The Florida Mobile Health Adherence Project for People Living With HIV (FL-mAPP): Longitudinal Assessment of Feasibility, Acceptability, and Clinical Outcomes

User Engagement With mHealth Interventions to Promote Treatment Adherence and Self-Management in People With Chronic Health Conditions: Systematic Review

BACKGROUND

There are numerous mobile health (mHealth) interventions for treatment adherence and self-management; yet, little is known about user engagement or interaction with these technologies.

OBJECTIVE

This systematic review aimed to answer the following questions: (1) How is user engagement defined and measured in studies of mHealth interventions to promote adherence to prescribed medical or health regimens or self-management among people living with a health condition? (2) To what degree are patients engaging with these mHealth interventions? (3) What is the association between user engagement with mHealth interventions and adherence or self-management outcomes? (4) How often is user engagement a research end point?

METHODS

Scientific database (Ovid MEDLINE, Embase, Web of Science, PsycINFO, and CINAHL) search results (2016-2021) were screened for inclusion and exclusion criteria. Data were extracted in a standardized electronic form. No risk-of-bias assessment was conducted because this review aimed to characterize user engagement measurement rather than certainty in primary study results. The results were synthesized descriptively and thematically.

RESULTS

A total of 292 studies were included for data extraction. The median number of participants per study was 77 (IQR 34-164). Most of the mHealth interventions were evaluated in nonrandomized studies (157/292, 53.8%), involved people with diabetes (51/292, 17.5%), targeted medication adherence (98/292, 33.6%), and comprised apps (220/292, 75.3%). The principal findings were as follows: (1) >60 unique terms were used to define user engagement; "use" (102/292, 34.9%) and "engagement" (94/292, 32.2%) were the most common; (2) a total of 11 distinct user engagement measurement approaches were identified; the use of objective user log-in data from an app or web portal (160/292, 54.8%) was the most common; (3) although engagement was inconsistently evaluated, most of the studies (99/195, 50.8%) reported >1 level of engagement due to the use of multiple measurement methods or analyses, decreased engagement across time (76/99, 77%), and results and conclusions suggesting that higher engagement was associated with positive adherence or self-management (60/103, 58.3%); and (4) user engagement was a research end point in only 19.2% (56/292) of the studies.

CONCLUSIONS

The results revealed major limitations in the literature reviewed, including significant variability in how user engagement is defined, a tendency to rely on user log-in data over other measurements, and critical gaps in how user engagement is evaluated (infrequently evaluated over time or in relation to adherence or self-management outcomes and rarely considered a research end point). Recommendations are outlined in response to our findings with the goal of improving research rigor in this area.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022289693; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022289693.

Implementation of free-draft text messaging to enhance care retention and satisfaction for persons living with HIV infection

Eligible persons with HIV infection can receive client-centered case management to coordinate medical and social services. Novel mobile health interventions could improve effective case management and retention in care, an important goal to help end the HIV epidemic. Using a hybrid type I effectiveness-implementation design, we assessed whether access to bidirectional, free-draft secure text messaging with a case manager and clinic pharmacist could improve client satisfaction and care retention in a Southern academic HIV clinic. Sixty-four clients enrolled between November 2019 and March 2020, had a median age of 39 years, and were mostly male, single, and African-American. Heavy app users texted over 100 times (n = 6) over the course of the 12-month intervention while others never texted (n = 12). App usage peaked during months of clinic closure due to COVID-19. Most participants reported high satisfaction with the app and planned continued usage after study completion. Changes in clinic retention and virologic suppression rates were not observed, a result confounded by practice changes due to COVID-19. High usage and satisfaction of free-draft text messaging in case-managed HIV clients supports inclusion of this communication option in routine HIV clinical care.

Development, feasibility testing and perceived benefits of a new app to help with adherence to antiretroviral therapy in people living with HIV in Brazil

BACKGROUND

Despite the availability of antiretroviral therapy (ART) in many countries, people living with HIV still experience difficulties with treatment. We propose a new smartphone mobile application to assist in adherence to ART. This study aimed to describe this new mobile application's development (content construction and usability), feasibility testing (recruitment, retention rates [attendance], satisfaction) and primary perceived benefits.

METHODS

Two consecutive studies were conducted. First, people living with HIV, health care workers and experts in information technology provided feedback to improve the content and usability of the app. After changes in the app were implemented according to the feedback, a second study was performed to assess the feasibility and perceived benefits. Effects on self-reported adherence and perceived well-being were also assessed.

RESULTS

Scores of participants (N = 11) showed differences in adherence (effect size .43) and well-being (effect size .45) after using the app. However, the differences did not reach statistical significance. Observing scores individually, six out of 11 participants improved their overall adherence scores, and seven out of 11 participants improved their perceived well-being scores. Recruitment was 95%, and attendance at sessions was 62.5%. In general, the participants were satisfied with the intervention and viewed the app as an informative tool.

CONCLUSION

The results are promising and allow us to recommend further studies with the app.

A Contemporary Review of Smart Phone Applications in Bariatric and Metabolic Surgery: an Underdeveloped Support Service

This study aims to be a contemporary review of mHealth apps in bariatric and metabolic surgery (BMS) to assess their quality using the Silberg scale as well as features, themes, usability, and medical/allied health professional involvement (MAPI). Apps were identified using search terms in the Android and Apple app stores. 52 apps were included. 42 (80.7%) apps main target users were patients. More than half, 27 (52%), targeted US based users. 29 (56%) had payment-restricted content. 42 (81%) had MAPI and the mean Silberg score was 5.2. Compared to previous studies the quality of BMS apps is improving with more MAPI and useful functionality. Wider use of mHealth apps for patient centred follow-up, management and care are yet to be widely implemented and explored.

Efficacy of an mHealth self-management intervention for persons living with HIV: the WiseApp randomized clinical trial

IMPORTANCE

Progression of HIV disease, the transmission of the disease, and premature deaths among persons living with HIV (PLWH) have been attributed foremost to poor adherence to HIV medications. mHealth tools can be used to improve antiretroviral therapy (ART) adherence in PLWH and have the potential to improve therapeutic success.

OBJECTIVE

To determine the efficacy of WiseApp, a user-centered design mHealth intervention to improve ART adherence and viral suppression in PLWH.

DESIGN, SETTING, AND PARTICIPANTS

A randomized (1:1) controlled efficacy trial of the WiseApp intervention arm (n = 99) versus an attention control intervention arm (n = 101) among persons living with HIV who reported poor adherence to their treatment regimen and living in New York City.

INTERVENTIONS

The WiseApp intervention includes the following components: testimonials of lived experiences, push-notification reminders, medication trackers, health surveys, chat rooms, and a "To-Do" list outlining tasks for the day. Both study arms also received the CleverCap pill bottle, with only the intervention group linking the pill bottle to WiseApp.

RESULTS

We found a significant improvement in ART adherence in the intervention arm compared to the attention control arm from day 1 (69.7% vs 48.3%, OR = 2.5, 95% CI 1.4-3.5, P = .002) to day 59 (51.2% vs 37.2%, OR = 1.77, 95% CI 1.0-1.6, P = .05) of the study period. From day 60 to 120, the intervention arm had higher adherence rates, but the difference was not significant. In the secondary analyses, no difference in change from baseline to 3 or 6 months between the 2 arms was observed for all secondary outcomes.

CONCLUSIONS

The WiseApp intervention initially improved ART adherence but did not have a sustained effect on outcomes.

Challenges in Participant Engagement and Retention using Mobile Health Apps: A Literature Review (Preprint)

Background

Mobile health (mHealth) apps are revolutionizing the way clinicians and researchers monitor and manage the health of their participants. However, many studies using mHealth apps are hampered by substantial participant dropout or attrition, which may impact the representativeness of the sample and the effectiveness of the study. Therefore, it is imperative for researchers to understand what makes participants stay with mHealth apps or studies using mHealth apps.

Objective

This study aimed to review the current peer-reviewed research literature to identify the notable factors and strategies used in adult participant engagement and retention.

Methods

We conducted a systematic search of PubMed, MEDLINE, and PsycINFO databases for mHealth studies that evaluated and assessed issues or strategies to improve the engagement and retention of adults from 2015 to 2020. We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Notable themes were identified and narratively compared among different studies. A binomial regression model was generated to examine the factors affecting retention.

Results

Of the 389 identified studies, 62 (15.9%) were included in this review. Overall, most studies were partially successful in maintaining participant engagement. Factors related to particular elements of the app (eg, feedback, appropriate reminders, and in-app support from peers or coaches) and research strategies (eg, compensation and niche samples) that promote retention were identified. Factors that obstructed retention were also identified (eg, lack of support features, technical difficulties, and usefulness of the app). The regression model results showed that a participant is more likely to drop out than to be retained.

Conclusions

Retaining participants is an omnipresent challenge in mHealth studies. The insights from this review can help inform future studies about the factors and strategies to improve participant retention.

A Smartphone App to Support Adherence to Inhaled Corticosteroids in Young Adults With Asthma: Multi-Methods Feasibility Study

Background

Young adults with asthma often report low adherence to inhaled corticosteroids (ICS), leading to uncontrolled symptoms and poor disease outcomes. Technology-enabled digital supports such as mobile health (mHealth) asthma smartphone apps have the potential to support adherence to ICS and asthma self-management. There is a need for feasibility studies to determine the usability, acceptability, and feasibility of these interventions. In addition, it is essential to determine the feasibility of recruiting and retaining young adults to plan future efficacy and effectiveness trials and therefore, establish evidence-based asthma apps.

Objective

This study aimed to determine (1) the feasibility of recruiting and retaining young adults to a trial and (2) the usability, acceptability, and feasibility of using the AsthmaMD app to support adherence to ICS in a population of young adults living with asthma.

Methods

A multi-methods feasibility study was conducted. Young adults aged 18-30 years with asthma and current prescription for ICS were eligible and invited to take part through a university circular email, social media, and general practice sites. Participation involved completing a baseline self-report questionnaire, downloading and using the AsthmaMD app for 2 weeks, and completing the follow-up assessment, including self-report and open-ended questions about participants’ experience of using the app. Primary outcomes included participant recruitment and retention and the usability, acceptability, and feasibility of using AsthmaMD. Quantitative self-report data were analyzed using descriptive statistics, and qualitative open-ended data were analyzed using inductive reflexive thematic analysis.

Results

A total of 122 young adults (females, n=101, 82.8%) with a mean age of 24.4 (SD 3.8) years were recruited and they completed baseline measures. Of the 122 young adults, 59 (48.4%) completed the study. The AsthmaMD app received a mean score of 63.1/100 (SD 20.1) on the System Usability Scale (ie, a standardized measure of usability for technology-based apps), and an overall user satisfaction score of 5.8/10 (SD 2.2). Of the 59 participants who completed the study, 49 (83%) participants used the app ≥1 day per week. Two main themes were identified in the qualitative analysis of user experiences: (1) learning how to use the app to suit the individual and (2) benefits and relevance of using the app.

Conclusions

The findings from this study indicate that it is feasible to recruit and retain young adults to examine efficacy and effectiveness in a future trial and that young adults living with asthma may find AsthmaMD to be usable, acceptable, and feasible to support adherence to ICS. Our findings also identified opportunities to further optimize the usability of AsthmaMD and similar apps. Based on our findings, we recommend providing more accessible information on how to use the app and replacing medical terminology with simplified language within the app to improve usability.

Trial Registration

ISRCTN Registry ISRCTN11295269; https://www.isrctn.com/ISRCTN11295269

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Design, deployment, and usability of a mobile system for cardiovascular health monitoring within the electronic Framingham Heart Study

Background

The electronic Framingham Heart Study (eFHS) is an ongoing nested study, which includes FHS study participants, examining associations between health data from mobile devices with cardiovascular risk factors and disease.

Objective

To describe application (app) design, report user characteristics, and describe usability and survey response rates.

Methods

Eligible FHS participants were consented and offered a smartwatch (Apple Watch), a digital blood pressure (BP) cuff, and the eFHS smartphone app for administering surveys remotely. We assessed usability of the new app using 2 domains (functionality, aesthetics) of the Mobile App Rating Scale (MARS) and assessed survey completion rates at baseline and 3 months.

Results

A total of 196 participants were recruited using the enhanced eFHS app. Of these, 97 (49.5%) completed the MARS instrument. Average age of participants was 53 ± 9 years, 51.5% were women, and 93.8% were white. Eighty-six percent of participants completed at least 1 measure on the baseline survey, and 50% completed the 3-month assessment. Overall subjective score of the app was 4.2 ± 0.7 on a scale from 1 to 5 stars. Of those who shared their health data with others, 46% shared their BP and 7.7% shared their physical activity with a health care provider.

Conclusion

Participants rated the new, enhanced eFHS app positively overall. Mobile app survey completion rates were high, consistent with positive in-app ratings from participants. These mobile data collection modalities offer clinicians new opportunities to engage in conversations about health behaviors.

Patient-Provider Text Messaging and Video Calling Among Case-Managed Patients Living With HIV: Formative Acceptability and Feasibility Study

Background

Patient-provider communication is critical for engaging and retaining people living with HIV in care, especially among medically case-managed patients in need of service coordination and adherence support. Expanding patient-provider communication channels to include mobile health modalities, such as text messaging and video calling, has the potential to facilitate communication and ultimately improve clinical outcomes. However, the implementation of these communication modalities in clinical settings has not been well characterized.

Objective

The purpose of this study is to understand patient and provider perspectives on the acceptability of and preferences for using text messaging and video calling as a means of communication; perceived factors relevant to adoption, appropriateness, and feasibility; and organizational perspectives on implementation within an HIV clinic in South Carolina.

Methods

We conducted 26 semistructured in-depth interviews among patients receiving case management services (n=12) and clinic providers (n=14) using interview guides and content analysis informed by the Proctor taxonomy of implementation outcomes and the Consolidated Framework for Implementation Research. Participants were purposefully sampled to obtain maximum variation in terms of age and gender for patients and clinic roles for providers. The data were analyzed using quantitative and qualitative content analyses.

Results

Most patients (11/12, 92%) and providers (12/14, 86%) agreed that they should have the capacity to text message and/or video call each other. Although consensus was not reached, most preferred using a secure messaging app rather than standard text messaging because of the enhanced security features. Perceived benefits to adoption included the added convenience of text messaging, and potential barriers included the cost and access of smartphone-based technology for patients. From an organizational perspective, some providers were concerned that offering text messaging could lead to unreasonable expectations of instant access and increased workload.

Conclusions

Patients and providers perceived text messaging and video calling as acceptable, appropriate, and feasible and felt that these expanded modes of communication could help meet patients’ needs while being safe and not excessively burdensome. Although patients and providers mostly agreed on implementation barriers and facilitators, several differences emerged. Taking both perspectives into account when using implementation frameworks is critical for expanding mobile health–based communication, especially as implementation requires active participation from providers and patients.

Mentoring Young African American Men and Transgender Women Who Have Sex With Men on Sexual Health: Formative Research for an HIV Mobile Health Intervention for Mentors

BACKGROUND

African American men who have sex with men (MSM) and transgender women bear a disproportionate burden of HIV. Young MSM account for 75% of this burden for youth. When youths lack socially protective resources such as strong networks of adults, including parents, teachers, or community members, mentors may play a critical role in promoting health behaviors. This is especially true for youth at risk for HIV, such as African American youth with sexual and gender minority (SGM) identities. In the past decade, natural mentoring and mentoring programs have proliferated as a key prevention and intervention strategy to improve outcomes for young people at risk for poor academic, social, and health issues. Mentors appear to be able to facilitate health promotion among young SGM by modeling healthy behaviors; however, mentors' knowledge and resource needs regarding sexual health topics including HIV are understudied, as is the potential role of mobile technology in enhancing mentoring relationships and the ability of mentors to learn about sensitive issues faced by youth.

OBJECTIVE

The aim of this study is to explore how mentoring plays a role in the sexual health of African American SGM youth and understand how mentoring relationships can be strengthened through mobile technology to promote youth HIV prevention behaviors.

METHODS

In-depth interviews were conducted with African American SGM youth mentees (n=17) and mentors (n=20) to such youths in 3 Mid-Atlantic cities. Mentee interviews focused on discussions regarding sexual health and HIV and how a mentor could broach such topics. Mentor interviews explored whether sexual health and HIV are currently mentoring topics, mentors' knowledge and confidence in mentoring on these issues, and barriers to discussions. All participants were asked if a mobile app could help facilitate mentoring on sensitive health issues, particularly HIV and sexual health. Data were transcribed, coded, and analyzed for relevant themes.

RESULTS

Sexual health was a common topic in mentoring relationships, occurring more in natural mentorships than in mentoring program pairs. Mentors and mentees felt positive about such discussions. Mentors expressed having limited knowledge beyond condom use and HIV testing, and expressed a need for more complete resources. Both mentors and mentees had mixed comfort levels when discussing sexual health. Sufficient trust and shared lived experiences made discussions easier. Mentees have multifaceted needs; however, mentors stated that an app resource that provided self-training, resources, support from other mentors, and tips for better mentoring could prove beneficial.

CONCLUSIONS

For the African American SGM community, access to natural mentors is crucial for young people to learn healthy behaviors. A mobile resource to assist mentors in confidently having discussions with mentees may be a promising way to promote healthy practices.