Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

A preventive integrated eHealth approach for individuals with a low socioeconomic position: protocol for a realist evaluation

BACKGROUND

Adoption of standalone eHealth tools is low among persons in lower socioeconomic groups. The preventive integrated eHealth approach combines blended care with an active and personal approach to facilitate access to local care, tailored to the needs of the participant. We describe the four step preventive integrated eHealth approach for individuals with a low socioeconomic position and the realist evaluation protocol of the intervention and implementation. The realist evaluation centers around the question, 'what works for whom in what circumstances and why'.

METHODS

The study population will consist of adult individuals with a low socioeconomic position, who participate in the preventive integrated eHealth approach in one of the participating locations in the Netherlands. The four-step intervention consists of: (1) a proactive invitation of participants by care professionals, (2) the use of an eHealth tool that produces a personalized health report, (3) a personal consultation with a care professional to discuss the personalized health report and set a goal to work on, and (4) active referral to local social and health care. An initial program theory theorized from literature and stakeholder involvement is presented. Qualitative and quantitative data collection and analysis with participants (survey at zero, three and twelve months and focus groups at six months) and professionals (interviews at three months) will inform the realist evaluation and serves to test and refine the initial program theory.

DISCUSSION

Our mixed-methods realist evaluation on the effect and implementation of a personal and active blended care approach will elucidate what elements trigger the mechanisms and responses of how individuals with a low socioeconomic position experience the preventive integrated eHealth approach. This will inform the way a preventative health check incorporating eHealth can be used to its full potential for low socioeconomic positioned groups to help close the digital divide and contribute to reduce health disparities.

Do immigrants know less than natives about cancer screening tests? - the case of Netherlands

Introduction

The Netherlands was one of the first countries in Europe to offer breast, colorectal and cervical cancer screening tests free of charge. Yet, a significant share of migrants in the Netherlands forgo the use of these preventive screenings. Qualitative research suggests, that lack of system knowledge on how the healthcare system operates (e.g. age eligibility of cancer screenings), is one factor contributing to this underuse among migrants. However, little is known about the extent to which migrants differ from natives in their system knowledge and about potential causes of this ethnic gap. The contribution of this study is therefore twofold: First, we examine whether migrants in the Netherlands have lower system knowledge regarding cancer screenings than the natives. Second, we examine which factors explain potential ethnic differences in system knowledge between migrants and non-migrants.

Method

Using the Longitudinal Internet Study for Social Sciences (LISS), we matched newly collected data on system knowledge about healthcare with Health module (wave 14). To assess the difference in system knowledge among migrants and non-migrants, while taking into account potential selection bias, we applied propensity score matching, one-to-one matching procedure with no replacement. We compared first generation non - Western migrants (FNWM) and second-generation non-western migrants (SNWM) with their most similar non-migrants group regarding their knowledge about breast, colorectal, and cervical screening. A Blinder-Oaxaca decomposition with non-matched samples was used to examine which factors can explain the differences in system knowledge among migrants and non-migrants.

Results

Our results show that first generation migrants have lower system knowledge about all three screening tests, while second generation migrants differ from non-migrants only with regard to knowledge about breast and colorectal cancer screenings. The ethnic differences found are not caused by personal or social factors such as education or income.

Conclusion

We recommend Dutch healthcare policy makes to focus in the strengthen of cancer screening system knowledge among migrant populations in order to increase their participation in these screening programs.

Chatbot for Social Need Screening and Resource Sharing With Vulnerable Families: Iterative Design and Evaluation Study

BACKGROUND

Health outcomes are significantly influenced by unmet social needs. Although screening for social needs has become common in health care settings, there is often poor linkage to resources after needs are identified. The structural barriers (eg, staffing, time, and space) to helping address social needs could be overcome by a technology-based solution.

OBJECTIVE

This study aims to present the design and evaluation of a chatbot, DAPHNE (Dialog-Based Assistant Platform for Healthcare and Needs Ecosystem), which screens for social needs and links patients and families to resources.

METHODS

This research used a three-stage study approach: (1) an end-user survey to understand unmet needs and perception toward chatbots, (2) iterative design with interdisciplinary stakeholder groups, and (3) a feasibility and usability assessment. In study 1, a web-based survey was conducted with low-income US resident households (n=201). Following that, in study 2, web-based sessions were held with an interdisciplinary group of stakeholders (n=10) using thematic and content analysis to inform the chatbot's design and development. Finally, in study 3, the assessment on feasibility and usability was completed via a mix of a web-based survey and focus group interviews following scenario-based usability testing with community health workers (family advocates; n=4) and social workers (n=9). We reported descriptive statistics and chi-square test results for the household survey. Content analysis and thematic analysis were used to analyze qualitative data. Usability score was descriptively reported.

RESULTS

Among the survey participants, employed and younger individuals reported a higher likelihood of using a chatbot to address social needs, in contrast to the oldest age group. Regarding designing the chatbot, the stakeholders emphasized the importance of provider-technology collaboration, inclusive conversational design, and user education. The participants found that the chatbot's capabilities met expectations and that the chatbot was easy to use (System Usability Scale score=72/100). However, there were common concerns about the accuracy of suggested resources, electronic health record integration, and trust with a chatbot.

CONCLUSIONS

Chatbots can provide personalized feedback for families to identify and meet social needs. Our study highlights the importance of user-centered iterative design and development of chatbots for social needs. Future research should examine the efficacy, cost-effectiveness, and scalability of chatbot interventions to address social needs.

Inequalities in the Ability for People With Type 2 Diabetes and Prediabetes to Adapt to the Reduction in In-Person Health Support and Increased Use of Digital Support During the COVID-19 Pandemic and Beyond: Qualitative Study

BACKGROUND

The COVID-19 pandemic created unprecedented challenges for people with type 2 diabetes (T2D) and prediabetes to access in-person health care support. Primary care teams accelerated plans to implement digital health technologies (DHTs), such as remote consultations and digital self-management. There is limited evidence about whether there were inequalities in how people with T2D and prediabetes adjusted to these changes.

OBJECTIVE

This study aimed to explore how people with T2D and prediabetes adapted to the reduction in in-person health support and the increased provision of support through DHTs during the COVID-19 pandemic and beyond.

METHODS

A purposive sample of people with T2D and prediabetes was recruited by text message from primary care practices that served low-income areas. Semistructured interviews were conducted by phone or video call, and data were analyzed thematically using a hybrid inductive and deductive approach.

RESULTS

A diverse sample of 30 participants was interviewed. There was a feeling that primary care had become harder to access. Participants responded to the challenge of accessing support by rationing or delaying seeking support or by proactively requesting appointments. Barriers to accessing health care support were associated with issues with using the total triage system, a passive interaction style with health care services, or being diagnosed with prediabetes at the beginning of the pandemic. Some participants were able to adapt to the increased delivery of support through DHTs. Others had lower capacity to use DHTs, which was caused by lower digital skills, fewer financial resources, and a lack of support to use the tools.

CONCLUSIONS

Inequalities in motivation, opportunity, and capacity to engage in health services and DHTs lead to unequal possibilities for people with T2D and prediabetes to self-care and receive care during the COVID-19 pandemic. These issues can be addressed by proactive arrangement of regular checkups by primary care services and improving capacity for people with lower digital skills to engage with DHTs.

Needs and Demands for e-Health Interventions in Patients Attending a Psychosomatic Outpatient Clinic: A Baseline Assessment for a User-Centered Design Approach

Objective: Increased utilization of e-health services can help to meet shortages of psychotherapeutic treatment. e-Health interventions can be effective if tailored according to the individual needs and demands of the target group. To gather comprehensive data for the development of a user-centered e-health intervention, a cross-sectional study was conducted among a heterogeneous cohort of 309 patients seeking treatment or consultation at psychosomatic university hospital in a densely populated region of Germany. Methods: Sociodemographic data, psychometric dimensions of mental burden, as well as needs and demands regarding an e-health intervention were assessed. A descriptive statistical analysis and a cluster analysis were performed to examine distribution of preferences and differences based on level of burden regarding needs and demands for e-health interventions. Results: Two hundred thirty-nine (N = 239) participants were included in the final data analysis. Among this primarily urban target group smartphone availability was favored by 77.8% of the participants. The cluster analysis revealed significant differences dependent on mental burden. 75.2% of participants with a high mental burden preferred longer interventions of 1-4 months compared with 49% in the low burden group, which also considered short interventions of up to 1 month (46%). Differences were also identified for content preferences and daily-life integration and were consistent irrespective of the initial reason for consultation. Conclusion: The findings of this study can provide a foundational framework for developing user-centered psychosomatic interventions. The potential relationship between individual burden and individual needs and demands highlights the crucial role of preliminary research to tailor interventions to effectively address diverse needs and preferences.

Needs and Demands for e-Health Symptom Management Interventions in Patients with Post-COVID-19 Condition: A User-Centered Design Approach

Introduction: Post-COVID-19 is an increasing chronic disease for which potential treatment options require further development and examination. A well-established approach to symptom management in post-COVID-19 patients could be e-Health interventions. To enhance the implementation and utilization of e-Health interventions, the needs and demands of patients should be taken into consideration. The aim of this study was to investigate needs and demands of post-COVID-19 patients concerning e-Health symptom management interventions. Methods: A total of 556 patients participated in this cross-sectional online survey study. Recruitment was performed from January 19 to May 24, 2022. Data related to the needs and demands for e-Health interventions were analyzed, along with medical and sociodemographic information. Results: The majority of the patients preferred interventions accessible on smartphones (95.3%). The favored content formats were applications (82.7%), interactive training (69.3%), or audio and video materials (61.1%). Furthermore, the preferred session length was about 10-20 min. The most desired topics included "quality of life," "information about how intensively I may exert myself or do sports," "adjustment to new life situation," and "handling physical changes." Conclusions: This study provides a detailed framework for the content and design of e-Health interventions to support patients managing their post-COVID-19 symptoms. The findings could significantly influence the further development of tailored e-Health interventions to address this pressing global health concern.

Evaluating the Digital Health Experience for Patients in Primary Care: Mixed Methods Study

BACKGROUND

The digital health divide for socioeconomic disadvantage describes a pattern in which patients considered socioeconomically disadvantaged, who are already marginalized through reduced access to face-to-face health care, are additionally hindered through less access to patient-initiated digital health. A comprehensive understanding of how patients with socioeconomic disadvantage access and experience digital health is essential for improving the digital health divide. Primary care patients, especially those with chronic disease, have experience of the stages of initial help seeking and self-management of their health, which renders them a key demographic for research on patient-initiated digital health access.

OBJECTIVE

This study aims to provide comprehensive primary mixed methods data on the patient experience of barriers to digital health access, with a focus on the digital health divide.

METHODS

We applied an exploratory mixed methods design to ensure that our survey was primarily shaped by the experiences of our interviewees. First, we qualitatively explored the experience of digital health for 19 patients with socioeconomic disadvantage and chronic disease and second, we quantitatively measured some of these findings by designing and administering a survey to 487 Australian general practice patients from 24 general practices.

RESULTS

In our qualitative first phase, the key barriers found to accessing digital health included (1) strong patient preference for human-based health services; (2) low trust in digital health services; (3) high financial costs of necessary tools, maintenance, and repairs; (4) poor publicly available internet access options; (5) reduced capacity to engage due to increased life pressures; and (6) low self-efficacy and confidence in using digital health. In our quantitative second phase, 31% (151/487) of the survey participants were found to have never used a form of digital health, while 10.7% (52/487) were low- to medium-frequency users and 48.5% (236/487) were high-frequency users. High-frequency users were more likely to be interested in digital health and had higher self-efficacy. Low-frequency users were more likely to report difficulty affording the financial costs needed for digital access.

CONCLUSIONS

While general digital interest, financial cost, and digital health literacy and empowerment are clear factors in digital health access in a broad primary care population, the digital health divide is also facilitated in part by a stepped series of complex and cumulative barriers. Genuinely improving digital health access for 1 cohort or even 1 person requires a series of multiple different interventions tailored to specific sequential barriers. Within primary care, patient-centered care that continues to recognize the complex individual needs of, and barriers facing, each patient should be part of addressing the digital health divide.

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.

The Political Economy of Digital Health Equity: Structural Analysis

Digital technologies have produced many innovations in care delivery and enabled continuity of care for many people when in-person care was impossible. However, a growing body of research suggests that digital health can also exacerbate health inequities for those excluded from its benefits for reasons of cost, digital literacy, and structural discrimination related to characteristics such as age, race, ethnicity, and socioeconomic status. In this paper, we draw on a political economy perspective to examine structural barriers to progress in advancing digital health equity at the policy level. Considering the incentive structures and investments of powerful actors in the field, we outline how characteristics of neoliberal capitalism in Western contexts produce and sustain digital health inequities by describing 6 structural challenges to the effort to promote health equity through digital health, as follows: (1) the revenue-first incentives of technology corporations, (2) the influence of venture capital, (3) inequitable access to the internet and digital devices, (4) underinvestment in digital health literacy, (5) uncertainty about future reimbursement of digital health, and (6) justified mistrust of digital health. Building on these important challenges, we propose future immediate and long-term directions for work to support meaningful change for digital health equity.

Testing Two Online Symptom Checkers With Vulnerable Groups: Usability Study to Improve Cognitive Accessibility of eHealth Services

BACKGROUND

The popularity of eHealth services has surged significantly, underscoring the importance of ensuring their usability and accessibility for users with diverse needs, characteristics, and capabilities. These services can pose cognitive demands, especially for individuals who are unwell, fatigued, or experiencing distress. Additionally, numerous potentially vulnerable groups, including older adults, are susceptible to digital exclusion and may encounter cognitive limitations related to perception, attention, memory, and language comprehension. Regrettably, many studies overlook the preferences and needs of user groups likely to encounter challenges associated with these cognitive aspects.

OBJECTIVE

This study primarily aims to gain a deeper understanding of cognitive accessibility in the practical context of eHealth services. Additionally, we aimed to identify the specific challenges that vulnerable groups encounter when using eHealth services and determine key considerations for testing these services with such groups.

METHODS

As a case study of eHealth services, we conducted qualitative usability testing on 2 online symptom checkers used in Finnish public primary care. A total of 13 participants from 3 distinct groups participated in the study: older adults, individuals with mild intellectual disabilities, and nonnative Finnish speakers. The primary research methods used were the thinking-aloud method, questionnaires, and semistructured interviews.

RESULTS

We found that potentially vulnerable groups encountered numerous issues with the tested services, with similar problems observed across all 3 groups. Specifically, clarity and the use of terminology posed significant challenges. The services overwhelmed users with excessive information and choices, while the terminology consisted of numerous complex medical terms that were difficult to understand. When conducting tests with vulnerable groups, it is crucial to carefully plan the sessions to avoid being overly lengthy, as these users often require more time to complete tasks. Additionally, testing with vulnerable groups proved to be quite efficient, with results likely to benefit a wider audience as well.

CONCLUSIONS

Based on the findings of this study, it is evident that older adults, individuals with mild intellectual disability, and nonnative speakers may encounter cognitive challenges when using eHealth services, which can impede or slow down their use and make the services more difficult to navigate. In the worst-case scenario, these challenges may lead to errors in using the services. We recommend expanding the scope of testing to include a broader range of eHealth services with vulnerable groups, incorporating users with diverse characteristics and capabilities who are likely to encounter difficulties in cognitive accessibility.

Youth perspectives on mobile health adherence interventions: A qualitative study guided by the supportive accountability model

OBJECTIVE

We applied a Supportive Accountability Model lens to understand how youth view remote human coaching versus automated reminders targeting medication adherence.

METHODS

We used thematic analysis to interpret (N = 22) youths' responses to semi-structured interviews after 12 weeks of mobile health intervention.

RESULTS

Participants reported that both coaching and automated reminders prompted them to take medication, improving their adherence. Participants found coaching helpful because they developed routines and strategies, were motivated to avoid disappointing their coach, and felt their coach cared for them. Automated support could be motivational for some but demanded less engagement. Participants described phone calls as disruptive to their daily lives, but conducive to developing a personal connection with their coach, whereas texts were easier and more flexible. Youth emphasized that individual preferences often differ.

CONCLUSION

Human coaching was viewed as a more potent, engaging adherence intervention than automated reminders, although individual needs and preferences differed. Phone calls may enhance the experience of supportive accountability for adherence, but also pose greater acceptability and usability barriers than texting.

PRACTICE IMPLICATIONS

Intervention developers should provide opportunities for youth to make personal connections with human adherence supporters and attend to youth preferences for communication modality.

Opportunities for healthcare digitalization in Europe: Comparative analysis of inequalities in access to medical services

Digitalization of healthcare systems is a great opportunity to address inequalities in access to healthcare in the European Union. There is an urgent need to build on what we learned from the COVID-19 pandemic, where digital health technologies were integrated swiftly to limit challenges in healthcare delivery. We created a database for the 27 European Union countries from the European Health Interview Survey (EHIS), the Digital Economy and Society Index (DESI), and other Eurostat databases. We performed k-means cluster analysis to group EU countries along two dimensions: inequalities in access to medical services and level of digitalization. We identified five distinct clusters: two clusters with high, two clusters with moderate, and one cluster with low unmet need for healthcare. Regarding digitalization, only one cluster comprising the Nordic countries, Spain and Cyprus exhibit high digital readiness. A cluster comprising the most developed countries in Western Europe represents moderate levels of both unmet need for healthcare and digitalization. For most EU countries, there is still a need to build digital infrastructure for the healthcare industry, which in the long term may increase the number of digital solutions used by both patients and healthcare professionals. Policy makers across the EU need to consider investing in initiatives that would support digital health solutions as an effective means of healthcare provision and healthcare management.

Digital HPV education to increase vaccine uptake among low income women

Objective

The objective of this formative study was to gather women's perspectives in the design and communication modalities of a health kiosk set within a Planned Parenthood setting to promote patient education about the Human papillomavirus (HPV) and to motivate uptake of the HPV vaccine.

Methods

Twenty-four women aged 18-35 participated in in-depth one-on-one interviews at a Planned Parenthood health center, which were analyzed in code-associated categories using NVivo11 Pro.

Results

Most women showed receptivity to using an on-site health kiosk, as well as QR codes linked to text messages, to receive HPV-related health information outside of the clinic setting and reminders. Participants provided suggestions for kiosk design and communication modalities.

Conclusions

Among low-income women we interviewed at Planned Parenthood, increasing HPV vaccination rates necessitates engaging digital health tools which incorporate both the preferences and needs of vulnerable populations.

Innovation

Designing a point-of-service health kiosk that 1) draws on user preferences early in the design phase, 2) integrates multiple communication technologies, and 3) disseminates culturally grounded HPV vaccination decisions narratives that are tailored to vaccination awareness level is a promising approach in reducing barriers to HPV vaccine education and vaccine uptake among low-income women at safety-net clinics.

The effect of personalized intelligent digital systems for self-care training on type II diabetes: a systematic review and meta-analysis of clinical trials

AIMS

Type 2 diabetes (T2D) is rising worldwide. Self-care prevents diabetic complications. Lack of knowledge is one reason patients fail at self-care. Intelligent digital health (IDH) solutions have a promising role in training self-care behaviors based on patients' needs. This study reviews the effects of RCTs offering individualized self-care training systems for T2D patients.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library, and Science Direct databases were searched. The included RCTs provided data-driven, individualized self-care training advice for T2D patients. Due to the repeated studies measurements, an all-time-points meta-analysis was conducted to analyze the trends over time. The revised Cochrane risk-of-bias tool (RoB 2.0) was used for quality assessment.

RESULTS

In total, 22 trials met the inclusion criteria, and 19 studies with 3071 participants were included in the meta-analysis. IDH interventions led to a significant reduction of HbA1c level in the intervention group at short-term (in the third month: SMD = - 0.224 with 95% CI - 0.319 to - 0.129, p value < 0.0; in the sixth month: SMD = - 0.548 with 95% CI - 0.860 to - 0.237, p value < 0.05). The difference in HbA1c reduction between groups varied based on patients' age and technological forms of IDH services delivery. The descriptive results confirmed the impact of M-Health technologies in improving HbA1c levels.

CONCLUSIONS

IDH systems had significant and small effects on HbA1c reduction in T2D patients. IDH interventions' impact needs long-term RCTs. This review will help diabetic clinicians, self-care training system developers, and researchers interested in using IDH solutions to empower T2D patients.

mHealth Self-Monitoring Model for Medicine Adherence of Patients With Diabetes in Resource-Limited Countries: Structural Equation Modeling Approach

BACKGROUND

The COVID-19 pandemic has led to serious challenges and emphasized the importance of using technology for health care operational transformation. Consequently, the need for technological innovations has increased, thus empowering patients with chronic conditions to tighten their adherence to medical prescriptions.

OBJECTIVE

This study aimed to develop a model for a mobile health (mHealth) self-monitoring system for patients with diabetes in rural communities within resource-limited countries. The developed model could be based on the implementation of a system for the self-monitoring of patients with diabetes to increase medical adherence.

METHODS

This study followed a quantitative approach, in which data were collected from health care providers using a questionnaire with close-ended questions. Data were collected from district hospitals in 3 South African provinces that were selected based on the prevalence rates of diabetes and the number of patients with diabetes treated. The collected data were analyzed using smart partial least squares to validate the model and test the suggested hypotheses.

RESULTS

Using variance-based structural equation modeling that leverages smart partial least squares, the analysis indicated that environmental factors significantly influence all the independent constructs that inform patients' change of behavior toward the use of mHealth for self-monitoring of medication adherence. Technology characteristics such as effort expectancy, self-efficacy, and performance expectancy were equally significant; hence, their hypotheses were accepted. In contrast, the contributions of culture and social aspects were found to be insignificant, and their hypotheses were rejected. In addition, an analysis was conducted to determine the interaction effects of the moderating variables on the independent constructs. The results indicated that with the exception of cultural and social influences, there were significant interacting effects on other independent constructs influencing mHealth use for self-monitoring.

CONCLUSIONS

On the basis of the findings of this study, we conclude that behavioral changes are essential for the self-monitoring of chronic diseases. Therefore, it is important to enhance those effects that stimulate the behavior to change toward the use of mHealth for self-monitoring. Motivational aspects were also found to be highly significant as they triggered changes in behavior. The developed model can be used to extend the research on the self-monitoring of patients with chronic conditions. Moreover, the model will be used as a basic architecture for the implementation of fully fledged systems for self-monitoring of patients with diabetes.

A study to assess the efficacy of print and digital health communication media tools (HCMT) in rural and urban communities

Background: Existing studies have described the potential of either digital or print media for health information in one discipline. Both media are excellent tools for disseminating information, promoting social awareness, and offering in-depth healthcare information thereby being considered as leading health communication media tools. Hence, this study aims to assess and compare the effectiveness of print and digital media in various aspects of health communication in rural and urban populations. Methodology: A cross-sectional population survey will be conducted in rural and urban areas, using a semi-structured, pre-tested questionnaire, which includes socio-demographic variables, media usage patterns, perception, and health behavior change from health information via both media. The study population size will include 342 individuals in the age group of 21 to 60 with minimum qualification of matriculation. Study implications: Our research will help to understand which media are more effective at reaching different populations and can help choose appropriate communication channels for health promotion efforts, develop more effective interventions, and identify potential disparities in access to health information and resources.

The Effectiveness of eHealth Interventions for Weight Loss and Weight Loss Maintenance in Adults with Overweight or Obesity: A Systematic Review of Systematic Reviews

PURPOSE OF REVIEW: The purpose of this study is to evaluate the effectiveness of eHealth interventions for weight loss and weight loss maintenance among adults with overweight or obesity through a systematic review of systematic reviews. RECENT FINDINGS: This study included 26 systematic reviews, covering a total of 338 original studies, published between 2018 and 2023. The review indicates that eHealth interventions are more effective than control interventions or no care and comparable to face-to-face interventions. The effect sizes remain relatively small when comparing eHealth interventions to any control conditions, with mean differences of weight loss results from - 0.12 kg (95% CI - 0.64 to 0.41 kg) in a review comparing eHealth interventions to face-to-face care to - 4.32 kg (- 5.08 kg to - 3.57 kg) in a review comparing eHealth interventions to no care. The methodological quality of the included studies varies considerably. However, it can be concluded that interventions with human contact work better than those that are fully automated. In conclusion, this systematic review of systematic reviews provides an updated understanding of the development of digital interventions in recent years and their effectiveness for weight loss and weight loss maintenance among adults with overweight or obesity. The findings suggest that eHealth interventions can be a valuable tool for delivering obesity care to more patients economically. Further research is needed to determine which specific types of eHealth interventions are most effective and how to best integrate them into clinical practice.

Can digital health researchers make a difference during the pandemic? Results of the single-arm, chatbot-led Elena+: Care for COVID-19 interventional study

Background

The current paper details findings from Elena+: Care for COVID-19, an app developed to tackle the collateral damage of lockdowns and social distancing, by offering pandemic lifestyle coaching across seven health areas: anxiety, loneliness, mental resources, sleep, diet and nutrition, physical activity, and COVID-19 information.

Methods

The Elena+ app functions as a single-arm interventional study, with participants recruited predominantly via social media. We used paired samples T-tests and within subjects ANOVA to examine changes in health outcome assessments and user experience evaluations over time. To investigate the mediating role of behavioral activation (i.e., users setting behavioral intentions and reporting actual behaviors) we use mixed-effect regression models. Free-text entries were analyzed qualitatively.

Results

Results show strong demand for publicly available lifestyle coaching during the pandemic, with total downloads (N = 7'135) and 55.8% of downloaders opening the app (n = 3,928) with 9.8% completing at least one subtopic (n = 698). Greatest areas of health vulnerability as assessed with screening measures were physical activity with 62% (n = 1,000) and anxiety with 46.5% (n = 760). The app was effective in the treatment of mental health; with a significant decrease in depression between first (14 days), second (28 days), and third (42 days) assessments: F2,38 = 7.01, p = 0.003, with a large effect size (η2G = 0.14), and anxiety between first and second assessments: t54 = 3.7, p = <0.001 with a medium effect size (Cohen d = 0.499). Those that followed the coaching program increased in net promoter score between the first and second assessment: t36 = 2.08, p = 0.045 with a small to medium effect size (Cohen d = 0.342). Mediation analyses showed that while increasing number of subtopics completed increased behavioral activation (i.e., match between behavioral intentions and self-reported actual behaviors), behavioral activation did not mediate the relationship to improvements in health outcome assessments.

Conclusions

Findings show that: (i) there is public demand for chatbot led digital coaching, (ii) such tools can be effective in delivering treatment success, and (iii) they are highly valued by their long-term user base. As the current intervention was developed at rapid speed to meet the emergency pandemic context, the future looks bright for other public health focused chatbot-led digital health interventions.

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.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study

BACKGROUND

Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered.

METHODS

We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques.

RESULTS

Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities.

CONCLUSION

This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

Barriers to and Facilitators of Digital Health Among Culturally and Linguistically Diverse Populations: Qualitative Systematic Review

BACKGROUND

Health care systems have become increasingly more reliant on patients' ability to navigate the digital world. However, little research has been conducted on why some communities are less able or less likely to successfully engage with digital health technologies (DHTs), particularly among culturally and linguistically diverse (CaLD) populations.

OBJECTIVE

This systematic review aimed to determine the barriers to and facilitators of interacting with DHTs from the perspectives of CaLD population groups, including racial or ethnic minority groups, immigrants and refugees, and Indigenous or First Nations people.

METHODS

A systematic review and thematic synthesis of qualitative studies was conducted. Peer-reviewed literature published between January 2011 and June 2022 was searched across 3 electronic databases. Terms for digital health were combined with terms for cultural or linguistic diversity, ethnic minority groups, or Indigenous and First Nations people and terms related to barriers to accessing digital technologies. A qualitative thematic synthesis was conducted to identify descriptive and analytical themes of barriers to and facilitators of interacting with DHTs. Quality appraisal was performed using the Mixed Methods Appraisal Tool.

RESULTS

Of the 1418 studies identified in the electronic search, a total of 34 (2.4%) were included in this review. Half of the included studies (17/34, 50%) were conducted in the United States. There was considerable variation in terms of the CaLD backgrounds of the participants. In total, 26% (9/34) of the studies focused on Indigenous or First Nations communities, 41% (14/34) were conducted among ethnic minority populations, 15% (5/34) of the studies were conducted among immigrants, and 18% (6/34) were conducted in refugee communities. Of the 34 studies, 21 (62%) described the development or evaluation of a digital health intervention, whereas 13 (38%) studies did not include an intervention but instead focused on elucidating participants' views and behaviors in relation to digital health. From the 34 studies analyzed, 18 descriptive themes were identified, each describing barriers to and facilitators of interacting with DHTs, which were grouped into 7 overarching analytical themes: using technology, design components, language, culture, health and medical, trustworthiness, and interaction with others.

CONCLUSIONS

This study identified several analytic and descriptive themes influencing access to and uptake of DHTs among CaLD populations, including Indigenous and First Nations groups. We found that cultural factors affected all identified themes to some degree and that cultural and linguistic perspectives should be considered in the design and delivery of DHTs, with this best served through the inclusion of the target communities at all stages of development. This may improve the potential of DHTs to be more acceptable, appropriate, and accessible to population groups currently at risk of not obtaining the full benefits of digital health.

The Cultural Adaption of a Sobriety Support App for Alaska Native and American Indian People: Qualitative Feasibility and Acceptability Study

BACKGROUND

Despite high rates of alcohol abstinence, Alaska Native and American Indian (ANAI) people experience a disproportionate burden of alcohol-related morbidity and mortality. Multiple barriers to treatment exist for this population, including a lack of culturally relevant resources; limited access to or delays in receiving treatment; and privacy concerns. Many ANAI people in the state of Alaska, United States, live in sparsely populated rural areas, where treatment access and privacy concerns regarding peer-support programs may be particularly challenging. In addition, prior research demonstrates that many ANAI people prefer a self-management approach to sobriety, rather than formal treatment. Taken together, these factors suggest a potential role for a culturally adapted smartphone app to support ANAI people interested in changing their behavior regarding alcohol use.

OBJECTIVE

This study was the first phase of a feasibility and acceptability study of a culturally tailored version of an off-the-shelf smartphone app to aid ANAI people in managing or reducing their use of alcohol. The aim of this qualitative needs assessment was to gather insights and preferences from ANAI people and health care providers serving ANAI people to guide feature development, content selection, and cultural adaptation before a pilot test of the smartphone app with ANAI people.

METHODS

From October 2018 to September 2019, we conducted semistructured interviews with 24 ANAI patients aged ≥21 years and 8 providers in a tribal health care organization in south-central Alaska.

RESULTS

Participants generally endorsed the usefulness of a smartphone app for alcohol self-management. They cited anonymity, 24/7 access, peer support, and patient choice as key attributes of an app. The desired cultural adaptations included ANAI- and land-themed design elements, cultural content (eg, stories from elders), and spiritual resources. Participants considered an app especially useful for rural-dwelling ANAI people, as well as those who lack timely access to treatment services or prefer to work toward managing their alcohol use outside the clinical setting.

CONCLUSIONS

This needs assessment identified key features, content, and cultural adaptations that are being implemented in the next phase of the study. In future work, we will determine the extent to which these changes can be accommodated in a commercially available app, the feasibility of implementation, and the acceptability of the culturally adapted version of the app among ANAI users.

Needs and Demands for e-Mental Health Interventions in Individuals with Overweight and Obesity: User-Centred Design Approach

INTRODUCTION

Several studies indicate an association between mental disorders and overweight or obesity. E-Mental health interventions offer an effective way to overcome barriers to health care access for individuals with overweight and obesity. The objective of this study was to examine the needs and demands for e-mental health interventions among individuals with overweight and obesity.

METHODS

A cross-sectional study was conducted from 2020 to 2021 in Germany. A total of 643 participants were recruited through specialized social media platforms and the Alfried-Krupp hospital in Essen, Germany. Sociodemographic and medical data were analysed, as well as data on depressive symptoms and on the needs and demands for e-mental health interventions.

RESULTS

Contact with and recommendation by experts appear to be key aspects in the acceptance and use of e-mental health interventions. In summary, most participants preferred a 20-30-min weekly session via smartphone over a 4-month period. The highest preference in terms of features included practicing coping skills and being provided with information; in regard to desired topics, nutrition consultation, quality of life, and adapting to new life situations were considered most important.

DISCUSSION

e-Mental health interventions can be highly beneficial for individuals, especially when developed through a user-centred design approach. The results of the study indicate which content and design are preferred and, thereby, provide valuable information for consideration when developing a tailored e-mental health intervention.

eHealth literacy and socioeconomic and demographic characteristics of parents of children needing paediatric surgery in Sweden

AIM

The aim of the study was to describe different eHealth literacy domains among parents of children needing paediatric surgery in Sweden, and the correlation between these eHealth literacy domains and parents' socioeconomic factors and demographic characteristics.

DESIGN

Descriptive correlational design.

METHOD

Thirty-five Swedish-speaking parents participated as a historical control group within an ongoing Swedish clinical trial developing eHealth solutions for families after hospital care; of these, 30 completed the eHealth Literacy Questionnaire and the socioeconomic and demographic questionnaire.

RESULTS

Of the seven eHealth literacy domains assessed, parents' strengths lay in those pertaining to their own digital competence, control and safety, while their weakness concerned their motivation to engage with digital services, and their ability to access eHealth platforms that work. Overall, parents presented adequate eHealth literacy. Of the five socioeconomic and demographic variables assessed (i.e. monthly wages, education levels, age, gender and residency), monthly wages correlated the strongest, and positively, with the seven eHealth literacy domains.

Blended Care Interventions to Promote Physical Activity: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Blended care interventions combine therapeutic guidance with digital care. Current research results show the promising role of the blended care approach in clinical care. This new way of delivering health care could have the potential to effectively promote physical activity in different public health settings.

OBJECTIVE

The aim of the systematic review is to investigate the varieties of intervention characteristics of blended care interventions to promote physical activity in terms of structure, behavior change goals, behavior change techniques, and effectiveness of blended care interventions compared to a control group.

METHODS

We searched for randomized controlled trials published from 2000 to March 2021 in MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, SPORTDiscus, PsycINFO, and Web of Science according to the PRISMA guidelines. Risk of bias was assessed using the Cochrane Collaboration tool. Study characteristics, intervention characteristics, and outcome data were extracted. Furthermore, the effect size on the outcome of physical activity was examined or calculated.

RESULTS

In total, the number of reports identified from the database searches was 4828. Of these, 25 studies were included in the review, with a total of 5923 study participants. Results indicated that the characteristics of blended care interventions showed a high heterogeneity. The combinations of therapist-guided interventions and digital interventions allowed the identification of specific subgroups, but they varied in length (range 8-52 weeks, SD 16.6), intensity, and the combination of the components. The most used combination of blended care interventions to promote physical activity was the combination of one-on-one meetings via telephone and Web-based interventions. Motivational models of behavior change were used most frequently as underlying theoretical foundations. Certain behavior change techniques were used consistently across the individual components, e.g., "problem solving" in the therapist-guided component and "feedback on behavior" in the digital component. Considering the effect size of blended care interventions compared with control groups, most studies showed a small effect.

CONCLUSIONS

It can be concluded that blended care interventions have potential to promote physical activity. In the future, further high-quality studies should investigate which type of blended care intervention is effective for which target group. Additionally, insights are required on which intervention characteristics are most effective, taking into account new evidence on behavior change. Registration This systematic literature review was registered in PROSPERO ( CRD42020188556 ).

Adding Mobile Elements to Online Physical Activity Interventions Targeted at Adults Aged 50 Years and Older: Protocol for a Systematic Design

BACKGROUND

Physical activity (PA) can increase mental and physical health in adults aged 50 years and older. However, it has been shown that PA guidelines are often not met within this population. Therefore, our research group developed 2 computer-tailored intervention programs in the last decade to stimulate PA: Active Plus and I Move. Although these programs were proven effective, positive effects diminished over time and attrition rates were relatively high. To respond to this, we will integrate 3 interactive mobile elements into the existing programs: activity tracker, ecological momentary intervention program, and virtual coach app.

OBJECTIVE

The goal of the research is to define systematic and evidence-based steps for extending our online computer-based PA intervention programs with 3 interactive mobile elements.

METHODS

Components often included in other (eHealth) design models were identified as key components and served as a base for the definition of systematic steps: exploration of context, involvement of the target population, prototype and intervention testing, and implementation. Based on these key components, 10 systematic steps were defined. The initial step is a literature search, with the results serving as a base for development of the low-fidelity prototypes in step 2. The pilot phase comprises the 3rd to 6th steps and includes semistructured interviews, pilot tests, and adaptations of the prototypes with intensive involvement of the target population of adults aged 50 years and older, where particular attention will be paid to lower educated persons. The 7th step is an effect evaluation in the form of a randomized controlled trial. During the 8th step, the most effective intervention programs will be selected and reinforced. These reinforced intervention programs will be used during the design of an implementation plan in the 9th step and the subsequent field study in the 10th step.

RESULTS

The project will be executed from December 2019 to December 2023. During this period, the systematic approach presented will be practically executed according to the methodological procedures described.

CONCLUSIONS

Based on the 4 identified key components, we were able to design an evidence-based systematic design approach for separately adding 3 mobile elements to our existing online PA intervention programs. The 10 steps are presented as a useful approach to guide future eHealth design studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31677.

Innovating under pressure: Adopting digital technologies in social care organizations during the COVID-19 crisis

To provide ongoing support for vulnerable groups during the COVID-19 pandemic, social care organizations had to shift abruptly to e-health solutions. Qualitative data from three cases illustrate that, more than a year into the pandemic, those adoptions of digital technologies developed differently; the current study aims to shed light on the processes that lead to such differences. Notably, the first organization resisted the large-scale use of digital technologies; the second faced intra-organizational disagreement about the role of digital technology for care provision; and the third organization struggled but managed a broader, more successful adoption of digital technology. The multiple case study findings contribute to extant literature, by (1) detailing the digital innovation process, focusing on the crucial adoption process for digital technology; (2) demonstrating that champions and a shared vision can both enable and constrain the adoption of digital technologies in crisis situations; (3) emphasizing the importance of individual members’ professional identities for determining adoption of digital technologies; and (4) reflecting on the conscious use of transformation practices, even in the ad hoc setting of adopting digital technology during a crisis.

An ethical plan for including forcibly displaced persons in omics and digital technology research

Forcibly displaced persons, such as refugees, are at an increased risk of physical and mental health conditions and so would benefit from novel healthcare technologies, research on which can be conducted under an ethical framework.

Nonusage Attrition of Adolescents in an mHealth Promotion Intervention and the Role of Socioeconomic Status: Secondary Analysis of a 2-Arm Cluster-Controlled Trial

Background

Mobile health (mHealth) interventions may help adolescents adopt healthy lifestyles. However, attrition in these interventions is high. Overall, there is a lack of research on nonusage attrition in adolescents, particularly regarding the role of socioeconomic status (SES).

Objective

The aim of this study was to focus on the role of SES in the following three research questions (RQs): When do adolescents stop using an mHealth intervention (RQ1)? Why do they report nonusage attrition (RQ2)? Which intervention components (ie, self-regulation component, narrative, and chatbot) prevent nonusage attrition among adolescents (RQ3)?

Methods

A total of 186 Flemish adolescents (aged 12-15 years) participated in a 12-week mHealth program. Log data were monitored to measure nonusage attrition and usage duration for the 3 intervention components. A web-based questionnaire was administered to assess reasons for attrition. A survival analysis was conducted to estimate the time to attrition and determine whether this differed according to SES (RQ1). Descriptive statistics were performed to map the attrition reasons, and Fisher exact tests were used to determine if these reasons differed depending on the educational track (RQ2). Mixed effects Cox proportional hazard regression models were used to estimate the associations between the use duration of the 3 components during the first week and attrition. An interaction term was added to the regression models to determine whether associations differed by the educational track (RQ3).

Results

After 12 weeks, 95.7% (178/186) of the participants stopped using the app. 30.1% (56/186) of the adolescents only opened the app on the installation day, and 44.1% (82/186) stopped using the app in the first week. Attrition at any given time during the intervention period was higher for adolescents from the nonacademic educational track compared with those from the academic track. The other SES indicators (family affluence and perceived financial situation) did not explain attrition. The most common reasons for nonusage attrition among participants were perceiving that the app did not lead to behavior change, not liking the app, thinking that they already had a sufficiently healthy lifestyle, using other apps, and not being motivated by the environment. Attrition reasons did not differ depending on the educational track. More time spent in the self-regulation and narrative components during the first week was associated with lower attrition, whereas chatbot use duration was not associated with attrition rates. No moderating effects of SES were observed in the latter association.

Conclusions

Nonusage attrition was high, especially among adolescents in the nonacademic educational track. The reported reasons for attrition were diverse, with no statistical differences according to the educational level. The duration of the use of the self-regulation and narrative components during the first week may prevent attrition for both educational tracks.

Trial Registration

ClinicalTrials.gov NCT04719858; http://clinicaltrials.gov/ct2/show/NCT04719858

Challenges and strategies for promoting health equity in virtual care: findings and policy directions from a scoping review of reviews

OBJECTIVE

We sought to understand and synthesize review-level evidence on the challenges associated with accessibility of virtual care among underserved population groups and to identify strategies that can improve access to, uptake of, and engagement with virtual care for these populations.

MATERIALS AND METHODS

A scoping review of reviews was conducted (protocol available at doi: 10.2196/22847). A total of 14 028 records were retrieved from MEDLINE, EMBASE, CINAHL, Scopus, and Epistemonikos databases. Data were abstracted, and challenges and strategies were identified and summarized for each underserved population group and across population groups.

RESULTS

A total of 37 reviews were included. Commonly occurring challenges and strategies were grouped into 6 key thematic areas based on similarities across communities: (1) the person's orientation toward health-related needs, (2) the person's orientation toward health-related technology, (3) the person's digital literacy, (4) technology design, (5) health system structure and organization, and (6) social and structural determinants of access to technology-enabled care. We suggest 4 important directions for policy development: (1) investment in digital health literacy education and training, (2) inclusive digital health technology design, (3) incentivizing inclusive digital health care, and (4) investment in affordable and accessible infrastructure.

DISCUSSION AND CONCLUSION

Challenges associated with accessibility of virtual care among underserved population groups can occur at the individual, technological, health system, and social/structural determinant levels. Although the policy approaches suggested by our review are likely to be difficult to achieve in a given policy context, they are essential to a more equitable future for virtual care.

Culturally adapting internet- and mobile-based health promotion interventions might not be worth the effort: a systematic review and meta-analysis

Health promotion interventions offer great potential in advocating a healthy lifestyle and the prevention of diseases. Some barriers to communicating health promotion to people of certain cultural groups might be overcome via the internet- and mobile-based interventions (IMI). This systematic review and meta-analysis aims to explore the effectiveness of culturally adapted IMI for health promotion interventions among culturally diverse populations. We systematically searched on Cochrane Central Register of Controlled Trials (CENTRAL), EbscoHost/MEDLINE, Ovid/Embase, EbscoHost/PsychINFO, and Web of Science databases in October 2020. Out of 9438 records, 13 randomized controlled trials (RCT) investigating culturally adapted health promotion IMI addressing healthy eating, physical activity, alcohol consumption, sexual health behavior, and smoking cessation included. From the included studies 10,747 participants were eligible. Culturally adapted IMI proved to be non-superior over active control conditions in short- (g = 0.10, [95% CI -0.19 to 0.40]) and long-term (g = 0.20, [95% CI -0.11 to 0.51]) in promoting health behavior. However, culturally adapted IMI for physical activity (k = 3, N = 296) compared to active controls yielded a beneficial effect in long-term (g = 0.48, [95%CI 0.25 to 0.71]). Adapting health promotion IMI to the cultural context of different cultural populations seems not yet to be recommendable given the substantial adaption efforts necessary and the mostly non-significant findings. However, these findings need to be seen as preliminary given the limited number of included trials with varying methodological rigor and the partly substantial between-trial heterogeneity pointing in the direction of potentially useful culturally adapted IMI which now need to be disentangled from the less promising approaches.PROSPERO registration number: 42020152939.

Predictors of Retention for Community-Based Telehealth Programs: A Study of the Telehealth Intervention Program for Seniors (TIPS)

Community-based telehealth programs (CTPs) allow patients to regularly monitor health at community-based facilities. Evidence from community-based telehealth programs is scarce. In this paper, we assess factors of retention-patients remaining active participants-in a CTP called the Telehealth Intervention Programs for Seniors (TIPS). We analyzed 5-years of data on social, demographic, and multiple chronic conditions among participants from 17 sites (N=1878). We modeled a stratified multivariable logistic regression to test the association between self-reported demographic factors, caregiver status, presence of multiple chronic conditions, and TIPS retention status by limited English proficient (LEP) status. Overall, 59.5% of participants (mean age: 75.8yrs, median 77yrs, SD 13.43) remained active. Significantly higher odds of retention were observed among LEP females, English-speaking diabetics, and English proficient (EP) participants without a caregiver. We discuss the impact of CTPs in the community, the role of caregiving, and recommendations for how to retain successfully recruited non-English speaking participants.

Online self-exclusion from multiple gambling venues: Stakeholder co-design of a usable and acceptable self-directed website

Gambling self-exclusion programs are under-utilised and barriers to entry include shame and embarrassment with face-to-face registration, and complex and effortful procedures. The current study aimed to facilitate self-exclusion from gambling venues via an online self-directed website. A co-design approach was used to elicit key stakeholders' perspectives on required website features, functionality, and to identify variables potentially impacting on development and implementation. Semi-structured focus groups and interviews were conducted across four stakeholders (N = 25): self-exclusion end users (consumers, n = 5), gambling counsellors (n = 7), venue staff (n = 6), and policy makers (n = 7). Overall, stakeholder perspectives were consistent with content analysis indicating the importance of website user-friendliness, flexibility, supportiveness, and trustworthiness. Importantly, these attributes were linked to target end users': perceived vulnerabilities, diverse backgrounds and individual expectations. Participants believed that the entire self-exclusion process should be conducted online, including identity verification, whilst expecting high-level data security measures to protect their personal privacy. A separate webpage was also suggested containing relevant information and links to additional help services, such as counselling. This study describes an adaptable co-design framework for developing a usable and acceptable self-exclusion website. Future studies should empirically test system usability and acceptability to refine and maximise system uptake upon implementation. Findings may have broader implications for digital health intervention design.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

Communication strategies in the prevention of type 2 diabetes and gestational diabetes in vulnerable groups: a scoping review

BACKGROUND

The global prevalence of diabetes is nearly 9%, with an upward trend in type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM). Although evidence shows that vulnerable groups are affected disproportionally, these groups are difficult to reach in terms of preventive measures. Currently, there is no gold standard regarding communication strategies and/or public awareness campaigns.

METHODS

We conducted a scoping review in September 2019. Two reviewers independently screened the results of the electronic literature search in several databases, including Medline, EMBASE, and PsycINFO. Extracted data were charted, categorized, and summarized.

RESULTS

All of the included articles (n=24) targeted T2DM; none targeted GDM. We identified the following five different vulnerable groups within the identified studies: migrants (n=9), ethnic groups such as African Americans (n=8), people with low socioeconomic status (n=3), older people (n=1), and people in need of care (n=1). Three categories of communication strategies were identified as follows: adapted diabetes prevention programs (n=21), community health workers (n=5), and technical approaches (n=9).

CONCLUSION

We found different approaches for preventive interventions for T2DM. Some of these approaches were already adapted to known barriers. Communication strategies should be adapted to barriers and facilitating factors to increase participation and motivation.

[Adherence to digital health interventions: definitions, methods, and open questions]

Many digital interventions rely on the participation of their users to have a positive impact. In various areas it can be observed that the use of digital interventions is often reduced or fully discontinued by the users after a short period of time. This is seen as one of the main factors that can limit the effectiveness of digital interventions. In this context, the concept of adherence to digital interventions is becoming increasingly important. Adherence to digital interventions is roughly defined as "the degree to which the user followed the program as it was designed," which can also be paraphrased as "intended use" or "use as it is designed." However, both the theoretical-conceptual and practical discussions regarding adherence to digital interventions still receive too little attention.The aim of this narrative review article is to shed more light on the concept of adherence to digital interventions and to distinguish it from related concepts. It also discusses the methods and metrics that can be used to operationalize adherence and the predictors that positively influence adherence. Finally, needs for action to better address adherence are considered critically.

A Scoping Review and General User's Guide for Facilitating the Successful Use of eHealth Programs for Diabetes in Clinical Care

The vast eHealth literature in diabetes can provide a useful foundation to aid in the selection, adoption, and implementation of eHealth methodologies in clinical care. Despite clear potential to enhance reach, efficiency, and clinical effectiveness, research has yielded mixed and often contradictory results, and wide-spread adoption and maintenance of eHealth programs in clinical care has been limited. Furthermore, few reports have identified the unique challenges that clinicians and health systems face when attempting to incorporate eHealth systems into clinical care. To address these gaps, we address two goals in this report: first, to summarize and integrate the major findings of the diabetes-related eHealth literature based on currently available systematic and narrative reviews; and second, based on the review, to provide practical guidelines to assist clinicians and health systems in selecting and implementing eHealth programs into diabetes care using dissemination and implementation science principles and perspectives.