of the Veterans' care plans, including monitoring progress toward health behavior goals. Veterans were overwhelmingly enthusiastic about using the Fitbits; this enthusiasm seems to extend beyond the 3 month "novelty period."

CONCLUSION

 The pilot program for distributing Fitbits to Veterans appears to be successful from both Veterans' and clinicians' perspectives and suggests that expanded use of wearable devices should be considered. Future studies will need to carefully consider how to incorporate the PGHD into the electronic health record and clinical workflow.

Choice Architecture Cueing to Healthier Dietary Choices and Physical Activity at the Workplace: Implementation and Feasibility Evaluation

Redesigning choice environments appears a promising approach to encourage healthier eating and physical activity, but little evidence exists of the feasibility of this approach in real-world settings. The aim of this paper is to portray the implementation and feasibility assessment of a 12-month mixed-methods intervention study, StopDia at Work, targeting the environment of 53 diverse worksites. The intervention was conducted within a type 2 diabetes prevention study, StopDia. We assessed feasibility through the fidelity, facilitators and barriers, and maintenance of implementation, building on implementer interviews (n = 61 informants) and observations of the worksites at six (t1) and twelve months (t2). We analysed quantitative data with Kruskall-Wallis and Mann-Whitney U tests and qualitative data with content analysis. Intervention sites altogether implemented 23 various choice architectural strategies (median 3, range 0-14 strategies/site), employing 21 behaviour change mechanisms. Quantitative analysis found implementation was successful in 66%, imperfect in 25%, and failed in 9% of evaluated cases. These ratings were independent of the ease of implementation of applied strategies and reminders that implementers received. Researchers' assistance in intervention launch (p = 0.02) and direct contact to intervention sites (p < 0.001) predicted higher fidelity at t1, but not at t2. Qualitative content analysis identified facilitators and barriers related to the organisation, intervention, worksite environment, implementer, and user. Contributors of successful implementation included apt implementers, sufficient implementer training, careful planning, integration into worksite values and activities, and management support. After the study, 49% of the worksites intended to maintain the implementation in some form. Overall, the choice architecture approach seems suitable for workplace health promotion, but a range of practicalities warrant consideration while designing real-world implementation.

Ensuring patient and public involvement in the transition to AI-assisted mental health care: A systematic scoping review and agenda for design justice

Background

Machine‐learning algorithms and big data analytics, popularly known as ‘artificial intelligence’ (AI), are being developed and taken up globally. Patient and public involvement (PPI) in the transition to AI‐assisted health care is essential for design justice based on diverse patient needs.

Objective

To inform the future development of PPI in AI‐assisted health care by exploring public engagement in the conceptualization, design, development, testing, implementation, use and evaluation of AI technologies for mental health.

Methods

Systematic scoping review drawing on design justice principles, and (i) structured searches of Web of Science (all databases) and Ovid (MEDLINE, PsycINFO, Global Health and Embase); (ii) handsearching (reference and citation tracking); (iii) grey literature; and (iv) inductive thematic analysis, tested at a workshop with health researchers.

Results

The review identified 144 articles that met inclusion criteria. Three main themes reflect the challenges and opportunities associated with PPI in AI‐assisted mental health care: (a) applications of AI technologies in mental health care; (b) ethics of public engagement in AI‐assisted care; and (c) public engagement in the planning, development, implementation, evaluation and diffusion of AI technologies.

Conclusion

The new data‐rich health landscape creates multiple ethical issues and opportunities for the development of PPI in relation to AI technologies. Further research is needed to understand effective modes of public engagement in the context of AI technologies, to examine pressing ethical and safety issues and to develop new methods of PPI at every stage, from concept design to the final review of technology in practice. Principles of design justice can guide this agenda.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

Background

Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.

Objective

This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.

Methods

A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.

Results

A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.

Conclusions

Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

Exploring Suicidal Ideation Using an Innovative Mobile App-Strength Within Me: The Usability and Acceptability of Setting up a Trial Involving Mobile Technology and Mental Health Service Users

BACKGROUND

Suicide is a growing global public health problem that has resulted in an increase in the demand for psychological services to address mental health issues. It is expected that 1 in 6 people on a waiting list for mental health services will attempt suicide. Although suicidal ideation has been shown to be linked to a higher risk of death by suicide, not everybody openly discloses their suicidal thoughts or plans to friends and family or seeks professional help before suicide. Therefore, new methods are needed to track suicide risk in real time together with a better understanding of the ways in which people communicate or express their suicidality. Considering the dynamic nature and challenges in understanding suicide ideation and suicide risk, mobile apps could be better suited to prevent suicide as they have the ability to collect real-time data.

OBJECTIVE

This study aims to report the practicalities and acceptability of setting up and trialing digital technologies within an inpatient mental health setting in the United Kingdom and highlight their implications for future studies.

METHODS

Service users were recruited from 6 inpatient wards in the north west of England. Service users who were eligible to participate and provided consent were given an iPhone and Fitbit for 7 days and were asked to interact with a novel phone app, Strength Within Me (SWiM). Interaction with the app involved journaling (recording daily activities, how this made them feel, and rating their mood) and the option to create safety plans for emotions causing difficulties (identifying strategies that helped with these emotions). Participants also had the option to allow the study to access their personal Facebook account to monitor their social media use and activity. In addition, clinical data (ie, assessments conducted by trained researchers targeting suicidality, depression, and sleep) were also collected.

RESULTS

Overall, 43.0% (80/186 response rate) of eligible participants were recruited for the study. Of the total sample, 67 participants engaged in journaling, with the average number of entries per user being 8.2 (SD 8.7). Overall, only 24 participants created safety plans and the most common difficult emotion to be selected was feeling sad (n=21). This study reports on the engagement with the SWiM app, the technical difficulties the research team faced, the importance of building key relationships, and the implications of using Facebook as a source to detect suicidality.

CONCLUSIONS

To develop interventions that can be delivered in a timely manner, prediction of suicidality must be given priority. This paper has raised important issues and highlighted lessons learned from implementing a novel mobile app to detect the risk of suicidality for service users in an inpatient setting.

Clinician Perspectives and Design Implications in Using Patient-Generated Health Data to Improve Mental Health Practices: Mixed Methods Study

Background

Patient-generated health data (PGHD) have been largely collected through mobile health (mHealth) apps and wearable devices. PGHD can be especially helpful in mental health, as patients’ illness history and symptom narratives are vital to developing diagnoses and treatment plans. However, the extent to which clinicians use mental health–related PGHD is unknown.

Objective

A mixed methods study was conducted to understand clinicians’ perspectives on PGHD and current mental health apps. This approach uses information gathered from semistructured interviews, workflow analysis, and user-written mental health app reviews to answer the following research questions: (1) What is the current workflow of mental health practice and how are PGHD integrated into this workflow, (2) what are clinicians’ perspectives on PGHD and how do they choose mobile apps for their patients, (3) and what are the features of current mobile apps in terms of interpreting and sharing PGHD?

Methods

The study consists of semistructured interviews with 12 psychiatrists and clinical psychologists from a large academic hospital. These interviews were thematically and qualitatively analyzed for common themes and workflow elements. User-posted reviews of 56 sleep and mood tracking apps were analyzed to understand app features in comparison with the information gathered from interviews.

Results

The results showed that PGHD have been part of the workflow, but its integration and use are not optimized. Mental health clinicians supported the use of PGHD but had concerns regarding data reliability and accuracy. They also identified challenges in selecting suitable apps for their patients. From the app review, it was discovered that mHealth apps had limited features to support personalization and collaborative care as well as data interpretation and sharing.

Conclusions

This study investigates clinicians’ perspectives on PGHD use and explored existing app features using the app review data in the mental health setting. A total of 3 design guidelines were generated: (1) improve data interpretation and sharing mechanisms, (2) consider clinical workflow and electronic health record integration, and (3) support personalized and collaborative care. More research is needed to demonstrate the best practices of PGHD use and to evaluate their effectiveness in improving patient outcomes.

Provider Perspectives on Integrating Sensor-Captured Patient-Generated Data in Mental Health Care

The increasing ubiquity of health sensing technology holds promise to enable patients and health care providers to make more informed decisions based on continuously-captured data. The use of sensor-captured patient-generated data (sPGD) has been gaining greater prominence in the assessment of physical health, but we have little understanding of the role that sPGD can play in mental health. To better understand the use of sPGD in mental health, we interviewed care providers in an intensive treatment program (ITP) for veterans with post-traumatic stress disorder. In this program, patients were given Fitbits for their own voluntary use. Providers identified a number of potential benefits from patients' Fitbit use, such as patient empowerment and opportunities to reinforce therapeutic progress through collaborative data review and interpretation. However, despite the promise of sensor data as offering an "objective" view into patients' health behavior and symptoms, the relationships between sPGD and therapeutic progress are often ambiguous. Given substantial subjectivity involved in interpreting data from commercial wearables in the context of mental health treatment, providers emphasized potential risks to their patients and were uncertain how to adjust their practice to effectively guide collaborative use of the FitBit and its sPGD. We discuss the implications of these findings for designing systems to leverage sPGD in mental health care.

The Role of Data Type and Recipient in Individuals' Perspectives on Sharing Passively Collected Smartphone Data for Mental Health: Cross-Sectional Questionnaire Study

Background

The growing field of personal sensing harnesses sensor data collected from individuals’ smartphones to understand their behaviors and experiences. Such data could be a powerful tool within mental health care. However, it is important to note that the nature of these data differs from the information usually available to, or discussed with, health care professionals. To design digital mental health tools that are acceptable to users, understanding how personal sensing data can be used and shared is critical.

Objective

This study aimed to investigate individuals’ perspectives about sharing different types of sensor data beyond the research context, specifically with doctors, electronic health record (EHR) systems, and family members.

Methods

A questionnaire assessed participants’ comfort with sharing six types of sensed data: physical activity, mood, sleep, communication logs, location, and social activity. Participants were asked about their comfort with sharing these data with three different recipients: doctors, EHR systems, and family members. A series of principal component analyses (one for each data recipient) was performed to identify clusters of sensor data types according to participants’ comfort with sharing them. Relationships between recipients and sensor clusters were then explored using generalized estimating equation logistic regression models.

Results

A total of 211 participants completed the questionnaire. The majority were female (171/211, 81.0%), and the mean age was 38 years (SD 10.32). Principal component analyses consistently identified two clusters of sensed data across the three data recipients: “health information,” including sleep, mood, and physical activity, and “personal data,” including communication logs, location, and social activity. Overall, participants were significantly more comfortable sharing any type of sensed data with their doctor than with the EHR system or family members (P<.001) and more comfortable sharing “health information” than “personal data” (P<.001). Participant characteristics such as age or presence of depression or anxiety did not influence participants’ comfort with sharing sensed data.

Conclusions

The comfort level in sharing sensed data was dependent on both data type and recipient, but not individual characteristics. Given the identified differences in comfort with sensed data sharing, contextual factors of data type and recipient appear to be critically important as we design systems that harness sensor data for mental health treatment and support.