Applying the Electronic Health Literacy Lens: Systematic Review of Electronic Health Interventions Targeted at Socially Disadvantaged Groups

Adaptation of a health literacy screener for computerized, self-administered use by U.S. adults

Objective

Health literacy is a critical health determinant, for which few computerized, self-administered assessments exist. This study adapted and tested the reliability of the Newest Vital Sign© (NVS) as a computerized, self-administered health literacy screener.

Methods

Phase one involved 33 participants to create response options for a computerized, self-administered NVS (C-NVS). Phase two was a randomized crossover trial to test the consistency of C-NVS and original, interviewer-administered NVS (I-NVS) scores in 89 participants.

Results

Linear mixed-effects regression model results showed a significant carryover effect (p < .001). Crossover trial data from time 1 showed that participants who initially received the C-NVS had significantly higher average scores (M = 5.7, SD = 0.6) than participants who received the I-NVS (M = 4.5, SD = 1.5; t(87) = 5.25, p < .001). Exploratory analysis results showed that when the washout period was longer than 33 days (75th percentile) the carryover effect was not statistically significant (p = .077).

Conclusion and innovation

Findings suggest learning can occur when health literacy screeners are administered more than once in less than a month's time and computerized, self-administered health literacy screeners may produce ceiling effects. A universal precautions approach to health literacy therefore remains germane.

Depression Literacy and Depressive Symptoms: The Mediating Role of Self-Rated Mental Health Among Korean Americans

OBJECTIVE

Depression literacy (DL) is increasingly recognized as an important predictor of mental health outcomes, but there remains a noticeable lack of scientific inquiry focusing on Korean Americans in this area. In addition, women are known to be more susceptible to depression, potentially affecting their DL and depressive symptoms differently than men. This study aimed to explore two primary objectives: (1) the potential role of self-rated mental health (SRMH) in mediating the association between DL and depressive symptoms in this population, and (2) whether gender differences exist in the presence and magnitudes of these mediation effects.

METHOD

Data were drawn from a survey with 693 Korean Americans aged 18 and older residing in New York and New Jersey. The PROCESS macro was used to test the mediation effect of self-rated mental health on the relationship between depression literacy and depressive symptoms in men and women.

RESULTS

Self-rated mental health was found to mediate the relation between depression literacy and depressive symptoms in women but not in men.

CONCLUSIONS

Providing evidence-informed, culturally tailored and gender specific depression literacy education and programs for the KA communities may be an important strategy to reduce depressive symptoms in this group.

Helping parents know when to seek help for an acutely ill child: Evidence based co-development of a mobile phone app using complex intervention methodology

BACKGROUND

Acute illness accounts for the majority of episodes of illness in children under five years of age and is the age group with the highest consultation rate in general practice in the UK. The number of children presenting to emergency care is also steadily increasing, having risen beyond pre-pandemic numbers. Such high, and increasing, rates of consultation have prompted concerns about parents' level of knowledge and confidence in caring for their children when they are ill, and particularly when and how to seek help appropriately.

AIM

The ASK SNIFF collaboration research programme identified parents' need for accurate and accessible information to help them know when to seek help for a sick child in 2010. This paper presents the resulting programme of research which aimed to co-develop an evidence-based safety netting intervention (mobile app) to help parents know when to seek help for an acutely ill child under the age of five years in the UK.

METHODS

Our programme used a collaborative six step process with 147 parent and 324 health professional participants over a period of six years including: scoping existing interventions, systematic review, qualitative research, video capture, content identification and development, consensus methodology, parent and expert clinical review.

RESULTS

Our programme has produced evidence-based content for an app supported by video clips. Our collaborative approach has supported every stage of our work, ensuring that the end result reflects the experiences, perspectives and expressed needs of parents and the clinicians they consult.

CONCLUSION

We have not found any other resource which has used this type of approach, which may explain why there is no published evaluation data demonstrating the impact of existing UK resources. Future mobile apps should be designed and developed with the service users for whom they are intended.

Participation in a digital self-management intervention for osteoarthritis and socioeconomic inequalities in patient-related outcomes

OBJECTIVE

To investigate changes in socioeconomic inequalities in patient-related outcomes and pain medication use, following participation in a digital self-management intervention for osteoarthritis (OA) in Sweden.

METHOD

Participants with hip/knee OA enrolled in the digital intervention were included. Self-reported outcomes collected were the numerical rating scale (NRS) pain, activity impairment, general health, Knee/Hip injury and Osteoarthritis Outcome Score (KOOS-12, HOOS-12) Pain, Function, and Quality of Life subscales, 5-level EuroQol 5 Dimensions (EQ-5D-5L), Patient Acceptable Symptom State (PASS) for function, walking difficulties, fear of movement, wish for surgery, pain medication use, physical function measured by the 30s chair-stand test, and level of physical activity. Educational attainment was used as a socioeconomic measure and the concentration index was used to assess the magnitude of inequalities at baseline and 3 month follow-up.

RESULTS

The study included 21,688 participants (mean ± sd age 64.1 ± 9.1 years, 74.4% females). All outcomes except for PASS demonstrated inequalities in favour of highly educated participants at both time-points, with highly educated participants reporting better outcomes. At 3 month follow-up, the magnitude of inequality widened for activity impairment, but narrowed for NRS pain, EQ-5D-5L, KOOS-12/HOOS-12 Pain and Function, physical function, and wish for surgery. There were no statistically conclusive changes in the magnitude of inequalities for the remaining outcomes.

CONCLUSIONS

There were inequalities in patient-related outcomes in favour of those with higher education among participants of a digital self-management intervention for OA, although the magnitude of these pre-existing inequalities generally narrowed after the 3 month intervention.

Meta-analysis: eHealth literacy and attitudes towards internet/computer technology

OBJECTIVE

To explore the relationship between eHealth literacy and attitudes towards internet/computer (I/C) technology use in healthcare.

METHODS

Analysis of data from 16 cross-sectional studies, involving literature search from databases like PubMed, EBSCO, JMIR, up to April 2023. Studies were selected based on a quantitative cross-sectional design, with no restrictions on participant characteristics.

RESULTS

A significant positive correlation (0.36; 95% CI 0.37-0.38, p < 0.05) was found between eHealth literacy and positive attitudes towards I/C technology use. Age and regional differences, especially in participants over 50 and from Asian and Middle Eastern countries, were notable.

CONCLUSION

Lower eHealth literacy is associated with more negative attitudes towards I/C technology in healthcare. This trend is consistent across diverse demographics and regions.

Determinants of physical activity promotion in primary care from the patient perspective of people at risk of or living with chronic disease: a COM-B analysis

BACKGROUND

Chronic disease (CD) accounts for more than half of the overall global disease burden and physical activity (PA) is an established evidence-based strategy for the prevention and management of CD. Global policy emphasises the value of embedding PA into primary healthcare, highlighting the positive effects on PA behaviour. However, there is limited implementation of PA protocols in primary care, and research is needed to guide its integration into routine practice. The voice of the patient is underrepresented in the literature, resulting in the absence of critical insights into determinants of PA promotion in primary care. The purpose of the research was to identify the perspectives of people at risk of or living with CD on the determinants of PA promotion in primary care and to map these determinants across the six COM-B constructs.

METHODS

Semi-structured interviews (n = 22), guided by the COM-B model were conducted with people aged 35-60 years, at risk of or living with CD and not meeting the PA guidelines. A hybrid analytic approach of thematic inductive and deductive analysis was applied to the participant transcripts guided by a COM-B informed coding framework.

RESULTS

In total, 37 determinants across constructs related to capability, opportunity and motivation were prominent, examples include; physical capability constraints, the conflation of exercise with weight management, credibility of the health services in PA advice, communication styles in PA promotion, expectations of tailored support for PA, social support, accessibility, and integration of PA into routine habits.

CONCLUSION

Exploring the determinants of PA promotion through the lens of the COM-B model facilitated a systematic approach to understanding the primary care user perspective of the healthcare professional (HCP) broaching the topic of PA. Findings emphasise the value of HCPs being supported to broach the issue of PA in a therapeutic and patient-centred manner using diverse and flexible approaches, while highlighting the importance of tailored, accessible PA opportunities that build self-efficacy and foster social support. The research provides valuable learnings to support PA promotion and the development of strategies in primary care through encompassing the perspective of those living with or at risk of CD.

Recruitment strategies for reaching adults aged 50 years and older with low socioeconomic status for participation in online physical activity interventions

Background

Generally, the health condition of those with higher socioeconomic status (SES) is better compared to those with lower SES. The application of appropriate strategies to reach low SES populations with electronic health (eHealth) interventions is thus of major importance to reduce health inequalities. eHealth-studies providing detailed information on recruitment strategies are scarce, despite the fact that this information is crucial for comparable research and implementation.

Objective

To provide insight into the reach, sample characteristics and costs of three pre-planned strategies for recruiting adults aged 50 years and older with low SES for participation in an online physical activity intervention, as part of a field study.

Methods

Recruitment took place via (1) invitation letters via a municipality, (2) gyms and (3) social media advertisements, aiming to include 400 participants. Additional procedures were followed to reach specifically the low SES group. Response rates, sociodemographic characteristics and costs per strategy were assessed.

Results

The highest response was shown for the municipality approach (N = 281), followed by social media (N = 71) and gyms (N = 45). Ten participants were recruited via family/friends. The most low-educated participants were reached via the municipality (N = 128) followed by social media (N = 9), gyms (N = 8) and family/friends (N = 5). Recruitment costs were with €2,142.37 the highest for the municipality compared to €96.81 for social media and no costs for gyms.

Conclusions

Recruitment via invitation letters through a municipality has the highest potential for reaching low SES participants of the three applied strategies, although the higher recruitment costs need to be taken into account.

Assessment of a Digital Health Coordination Program to Mitigate Telehealth Access Disparities

Objective: Patients with digital disparity experience challenges with utilizing and accessing virtual care. This study implemented a digital coordination program for patients in outpatient psychiatry. Methods: Clinicians referred patients to a digital health coordinator who provided training to enhance virtual access. Outcomes were patient sociodemographics, barriers to digital health care utilization, change in completed video visits, and clinician satisfaction. Results: The patient cohort included 44 patients with a mean age of 59.8, 75% female, 73% Caucasian, and 84% non-Hispanic. The median household income was less than $25,000. The most common barrier to completing a video visit was difficulty using Zoom. The proportion of completed to scheduled video visits increased in 27% of patients. In such patients, the mean increase in completed visits was 32%. A majority of referring providers (64%) reported increased meaningfulness of work. Conclusion: This pilot proactively identified disparities in virtual care access and mitigated digital literacy barriers, boosting meaningfulness of work for clinicians.

Tailoring Household Disaster Preparedness Interventions to Reduce Health Disparities: Nursing Implications from Machine Learning Importance Features from the 2018-2020 FEMA National Household Survey

Tailored disaster preparedness interventions may be more effective and equitable, yet little is known about specific factors associated with disaster household preparedness for older adults and/or those with African American/Black identities. This study aims to ascertain differences in the importance features of machine learning models of household disaster preparedness for four groups to inform culturally tailored intervention recommendations for nursing practice. A machine learning model was developed and tested by combining data from the 2018, 2019, and 2020 Federal Emergency Management Agency National Household Survey. The primary outcome variable was a composite readiness score. A total of 252 variables from 15,048 participants were included. Over 10% of the sample self-identified as African American/Black and 30.3% reported being 65 years of age or older. Importance features varied regarding financial and insurance preparedness, information seeking and transportation between groups. These results reiterate the need for targeted interventions to support financial resilience and equitable resource access. Notably, older adults with Black racial identities were the only group where TV, TV news, and the Weather Channel was a priority feature for household disaster preparedness. Additionally, reliance on public transportation was most important among older adults with Black racial identities, highlighting priority needs for equity in disaster preparedness and policy.

A qualitative exploration of the barriers and facilitators to self-managing multiple long-term conditions amongst people experiencing socioeconomic deprivation

BACKGROUND

Globally, it is estimated that one in three adults live with two or more long-term conditions (multiple long-term conditions, MLTCs), that require self-management. People who experience socioeconomic deprivation face significant health inequalities due to a range of interrelated characteristics that lead to a lack of resources and opportunities. Previous research with underserved populations indicate low levels of trust towards primary care providers and potential barriers for developing patient-healthcare professional relationships. The purpose of this paper is to explore the barriers and facilitators to self-managing MLTCs, amongst people who experience socioeconomic deprivation.

METHODS

Semistructured one-to-one interviews with adults (n = 28) living in London and Sheffield, United Kingdom with MLTCs who are experiencing socioeconomic deprivation. Participants were recruited through general practices, community channels and social media. Data were analysed in NVivo using reflexive thematic analysis methods.

FINDINGS

Four analytical themes were developed: (1) challenges in accessing healthcare services, financial assistance, and cultural awareness; (2) empowerment and disempowerment through technology, including digital exclusion, and use of technology; (3) impact and causes of exclusion on self-management, including social isolation, area-based and economic exclusion, and health-related stigma and (4) adapting self-management strategies, including cost-effective, and culturally/lifestyle appropriate strategies.

CONCLUSIONS

Future health interventions and services need to be developed with consideration of the combined complexities of managing MLTCs while experiencing socioeconomic deprivation. Increased awareness in practitioners and commissioners of the complexities surrounding the lives of people experiencing socioeconomic deprivation, and the need for targeted strategies to promote self-management of MLTCs are of great importa.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory group contributed to all stages of the study, including providing important feedback on study documents (topic guides and recruitment materials), as well as providing critical insights surrounding the interpretation of interview data.

Online Health Information Seeking and Preventative Health Actions: Cross-Generational Online Survey Study

BACKGROUND

The popularity of online health information seeking (OHIS) has increased significantly owing to its accessibility and affordability. To facilitate better health management, it is essential to comprehend the generational differences in OHIS behavior and preventative health actions after seeking online health information (OHI).

OBJECTIVE

This study investigates the variations in OHIS and engagement in preventative health actions between 2 generations based on their technology use (digital natives [aged 18-42 years] and digital immigrants [aged ≥43 years]). Additionally, this research explores the mediating role of OHIS types on the generational effect on preventative health actions and the moderating role of OHI search frequency, gender, and the presence of chronic diseases on the generational effect on OHIS types and preventative health actions.

METHODS

A preregistered online survey was conducted on the Prolific online data collection platform using stratified sampling of 2 generations (digital natives and digital immigrants) from the United States in November 2023. Overall, 3 types of OHIS were collected: health wellness information search, health guidance information search, and health management information search. A 1-way analysis of covariance tested the generational differences in types of OHIS and preventative health actions, and a 2-way analysis of covariance tested the moderating role of OHIS search frequency, gender, and the presence of chronic diseases using 7 control variables. The PROCESS Macro Model 4 was used to conduct mediation analyses, testing OHI search types as mediators. Linear regression analyses tested age as a predictor of OHIS and preventative health actions.

RESULTS

The analysis of 1137 responses revealed generational differences in OHIS. Digital natives searched for health wellness information more frequently (P<.001), whereas digital immigrants searched for health guidance (P<.001) and health management information (P=.001) more frequently. There were no significant differences between the 2 generations regarding preventative health actions (P=.85). Moreover, all 3 types of OHIS mediated the relationship between generational differences and preventative health actions. Furthermore, as people aged, they searched for significantly less health wellness information (P<.001) and more health guidance (P<.001), and health management information (P=.003). Age was not a significant predictor of preventative health actions (P=.48). The frequency of OHI searches did not moderate the effect of generations on OHIS types and preventative health actions. Gender only moderated the relationship between generation and health guidance information search (P=.02), and chronic diseases only moderated the relationship between generation and health wellness information search (P=.03).

CONCLUSIONS

To the best of our knowledge, this study is the first to explore how 2 digital generations vary in terms of searching for OHI and preventative health behaviors. As the older adult population grows, it is crucial to understand their OHIS behavior and how they engage in preventative health actions to enhance their quality of life.

Collaborative practice competencies needed for telehealth delivery by health and social care professionals: a scoping review

In the context of the COVID-19 pandemic, many healthcare and social services professionals have had to provide services through virtual care. In the workplace, such professionals often need to be sufficiently resourced to collaborate and address collaborative care barriers in telehealth. We performed a scoping review to identify the competencies required to support interprofessional collaboration among clinicians in telehealth. We followed Arksey and O'Malley's and the Joanna Briggs Institute's methodological guidelines, including quantitative and qualitative peer-reviewed articles published between 2010 and 2021. We expanded our data sources by searching for any organization or experts in the field via Google. The analysis of the resulting thirty-one studies and sixteen documents highlighted that health and social services professionals are generally unaware of the competencies they need to develop or maintain interprofessional collaboration in telehealth. In an era of digital innovations, we believe this gap may jeopardize the quality of the services offered to patients and needs to be addressed. Of the six competency domains in the National Interprofessional Competency Framework, it was observed that interprofessional conflict resolution was the competency that emerged least as an essential competency to be developed, while interprofessional communication and patient/client/family/community-centered care were identified as the two most reported essential competencies.

Co-designing care for multimorbidity: a systematic review

BACKGROUND

The co-design of health care enables patient-centredness by partnering patients, clinicians and other stakeholders together to create services.

METHODS

We conducted a systematic review of co-designed health interventions for people living with multimorbidity and assessed (a) their effectiveness in improving health outcomes, (b) the co-design approaches used and (c) barriers and facilitators to the co-design process with people living with multimorbidity. We searched MEDLINE, EMBASE, CINAHL, Scopus and PsycINFO between 2000 and March 2022. Included experimental studies were quality assessed using the Cochrane risk of bias tool (ROB-2 and ROBINS-I).

RESULTS

We screened 14,376 reports, with 13 reports meeting the eligibility criteria. Two reported health and well-being outcomes: one randomised clinical trial (n = 134) and one controlled cohort (n = 1933). Outcome measures included quality of life, self-efficacy, well-being, anxiety, depression, functional status, healthcare utilisation and mortality. Outcomes favouring the co-design interventions compared to control were minimal, with only 4 of 17 outcomes considered beneficial. Co-design approaches included needs assessment/ideation (12 of 13), prototype (11 of 13), pilot testing (5 of 13) (i.e. focus on usability) and health and well-being evaluations (2 of 13). Common challenges to the co-design process include poor stakeholder interest, passive participation, power imbalances and a lack of representativeness in the design group. Enablers include flexibility in approach, smaller group work, advocating for stakeholders' views and commitment to the process or decisions made.

CONCLUSIONS

In this systematic review of co-design health interventions, we found that few projects assessed health and well-being outcomes, and the observed health and well-being benefits were minimal. The intensity and variability in the co-design approaches were substantial, and challenges were evident. Co-design aided the design of novel services and interventions for those with multimorbidity, improving their relevance, usability and acceptability. However, the clinical benefits of co-designed interventions for those with multimorbidity are unclear.

Social Support, eHealth Literacy, and mHealth Use in Older Adults With Diabetes: Moderated Mediating Effect of the Perceived Importance of App Design

Mobile healthcare has emerged as a prominent technological solution for self-management of health. However, the development and utilization of tailored mobile healthcare applications for older adults with diabetes mellitus remain limited. This study examined the relationship between social support and mobile healthcare use and further explored how this relationship varies with eHealth literacy and application design among older adults with diabetes mellitus. A descriptive cross-sectional trial was conducted with a structured self-report questionnaire, surveying 252 South Korean older adults with diabetes mellitus via offline and online modes. The mediating effect and moderated mediating effect were analyzed with the PROCESS macro of SPSS. eHealth literacy mediated the relationship between social support and mobile healthcare use. High levels of eHealth literacy and social support may increase mobile healthcare use among older adults with diabetes. Application design aesthetics facilitated mobile healthcare use. Future researchers, healthcare providers, and developers can contribute to the development of tailored mobile healthcare applications for older adults with diabetes mellitus by considering application design aspects such as font size, color, and menu configuration.

Digital Health Literacy and Social Determinants of Health Affecting Telehealth Use by Athletic Trainers

CONTEXT

While increasing telehealth use throughout sports medicine has improved patients' access to health care, some communities may not have the same opportunities to connect with a provider. Barriers to telehealth implementation can be influenced by internal (eg, provider's digital health literacy and resources) and external (eg, community's social determinants of health or "SDOH") factors. This study aimed to assess the impact of internal and external factors on telehealth use by athletic trainers (ATs).

DESIGN

Cross-sectional survey.

METHODS

In total, 767 ATs participated in the study. Participants (age = 39 [13] y) completed a survey containing the electronic health literacy scale and digital health literacy instrument, reported professional use of telehealth as a provider (yes/no), provided resources at their clinical site, and provided the zip code for the community they served. After data collection, the researchers extracted SDOH information using the zip code data from 2 US databases, including population density, median household income, poverty index, education level, and technology access. Chi-square or independent samples t tests were conducted to compare telehealth use by each SDOH factor.

RESULTS

In total, 62.3% (n = 478/767) of ATs reported using telehealth, and 81.6% of ATs (n = 626) had a dedicated facility to offer health care services. We identified a significant difference in digital health literacy scores between users and nonusers of telehealth (P = .013). We did not identify any significant differences between telehealth users by community type (P = .957), population density (P = .053), income (P = .462), poverty index (P = .073), and computer (P = .211) or broadband internet access (P = .295).

CONCLUSIONS

Our data suggest that internal factors such as digital health literacy and clinical site resources may have contributed to an AT's previous telehealth use in clinical practice. However, the SDOH data extracted from the community zip code where the AT provided clinical services were similar for those with and without previous telehealth use.

Digital health and patient adherence: A qualitative study in older adults

Introduction

Computer confidence and computer self-efficacy can impact an individual's perceived ease of use and usefulness of technology, ultimately determining adherence to digital healthcare services. However, few studies focus on assessing the impact of non-clinical factors on the efficacy and adherence to digital healthcare platforms.

Objective

We aimed to analyse the role of non-clinical factors (i.e. computer confidence and computer self-efficacy) in the interaction experience (IX) and the feasibility of a digital neuropsychological platform called NeuroVRehab.PT in a group of older adults with varying levels of computer confidence.

Methods

Eight older adults (70.63 ± 6.1 years) evaluated the platform, and data was collected using the Think-Aloud method and a semi-structured interview. Sessions were audio-recorded and analysed through an inductive-deductive informed Thematic Analysis protocol. This study was conducted according to the Consolidated Criteria for Reporting Qualitative Research guidelines.

Results

Three main themes were identified (Interaction Experience, Digital Literacy, and Attitudes toward NeuroVRehab.PT). Computer anxiety and fear of making errors were not uncommon, even among older adults who perceive themselves as confident in technology use, and negatively impacted IX. Moreover, some game elements (e.g. three-star system, progression bar) were not intuitive to all participants, leading to misleading interpretations. On the other hand, human support and the platform's realism seemed to impact participants' IX positively.

Conclusions

This study shed light on the barriers raised by non-clinical factors in adopting and using digital healthcare services by older adults. Furthermore, a critical analysis of the platform's features that promote user adoption is done, and suggestions for overcoming limitations are presented.

"Who is Anders Tegnell?" Unanswered questions hamper COVID-19 vaccine uptake: A qualitative study among ethnic minorities in Sweden

BACKGROUND

Despite high COVID-19 vaccination coverage in many European countries, vaccination uptake has been lower among ethnic minorities, including in Sweden. This is in spite of the increased risk of contracting the virus and targeted efforts to vaccinate among first and second generation migrants. The aim of this study was to understand this dilemma by investigating ethnic minorities' perceptions and their experience of accessing the COVID-19 vaccine.

METHODS

This is a qualitative study drawing on 18 semi-structured interviews with health volunteers working in ethnic minority communities and with participants from the two largest ethnic minorities in Sweden (Syria and Somalia). Deductive qualitative analysis was completed using the 3C model by WHO (Complacency, Confidence and Convenience).

RESULTS

Complacency does not appear to be a barrier to intention to vaccinate. Participants are well aware of COVID-19 risk and the benefits of the vaccine. However, confidence in vaccine poses a barrier to uptake and there are a lot of questions and concerns about vaccine side effects, efficacy and related rumors. Confidence in health providers, particularly doctors is high but there was a sense of conflicting information. Accessing individually tailored health information and health providers is not convenient and a major reason for delaying vaccination or not vaccinating at all. Trust in peers, schools and faith-leaders is high and constitute pathways for effective health information sharing.

CONCLUSION

Ethnic minorities in Sweden are willing to get vaccinated against COVID-19. However, to increase vaccination uptake, access to individually tailored and face to face health information to answer questions about vaccine safety, efficacy, conflicting information and rumors is urgently required.

eHealth usage among parents to premature or surgically treated neonates: associations with eHealth literacy, healthcare satisfaction or satisfaction with an eHealth device

BACKGROUND

A specific eHealth device, a surf tablet, was developed for bridging between advanced in-hospital care and children's homes. Since little is known about determinators for parental eHealth usage, the study's aim was to explore if parents' usage of the device was associated with their eHealth literacy, or their satisfaction with their child's healthcare or with the specific surf tablet.

METHODS

In this explorative usage and questionnaire study, parents to neonates who were discharged home after advanced in-hospital care were included. Their surf tablet usage at maximum 30 days after discharge was reported as frequency (%) of active days (usage days/days having the device) and median number of tablet activities (chat and photo) per usage day. eHealth literacy (eHealth Literacy Questionnaire; eHLQ), healthcare satisfaction (PedsQL Healthcare Satisfaction Generic Module), and satisfaction with the surf tablet were explored regarding tablet usage. Statistics were described in median (range) and (%) using non-parametric and regression models (p < 0.05).

RESULTS

Parents to 32 children (11 premature, 21 operated) were included. Active days with eHealth communication using the device was 39% (9.0/29.5), with 2.0 (1.0-4.2) usage occasions per active day. Activity on the tablet was higher among parents reporting to be very satisfied or satisfied with the device (n = 25) compared with neutral/dissatisfied parents (n = 7) (2.8 vs. 2.2 vs. 1.6 activities) (p = 0.030), while their frequency of active days did not differ (31.6% vs. 38.3% vs. 40%) (p = 0.963). A higher eHealth literacy was not associated with frequency of active days (0.926 (0.652-1.317); p = 0.659) or number of eHealth activities (0.973 (0.758-1.250); p = 0.825). Healthcare satisfaction was not associated with higher frequency of active days 0.996 (0.983-1.009; p = 0.519); neither was number of eHealth activities 1.001 (0.991-1.011; p = 0.883).

CONCLUSION

In this study, eHealth usage was associated with parental satisfaction with the specific eHealth device, but not with eHealth literacy or healthcare satisfaction. To assure equal access to healthcare when using eHealth, the user-friendliness of the device seems to be crucial, and technical support needs to be in place.

CLINICALTRIALS

GOV REGISTRATION IDENTIFIER

NCT04150120 (04/11/2019).

Social determinants of health of racial and ethnic minority adolescents: An integrative literature review

Integration of adolescents with diverse cultural backgrounds into the country of residence is associated with some form of rejection and discrimination, predisposing them to undesirable health outcomes. In this regard, the aim of this study was to identify the social determinants of the health of racial and ethnic minority adolescents. In this integrative literature review, PubMed, EMBASE, Cochrane Library, and CINAHL databases were searched from 2016 to 2021 and studies were selected according to the PRISMA 2020 guidelines. Health status was limited to health outcomes according to the definition proposed by the World Health Organization and Healthy People 2020. The social determinants of health were classified according to the research framework of the National Institute on Minority Health and Health Disparities. Six types of health status were identified: self-rated health, obesity and overweight, global self-worth, emotional well-being, anthropometric measurement, and psychosocial adjustment. The social determinants of health were at the individual and interpersonal level, and the domains included the biological (gender, illness experience), psychological (acculturative stress), and sociocultural environment (e.g., socioeconomic status, parents' educational level, household death due to violence). Therefore, future research must prioritize their sociocultural environments to reduce the negative impact of discrimination and sociocultural and structural differences on racial and ethnic minority adolescents.

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study

BACKGROUND

Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk.

OBJECTIVE

We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland.

METHODS

We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3).

RESULTS

In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity.

CONCLUSIONS

We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

The Profound Implications of the Meaning of Health for Health Care and Health Equity

Policy Points The meaning of health in health care remains poorly defined, defaulting to a narrow, biomedical disease model. A national dialogue could create a consensus regarding a holistic and humanized definition of health that promotes health care transformation and health equity. Key steps for operationalizing a holistic meaning of health in health care include national leadership by federal agencies, intersectoral collaborations that include diverse communities, organizational and cultural change in medical education, and implementation of high-quality primary care. The 2023 report by the National Academies of Sciences, Engineering, and Medicine on achieving whole health offers recommendations for action.

Women's experience of the health information process involving a digital information tool before commencing radiation therapy for breast cancer: a deductive interview study

BACKGROUND

Individuals undergoing radiation therapy for breast cancer frequently request information before, throughout and after the treatment as a means to reduce distress. Nevertheless, the provision of information to meet individuals needs from their level of health literacy is often overlooked. Thus, individuals information needs are often unmet, leading to reports of discontent. Internet and digital information technology has significantly augmented the available information and changed the way in which persons accesses and comprehends information. As health information is no longer explicitly obtained from healthcare professionals, it is essential to examine the sequences of the health information process in general, and in relation to health literacy. This paper reports on qualitative interviews, targeting women diagnosed with breast cancer who were given access to a health information technology tool, Digi-Do, before commencing radiation therapy, during, and after treatment.

METHODS

A qualitative research design, inspired by the integrated health literacy model, was chosen to enable critical reflection by the participating women. Semi-structured interviews were conducted with 15 women with access to a digital information tool, named Digi-Do, in addition to receiving standard information (oral and written) before commencing radiation therapy, during, and after treatment. A deductive thematic analysis process was conducted.

RESULTS

The results demonstrate how knowledge, competence, and motivation influence women's experience of the health information process. Three main themes were found: Meeting interactive and personal needs by engaging with health information; Critical recognition of sources of information; and Capability to communicate comprehended health information. The findings reflect the women's experience of the four competencies: to access, understand, appraise, and apply, essential elements of the health information process.

CONCLUSIONS

We can conclude that there is a need for tailored digital information tools, such as the Digi-Do, to enable iterative access and use of reliable health information before, during and after the radiation therapy process. The Digi-Do can be seen as a valuable complement to the interpersonal communication with health care professionals, facilitating a better understanding, and enabling iterative access and use of reliable health information before, during and after the radiotherapy treatment. This enhances a sense of preparedness before treatment starts.

The Association between Electronic Health Literacy and Oral Health Outcomes among Dental Patients in Saudi Arabia: A Cross-Sectional Study

OBJECTIVE

This cross-sectional study aimed to investigate the association between electronic health (eHealth) literacy and oral health outcomes, including the number of teeth and brushing frequency.

METHODS

A total of 478 participants were included in the study and assessed for their eHealth literacy levels. Demographic variables, including age, gender, income, and education, were collected. The participants' number of teeth and brushing frequency were also recorded. Multiple regression analyses were performed to examine the relationship between eHealth literacy and oral health outcomes, adjusting for sociodemographic variables.

RESULTS

The study sample consisted of both males (66.5%) and females (33.5%), with a mean age of 31.95 years. Among the participants, 16.95% were classified as having inadequate eHealth literacy, 24.06% had problematic eHealth literacy, and the majority (59.00%) demonstrated sufficient eHealth literacy. There was a significant association between eHealth literacy and oral health outcomes. Individuals with problematic eHealth literacy had a higher likelihood of having a greater number of teeth (RR = 1.12, 95% CI: 1.05-1.20, p < 0.001) compared to those with inadequate eHealth literacy. Similarly, individuals with sufficient eHealth literacy showed a higher likelihood of having more teeth (RR = 1.14, 95% CI: 1.07-1.21, p < 0.001) compared to the inadequate eHealth literacy group controlling for age, gender, income, and education. Individuals with problematic eHealth literacy exhibited a tendency towards lower odds of irregular brushing (OR = 0.39, 95% CI: 0.15-1.02, p = 0.054), although this result was marginally significant. In contrast, individuals with sufficient eHealth literacy had significantly lower odds of irregular brushing frequency (OR = 0.24, 95% CI: 0.10-0.62, p = 0.003) compared to the inadequate eHealth literacy group.

CONCLUSION

The findings suggest a positive association between eHealth literacy and oral health outcomes. Improving eHealth literacy may have implications for promoting better oral health behaviors and outcomes.

Depression literacy and misconceptions scale (DepSter): a new two-factorial tool for measuring beliefs about depression

BACKGROUND

Depression literacy has received extensive attention within mental health research. It has been studied by different social groups and professions in Western and non-Western cultures. The importance of this topic stems from the fact that depression literacy is strongly related to attitudes toward people who are diagnosed with depression, the tendency to stigmatize this mental disorder, and to the propensity to undertake help-seeking behaviors. Therefore, understanding and promoting depression literacy is crucial in contemporary mental health prevention and promotion. We propose a new two-factorial tool measuring beliefs about depression. This 14-item self-report measure captures how people vary across two dimensions of beliefs about depression-depression literacy and misconceptions about depression.

METHODS

In ten studies with a total sample of over 4,600 participants from three countries, we demonstrated the two-factorial structure of the Depression Literacy and Misconceptions Scale (DepSter) in Polish (Studies 1 and 2), American (Study 4), and British (Study 5) samples. We showed measurement equivalence for the Polish and English versions of the scale (Study 3). Furthermore, we tested the discriminant meaning of the two dimensions of beliefs about depression analyzing its association with health literacy, mental health literacy, and prejudice toward people with mental illness (Study 4), depression literacy and depression stigma (Study 5), empathetic concerns (Study 7), social dominance orientation (Study 8), and the Big Five personality traits (Study 9). We also investigated whether individuals with formal education in psychology and direct or indirect experience with depression demonstrate a higher level of depression literacy and a lower level of misconceptions about depression (Study 6). Our measure showed high stability for two dimensions of beliefs about depression (Study 10), in both its Polish and English versions, with the measurement conducted after three weeks and three months.

DISCUSSION

We conclude that the proposed approach to beliefs about depression capturing both depression literacy and misconceptions about depression measured with the DepSter scale can easily be applied in clinical and social settings, especially in studies concerning the perception of those diagnosed with depression.

Cyberchondria and its Association with Smartphone Addiction and Electronic Health Literacy among a Saudi Population

Background

Cyberchondria is a recent phenomenon characterized by the excessive/frequent searching of the internet for health-related information (HRI) that results in concerns/anxiety over health and wellness. Studies have shown an increase in the prevalence of cyberchondria and that it is associated with smartphone addiction and eHealth literacy, but few such studies are available from Saudi Arabia.

Methods

This cross-sectional study included adult Saudis living in Jeddah, Saudi Arabia, and was conducted between May 1 and June 30, 2022. A four-section questionnaire was distributed using Google Forms, and included the Cyberchondria Severity Scale (CSS), Smartphone Addiction Scale-Short Version (SAS), and Electronic Health Literacy scale (eHEALS). The scales were translated into Arabic using the forward-backward technique, and then evaluated for content validity, face validity, and reliability.

Results

The reliability of the translated versions was satisfactory: CSS Cronbach's alpha = 0.882; SAS = 0.887; eHEALS = 0.903. A total of 518 participants were inlcuded, of which the majority were female (64.1%). The prevalence of cyberchondria was 2.1% (95% CI: 1.1-3.8), 83.4% (79.9-86.5), and 14.5% (11.6-17.8) for low, moderate, and high grades, respectively. Two-thirds of the participants (66.6%) had smartphone addiction, while three-fourths (72.6%) had a high level of eHealth literacy. There were significant correlations between cyberchondria and smartphone addiction (r = 0.395, CI = 0.316/0.475, P = 0.0001) and high eHealth literacy (r = 0.265, CI = 0.182/0.349, P = 0.0001).

Conclusion

The study revealed a high prevalence of cyberchondria in a Saudi population, and this was associated with smartphone addiction and high eHealth literacy.

Diagnostic accuracy of eHealth literacy measurement tools in older adults: a systematic review

BACKGROUND

In Canada, virtual health care rapidly expanded during the COVID-19 pandemic. There is substantial variability between older adults in terms of digital literacy skills, which precludes equitable participation of some older adults in virtual care. Little is known about how to measure older adults' electronic health (eHealth) literacy, which could help healthcare providers to support older adults in accessing virtual care. Our study objective was to examine the diagnostic accuracy of eHealth literacy tools in older adults.

METHODS

We completed a systematic review examining the validity of eHealth literacy tools compared to a reference standard or another tool. We searched MEDLINE, EMBASE, CENTRAL/CDSR, PsycINFO and grey literature for articles published from inception until January 13, 2021. We included studies where the mean population age was at least 60 years old. Two reviewers independently completed article screening, data abstraction, and risk of bias assessment using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We implemented the PROGRESS-Plus framework to describe the reporting of social determinants of health.

RESULTS

We identified 14,940 citations and included two studies. Included studies described three methods for assessing eHealth literacy: computer simulation, eHealth Literacy Scale (eHEALS), and Transactional Model of eHealth Literacy (TMeHL). eHEALS correlated moderately with participants' computer simulation performance (r = 0.34) and TMeHL correlated moderately to highly with eHEALS (r = 0.47-0.66). Using the PROGRESS-Plus framework, we identified shortcomings in the reporting of study participants' social determinants of health, including social capital and time-dependent relationships.

CONCLUSIONS

We found two tools to support clinicians in identifying older adults' eHealth literacy. However, given the shortcomings highlighted in the validation of eHealth literacy tools in older adults, future primary research describing the diagnostic accuracy of tools for measuring eHealth literacy in this population and how social determinants of health impact the assessment of eHealth literacy is needed to strengthen tool implementation in clinical practice.

PROTOCOL REGISTRATION

We registered our systematic review of the literature a priori with PROSPERO (CRD42021238365).

Editorial Perspective: Reducing mental health disparities among underserved youth: using technology to equip parents as agents of change

Prevalence rates for youth psychopathology have steadily increased over the last two decades. Youth from underserved families (e.g. racial/ethnic minority, rural, poor, gender, and sexual minority) are disparately impacted as they face myriad risk factors that adversely affect their mental health. Parents play an integral role in their mental health of underserved youth as they are responsible for making sure that their children get the help that they need. Yet, parents in underserved families often cannot access mental health treatment due to persistent barriers they face such as stigma, discrimination, and high treatment costs, to name a few. Consequently, parents from these families are less likely to receive the psychological training necessary to intervene in their youths' mental health. Although traditional parent management training programs have made progress toward equipping parents with important mental health services, these programs often require considerable investment of time and resources (e.g. money, childcare, in-person attendance) that make them inaccessible to disadvantaged families. Digital mental health interventions (DMHIs) offer to provide parents in underserved families with the psychological training they need to effectively intervene in their youth's mental health while overcoming barriers to care. However, few to no culturally sensitive and evidence-based DMHIs exist to address the mental health needs of underserved families. This editorial perspective highlights the need to develop and implement parent-focused DMHIs for underserved families so that parents will have the mental health resources they need to act as agents of change.

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.

e-Health Literacy Skills in People with Chronic Diseases and What Do the Measurements Tell Us: A Scoping Review

Background: Use of electronic health (e-Health) technologies has increased in the past decade and inadequate e-Health literacy may lead to health-related social inequality. This is especially true for patients living with chronic diseases who are often involved in self-care. However, the measurement of e-Health literacy represents several challenges. Among available instruments, the e-Health Literacy Scale (eHEALS) is the only instrument with available psychometric properties. Aim: To identify studies measuring e-Health literacy in adults living with chronic disease and its relationship to health-related behaviors and other perceptions such as quality of life, self-efficacy, or specific disease biomarkers, and studies analyzing the impact of educational intervention on e-Health literacy. Methods: The authors searched MEDLINE, the Cochrane Library, and Web of Science databases to identify studies published in English language until April 2022. Results: Seventeen studies involving 4,877 participants were included. A majority of the studies were cross-sectional with a lack of appropriate controls. Five of the included studies were experimental, involving 758 participants. All of them reported positive effects of educational interventions on the improvements in self-reported e-Health literacy skills. However, most studies were at risk of bias. Conclusion: Despite these limitations, the findings of this review indicate the positive relationship between e-Health literacy and various health care processes in adults with chronic diseases and highlights a need for prospective controlled studies. Promoting e-Health literacy might give better opportunities for the active involvement of people with chronic diseases in self-care and for the implementation of online interventions into existing system of care.

Disability digital divide: survey of accessibility of eHealth services as perceived by people with and without impairment

BACKGROUND

Sustainable and effective eHealth requires accessibility for everyone. Little is known about how accessibility of eHealth is perceived among people with various impairments. The aim of this study was to compare use and perceived difficulty in the use of eHealth among people with and without impairment, and how different types of impairment were associated with perceived difficulty in the use of eHealth.

METHODS

This study used data collected in a nationwide survey in Sweden. Snowball sampling was used to recruit participants with self-reported impairment, from June to October 2019. In February 2020, the survey was posted to people in the general population who were matched to the participants with impairment by age, gender and county of residence. Multiple logistic regression was used to analyse the use of four eHealth services, and perceived difficulty in the use of six eHealth services.

RESULTS

In total, 1631 participants with, and 1084 participants without impairment responded to the survey. Participants with impairment reported less use and more difficulty in the use of all eHealth services as compared to participants without impairment. When comparing types of impairment, booking healthcare appointments online was least used and most avoided by participants with communication, language and calculation impairments (adjusted odds ratio (aOR) use 0.64, 95% confidence interval (95%CI) 0.49-0.83; aOR avoid 1.64, 95%CI 1.19-2.27), and intellectual impairments (aOR use 0.28, 95%CI 0.20-0.39; aOR avoid 2.88, 95%CI 1.86-4.45). The Swedish national web-portal for health information and services, 1177.se, was reported difficult to use the most among participants with communication, language and calculation impairments (aOR 2.24, 95%CI 1.50-3.36), deaf-blindness (aOR 11.24, 95%CI 3.49-36.23) and hearing impairment (aOR 2.50, 95%CI 1.17-5.35).

CONCLUSIONS

The results confirm the existence of an eHealth disability digital divide. People with impairment were not one homogeneous group, but differed in perceived difficulties in regard to eHealth. Based on a purposeful subgrouping of impairments, we showed that people with communication, language and calculation impairments, and intellectual impairments, reported least use and most difficulty in using eHealth. The findings can guide further research in creating eHealth that is accessible for all, including those with the most significant difficulties.

Adding Mobile Elements to Online Physical Activity Interventions for Adults Aged Over 50 Years: Prototype Development Study

BACKGROUND

Only a minority of adults aged over 50 years meet physical activity (PA) guidelines of the World Health Organization (WHO). eHealth interventions are proven effective tools to help this population increase its PA levels in the short term, among which the Active Plus and I Move interventions have been developed by our own research group. To achieve long-term effects, increase intervention use, and decrease dropout rates, 3 emergent but different mobile elements (an activity tracker, an ecological momentary intervention [EMI] program, and a chatbot) were added separately to Active Plus and I Move. In this study, the prototype development and pilot-testing of these interventions is described.

OBJECTIVE

This study aims to enhance 2 existing PA-stimulating computer-based interventions with 3 mobile elements (an activity tracker, an EMI program, or a chatbot) and test the prototypes on usability and appreciation within a target population of adults aged over 50 years.

METHODS

A systematic design protocol consisting of development, evaluation, and adaptation procedures was followed with involvement of the target population. Literature searches separated per mobile element and interviews with the target population (N=11) led to 6 prototypes: Active Plus or I Move including (1) an activity tracker, (2) EMI, or (3) a chatbot. These prototypes were tested on usability and appreciation during pilot tests (N=47) and subsequently fine-tuned based on the results.

RESULTS

The literature searches and interviews provided important recommendations on the preferences of the target population, which enabled us to develop prototypes. The subsequent pilot tests showed that the mobile elements scored moderate to good on usability, with average System Usability Scale (SUS) scores of 52.2-82.2, and moderate to good on enjoyment and satisfaction, with average scores ranging from 5.1 to 8.1 on a scale of 1-10. The activity tracker received the best scores, followed by EMI, followed by the chatbot. Based on the findings, the activity tracker interventions were fine-tuned and technical difficulties regarding EMI and the chatbot were solved, which is expected to further improve usability and appreciation.

CONCLUSIONS

During this study, 6 prototypes of online PA interventions with added mobile elements were developed and tested for usability and appreciation. Although all prototypes scored moderate to high on usability, enjoyment, and satisfaction, it can be concluded that the integration of an activity tracker with a computer-based PA intervention is the most promising option among the 3 mobile elements tested during this study. The prototype development steps of the systematic design protocol followed can be considered useful and successful for the purposes of this study. The interventions can now be evaluated on a larger scale through a randomized controlled trial.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31677.

Access to What for Whom? How Care Delivery Innovations Impact Health Equity

Achieving health equity (where every person has the opportunity to attain their full health potential) requires the removal of obstacles to health, including barriers to high-quality medical care. Innovations in service delivery can inadvertently maintain, worsen, or introduce inequities. As such, implementation of innovations must be accompanied by a dual commitment to evaluate impact on marginalized groups and to restructure systems that obstruct people from health and healthcare. Understanding the impact innovations have on access to high-quality care is central to this effort. In this Perspective, we join conceptual models of healthcare access and quality with health equity frameworks to conceptualize healthcare receipt as a series of interactions between people and systems unfolding over time. This synthesized model is applied to illustrate the effects of telemedicine on patient, population, and system outcomes. Telemedicine may improve or worsen health equity by altering access to care and by altering quality of care once it is accessed. Teasing out these varied effects is complex and requires considering multilevel influences on the outcome of a care-seeking episode. This synthesized model can be used to inform research, practice, and policy surrounding the equity implications of care delivery innovations more broadly.

Cut-off value of the eHEALS score as a measure of eHealth skills among rural residents in Gansu, China

Background

In this study, our aim was to quantify eHealth literacy and determine a cut-off value for eHEALS scores that signifies adequate eHealth literacy among rural residents in Gansu, China.

Methods

This cross-sectional investigation encompassed 18 rural areas across three cities-Lanzhou, Wuwei, and Dingxi-in Gansu. A total of 451 residents were recruited and underwent evaluations for both eHealth literacy and eHealth skills, utilizing the eHEALS and self-constructed tasks, respectively. A receiving operator characteristic curve was plotted with eHealth skills as the dependent variable and eHealth literacy levels as the independent variable, aiming to determine a cut-off value for eHEALS indicating adequate eHealth literacy and evaluate its predictive capacity.

Results

Among the 451 respondents, 10.9% did not possess a personal electronic device with Internet access, while 6.4% owned but had never used them. Within the remaining 373 residents, the mean eHealth literacy score was 25.85 (SD:10.93), item scores ranged from 3.12 (SD:1.45) to 3.42 (SD:1.60). Completion rates for three eHealth skills varied from 39.1% to 59.8%. The cut-off value was 29.5 determined by the Youden index. The area under the receiver operating curve was 0.829, with a sensitivity of 86.7%, and a specificity of 66.8%.

Conclusions

Our findings emphasized that eHealth literacy among rural residents remains at a low level. Moreover, we identified a cut-off value of 29.5 for eHEALS scores that signifies adequate eHealth literacy within this demographic.

Association of social capital with self-perceived eHealth literacy among community-dwelling older people: Age and gender differences

Background

Studies have confirmed that social factors, including social capital and eHealth literacy, are important in later life. Currently, few studies are available for determining the relationship between social capital and eHealth literacy, and whether such a relationship exists among older people and there are age and gender differences in the relationship remain unclear. Consequently, this study aimed to investigate the association between social capital and eHealth literacy, specifically examing its variations in age and gender.

Methods

A cross-sectional study of 4,257 residents aged ≥ 60 years and dwelling in the community was conducted across four cities in China. A structured questionnaire was used to collect data on general characteristics, socioeconomic status, social capital, and eHealth literacy. Generalized linear models were employed to assess these associations.

Results

There were 4,218 respondents (age 71.9 ± 7.2 years; 64.8% women). Overall, social participation, social connection, trust, cohesion, and reciprocity were all statistically associated with eHealth literacy (p < 0.05), while such an association was not observed for social support (p > 0.05). Specifically, a higher level of social participation was associated with better eHealth literacy scores among participants aged 70-79 years (p < 0.001), and a higher level of social connection was associated with better eHealth literacy scores for those aged 60-69 and 70-79 years (p < 0.001). Meanwhile, no gender differences in the associations were found.

Conclusion

There is an association between social capital and eHealth literacy in older men and women. The association varis with age. The findings provide a reference for developing targeted measures to improve self-perceived eHealth literacy among older people. It is essential for achieving active and healthy aging and developing the knowledge and understanding of relevant theories, concepts, and evidence within the field of health and social capital.

Telehealth Use for Enhancing the Health of Rural Older Adults: A Systematic Mixed Studies Review

BACKGROUND AND OBJECTIVES

Telehealth holds potential for inclusive and cost-saving health care; however, a better understanding of the use and acceptance of telehealth for health promotion among rural older adults is needed. This systematic review aimed to synthesize evidence for telehealth use among rural-living older adults and to explore cost-effectiveness for health systems and patients.

RESEARCH DESIGN AND METHODS

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study designs reporting health promotion telehealth interventions with rural-living adults aged 55 and older were eligible for review. Following screening and inclusion, articles were quality-rated and ranked by level of evidence. Data extraction was guided by the Technology Acceptance Model and organized into outcomes related to ease of use, usefulness, intention to use, and usage behavior along with cost-effectiveness.

RESULTS

Of 2,247 articles screened, 42 were included. Positive findings for the usefulness of telehealth for promoting rural older adults' health were reported in 37 studies. Evidence for ease of use and usage behavior was mixed. Five studies examined intention to continue to use telehealth and in 4 of these, patients preferred telehealth. Telehealth was cost-effective for health care delivery (as a process) compared to face to face. However, findings were mixed for cost-effectiveness with both reports of savings (e.g., reduced travel) and increased costs (e.g., insurance).

DISCUSSION AND IMPLICATIONS

Telehealth was useful for promoting health among rural-living older adults. Technological supports are needed to improve telehealth ease of use and adherence. Cost-effectiveness of telehealth needs more study, particularly targeting older adults.

Community stakeholder-driven technology solutions towards rural health equity: A concept mapping study in Western Canada

BACKGROUND

Technology holds great potential for promoting health equity for rural populations, who have more chronic illnesses than their urban counterparts but less access to services. Yet, more participatory research approaches are needed to gather community-driven health technology solutions. The purpose was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity through community stakeholder engagement.

METHODS

Concept mapping, a quantitative statistical technique, embedded within a qualitative approach, was used to identify and integrate technological solutions towards rural health equity from community stakeholders in three steps: (1) idea generation; (2) sorting and rating feasibility/importance and (3) group interpretation. Purposeful recruitment strategies were used to recruit key stakeholders and organizational representatives from targeted rural communities.

RESULTS

Overall, 34 rural community stakeholders from western Canada (76% female, mean age = 55.4 years) participated in the concept mapping process. In Step 1, 84 ideas were generated that were reduced to a pool of 30. Multidimensional scaling and cluster analysis resulted in a six-cluster map representing how technological solutions can contribute toward rural health equity. The clusters of ideas included technological solutions and applications, but also ideas to make health care more accessible regardless of location, training and support in the use of technology, ensuring digital tools are simplified for ease of use, technologies to support collaboration among healthcare professionals and ideas for overcoming challenges to data sharing across health systems/networks. Each cluster included ideas that were rated as equally important and feasible. Key themes included organizational and individual-level solutions and connecting patients to newly developed technologies.

CONCLUSIONS

Overall, the grouping of solutions revealed that technological applications require not only access but also support and collaboration. Concept mapping is a tool that can engage rural community stakeholders in the identification of technological solutions for promoting rural health equity.

PATIENT OR PUBLIC CONTRIBUTION

Rural community stakeholders were involved in the generation and interpretation of technological solutions towards rural health equity in a three-step process: (1) individual brainstorming of ideas, (2) sorting and rating all ideas generated and (3) collective interpretation and group consensus on final results.

The digital rainbow: Digital determinants of health inequities

The widely used socioecological rainbow model from Dahlgren and Whitehead specifies determinants of health inequity on multiple hierarchical levels and suggests that these determinants may interact both within and between levels. At the time of its inception, digital determinants only played a minor role in tackling inequities in public health and were therefore not specifically considered. This has dramatically changed: From today's perspective, health inequities increasingly depend on digital determinants. In this article, we suggest adapting the Dahlgren-Whitehead model to reflect these developments. We propose a model that allows formulating testable hypotheses, interpreting research findings, and developing policy implications against the background of the global spread of digital technologies. This may facilitate the development of a new line of research and logic models for public health interventions in the digital age. Using the COVID-19 pandemic as a case study, we illustrate how the digitization of all aspects of life affects the different levels of determinants of health inequities in the Dahlgren-Whitehead model. In doing so, we deliberately argue for not introducing a separate digital sphere in its own right, but for understanding digitization as a phenomenon that permeates all levels of determinants of health inequities. As a result, we present a digital rainbow model that integrates Dahlgren and Whitehead's 1991 model with digital environments to identify current health promotion and research issues without changing the rainbow model's initial structure.

Disparities in Vision Health and Eye Care

Significant disparities in vision health and eye care exist. To achieve health equity, we must understand the root causes and drivers of health disparities and inequities, including social determinants of health and systemic racism.

The Importance of Health Literacy in Addressing Eye Health and Eye Care Disparities

Disparities in eye health and eye care frequently result from a lack of understanding of ocular diseases and limited use of ophthalmic health services by various populations. The purpose of this article is to describe the principle of health literacy and its central role in enhancing health, and how its absence can result in poorer health outcomes. The article evaluates the current status of health literacy in visual health and disparities that exist among populations. It also explores ways to improve health literacy as a means of reducing disparities in visual health and eye care. Advancing dissemination of health information and enhancing health literacy may help not only to reduce healthcare barriers in the underserved populations but also to lessen visual health disparities.

Mobile Health Use by Older Individuals at Risk of Cardiovascular Disease and Type 2 Diabetes Mellitus in an Australian Cohort: Cross-sectional Survey Study

Background

The digital transformation has the potential to change health care toward more consumers’ involvement, for example, in the form of health-related apps which are already widely available through app stores. These could be useful in helping people understand their risk of chronic conditions and helping them to live more healthily.

Objective

With this study, we assessed mobile health app use among older Australians in general and among those who were at risk of cardiovascular disease or type 2 diabetes mellitus.

Methods

In this cross-sectional analysis, we used data from the second follow-up wave of the 45 and Up Study. It is a cohort study from New South Wales, Australia, with 267,153 participants aged 45 years and older that is based on a random sample from the Services Australia (formerly the Australian Government Department of Human Services) Medicare enrollment database. The 2019 follow-up questionnaire contained questions about technology and mobile health use. We further used data on prescribed drugs and hospitalizations to identify participants who already had cardiovascular disease or diabetes or who were at risk of these conditions. Our primary outcome measure was mobile health use, defined as having used a mobile health app before. We used descriptive statistics and multivariate logistic regression to answer the research questions.

Results

Overall, 31,946 individuals with a median age of 69 (IQR 63-76) years had completed the follow-up questionnaire in 2019. We classified half (16,422/31,946, 51.41%) of these as being at risk of cardiovascular disease or type 2 diabetes mellitus and 38.04% (12,152/31,946) as having cardiovascular disease or type 1 or type 2 diabetes mellitus. The proportion of mobile health app users among the at-risk group was 31.46% (5166/16,422) compared to 29.16% (9314/31,946) in the total sample. Those who used mobile health apps were more likely to be female, younger, without physical disability, and with a higher income. People at risk of cardiovascular disease or type 2 diabetes mellitus were not statistically significantly more likely to use mobile health than were people without risk (odds ratio 1.06, 95% CI 0.97-1.16; P=.18; adjusted for age, sex, income, and physical disability).

Conclusions

People at risk of cardiovascular disease or type 2 diabetes mellitus were not more likely to use mobile health apps than were people without risk. Those who used mobile health apps were less likely to be male, older, with a physical disability, and with a lower income. From the results, we concluded that aspects of equity must be considered when implementing a mobile health intervention to reach all those that can potentially benefit from it.

Challenges and Opportunities in Designing and Deploying Remote Health Monitoring Technology for Older Adults With Cancer

Remote health monitoring (RHM) technologies (eg, wearables, smart phones, embedded sensors, and telehealth platforms) offer significant opportunities to improve health and wellness for older adults facing serious illness. This article highlights key challenges and opportunities for designing and deploying RHM systems in the context of caring for older adults with cancer, with an emphasis on the key role nurses can play in this work. Focal topics include user-centered design, interdisciplinary collaboration, addressing health inequities and disparities, privacy and data security, participant recruitment and burden, personalized and tailored care, rapid technological change, family caregiver perspectives, and naturalistic data collection. It is critical for nurses to be aware of both challenges and opportunities within each of these areas in order to develop RHM systems that are optimally beneficial for patients, family caregivers, clinicians, and organizations. By leveraging their unique knowledge of the illness experience from the patient, family, and health care provider perspective, nurses can make essential clinical and scientific contributions to advance the field of RHM.

eHealth Literacy of Australian Undergraduate Health Profession Students: A Descriptive Study

Rapid growth in digital health technologies has increased demand for eHealth literacy of all stakeholders within health and social care environments. The digital future of health care services requires the next generation of health professionals to be well-prepared to confidently provide high-quality and safe health care. The aim of this study was to explore the eHealth literacy of undergraduate health profession students to inform undergraduate curriculum development to promote work-readiness. A cross-sectional survey was undertaken at an Australian university using the seven-domain eHealth Literacy Questionnaire (eHLQ), with 610 students participating. A one-way Multivariate Analysis of Variance (MANOVA) with follow-up univariate analysis (ANOVA) was used to determine if there were differences in eHLQ scores across 11 sociodemographic variables. Students generally had good knowledge of health (Scale 2); however, they had concerns over the security of online health data (Scale 4). There were also significant differences in age and ownership of digital devices. Students who were younger reported higher scores across all seven eHLQ scales than older students. This research provided an understanding of eHealth literacy of health profession students and revealed sub-groups that have lower eHealth literacy, suggesting that digital health skills should be integrated into university curriculums, especially related to practice-based digital applications with special focus to address privacy and security concerns. Preparation of health profession students so they can efficiently address their own needs, and the needs of others, is recommended to minimise the digital divide within health and social care environments.

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.

Empirical investigation of e-health intervention in cervical cancer screening: A systematic literature review

Cervical cancer (CC) screening can detect the cancer early but is underutilized, especially among the developing countries and low- to middle-income countries. Electronic health (e-health) has the potential for disseminating health education and is widely used in the developed countries. This systematic literature review investigates the effectiveness of e-health intervention for improving knowledge of CC and the intention or uptake for CC screening. We followed the PRISMA 2020 guideline and registered with PROSPERO (registration ID CRD42021276036). We searched the Web of Science, Scopus and EBSCO Medline Complete databases for eligible studies. Studies that conveyed informational material through e-health intervention were selected. The results were analyzed using narrative synthesis, and the pooled estimates were calculated using meta-analysis. A total of six studies involving 1886 women were included in this review. The use of e-health aids alone led to increased knowledge. The meta-analysis demonstrated that the mixed-education method of e-health movies and video education with didactic sessions increased CC screening uptake. A random-effects model revealed that CC screening uptake following e-health interventions were almost double of that of their comparison (odds ratio = 2.29, 95% confidence interval: 1.28–4.10, p < 0.05). Various areas of study demonstrated e-health intervention effectiveness (minority communities, urban areas, rural areas). Health education through e-health intervention has huge potential for promoting CC screening in the community. Nevertheless, the use of appropriate frameworks, user engagement and culturally tailored e-health need to be prioritized.

Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study

BACKGROUND

Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality.

OBJECTIVE

We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression.

METHODS

We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression.

RESULTS

We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22).

CONCLUSIONS

In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.

Telemedicine based on patient-reported outcomes in management of patients with inflammatory bowel disease in a real-life setting - a before and after cohort study

BACKGROUND

Avoidable appointments and increasing incidence of inflammatory bowel disease (IBD) call for alternative ways of organizing outpatient visits. In controlled studies, telemedicine including patient reported outcome (PRO) has shown to improve outcomes in IBD and reduce health care utilization. However, we lack studies of telemedicine implemented in everyday practice. We therefore described use of a PRO-based telemedicine follow-up (AmbuIBD) in a real-life setting and investigated the effect on outpatient visits and hospital admissions.

METHODS

We conducted a cohort study including patients with IBD in an outpatient clinic at a Danish regional hospital August 2018. Data included extracts from the Patient Administration System and the AmbuFlex system between 2017 and August 2018, plus questionnaire data from clinicians. Descriptive statistics were used to describe use of AmbuIBD and differences between before and after results were tested with Wilcoxon's signed-rank test.

RESULTS

Of 848 patients in outpatient care, 77% were included in AmbuIBD. Most patients were set to answer a PRO questionnaire once a year (n = 407, 62%), and 66% of 1913 answered questionnaires were handled with no further contact. AmbuIBD was well accepted by clinicians. Outpatient visits the year after AmbuIBD compared to the year before were reduced with 14% (p ≤ .001). The largest reduction was for patients with mild or no disease activity (45%, p ≤ .001). No difference was found for hospital admissions.

CONCLUSIONS

AmbuIBD is feasible and well accepted when implemented in an outpatient clinic. More than half of patients are only followed by questionnaire, and we found a reduction in outpatient visits.

How to Best Develop and Deliver Generic Long-Term Condition Rehabilitation Programmes in Rural Settings: An Integrative Review

People living rurally frequently experience health disparities especially if living with a long-term condition (LTC) or multi-morbidity. Self-management support is a key component of LTC management and commonly included in rehabilitation programmes to enhance ability to self-manage health and encourage physical activity. Such programmes are however often condition focussed and despite evidence for their effectiveness, are not always feasible to deliver in rural settings. Generic programmes are arguably more optimal in the rural context and delivery can be face to face or remotely (via telehealth). The aim of this explorative integrative review was to collate and present international evidence for development, delivery, integration, and support of community-based, generic LTC group rehabilitation programmes delivered rurally in person, or remotely using telehealth. Electronic databases were systematically searched using MeSH terms and keywords. For inclusion, articles were screened for relevance to the aim, and practical information pertaining to the aim were extracted, charted, and organized deductively into themes of Development, Delivery, Integration, and Support. Within each theme, data were synthesized inductively into categories (Theory, Context, Interpersonal aspects, and Technology and Programme aspects). Fifty-five studies were included. Five studies contributed information about community based programmes delivered via the internet. Development was the only theme populated by information from all categories. The theme of Support was only populated with information from one category. Our review has drawn together a large body of diverse work. It has focused on finding practical information pertaining to the best ways to develop, deliver, integrate, and support a community-based generic rehabilitation programme for people living with long-term health conditions, delivered rurally and/or potentially via the internet. Practical suggestions were thematically organized into categories of theory, context, interpersonal aspects, and technology and programme aspects. While the findings of this review might appear simple and self-evident, they are perhaps difficult to enact in practice.

Health Literacy Development among People with Chronic Diseases: Advancing the State of the Art and Learning from International Practices

Chronic diseases account for a considerable part of the strain on health care systems [...].