Designing Effective eHealth Interventions for Underserved Groups: Five Lessons From a Decade of eHealth Intervention Design and Deployment

Characterizing syndemic HIV risk profiles and mHealth intervention acceptability among patients in the emergency department

Syndemic theory proposes that co-occurring, mutually reinforcing psychosocial challenges (mental health, substance use, minority stress [discrimination/stigma], abuse, unmet basic needs) drive HIV risk behavior and create barriers to care for marginalized populations. It is thus necessary to address this holistic, complex picture in HIV prevention. Emergency department (ED) visits are a prime opportunity to engage key risk groups, given their low engagement in regular clinic-based care and high utilization of drop-in care via EDs. Yet, EDs are overburdened and under-resourced; mHealth may be a vehicle for intervention delivery in this context. This study aimed to 1) characterize demographics, syndemic profiles, and HIV risk behavior among ED patients and 2) assess the acceptability of addressing syndemic issues, particularly via an mHealth approach, in the ED. A sample of N = 198 ED patients with an indication of HIV risk completed a cross-sectional psychosocial assessment. Descriptive statistics and bivariate correlations between syndemic issues were examined. Patients presenting to the ED reported marginalized identities and complex syndemic profiles including mental health issues (77%), at risk substance use (30%), childhood abuse (35%), adult abuse (31%), minority stress (63%), and unmet basic needs (37%). Over half the sample reported at least three syndemic issues (54%). All syndemic issues were significantly correlated with each other, supporting a synergistic nature. The sample reported indicators of HIV risk including lack of PrEP awareness (33%)/uptake (94%), condomless sex (37%), and not testing for HIV (41%). Majority reported syndemic profiles have never been addressed in the ED (71%), think it would be helpful (88%), and willing to utilize mHealth during an ED visit (76%). The current study provides information to guide next steps for ED-based point-of-care HIV prevention, and more broadly, working towards equitable HIV prevention services reaching those missed by existing interventions.

What internet- and mobile-based interventions are currently available for adults with overweight or obesity experiencing symptoms of depression? A systematic review

Given the high prevalence of overweight and obesity and high comorbidity of depressive symptoms, there is a need for low-threshold, accessible care approaches for people with overweight/obesity aimed at improving mental health. Internet and mobile-based interventions (IMI) represent an innovative complementary treatment option. This review systematically searches for IMI aimed at improving mental health in people with overweight/obesity. We conducted a systematic literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria in the databases MEDLINE, Cochrane Library, PsycINFO, Web of Science and Google Scholar. Randomized controlled trials (RCTs) of IMI for adults with overweight/obesity and comorbid depressive symptoms aiming at improving mental health were screened and extracted. Study quality was assessed with RoB 2 (revised Cochrane Risk of Bias tool in RCTs). After excluding duplicates, n = 790 results were included in title and abstract screening. After full-text-screening of n = 26 studies, n = 3 RCT studies were included. All interventions aimed to reduce both weight and depressive symptoms. In two RCTs, a significant reduction in both depressive symptoms and weight was achieved. One RCT indicated a significant reduction in depressive symptoms, but not in weight. Two intervention had a duration of 6 months and were guided by health carers, the third takes 3 months and can be used without professional guidance. There is evidence that IMI are effective in improving mental health for people with overweight/obesity and comorbid depressive symptoms. However, currently there are few interventions aiming at reducing depressive symptoms, all targeting English-speaking people. As IMI for depressive symptoms can be easily integrated in the somatic therapy of obesity as additional option and has high public health potential, target group-adapted and low-threshold accessible interventions in different languages should be developed and implemented for improving mental health in people with overweight/obesity. Prospero registration number: CRD42023361771.

Physical activity interventions: an update on advancing sedentary time, technology, and dissemination and implementation research

Approximately 28% of American adults meet both the physical activity (PA) and strength training guidelines despite the numerous health benefits associated with a physically active lifestyle. The purpose of this paper is to provide an update of the 2017 Society of Behavioral Medicine PA Special Interest Group article that outlined future directions in sedentary time reduction interventions, technology-based PA interventions, and the dissemination and implementation of PA interventions. Since the prior review, there has been significant progress on effective interventions for reducing sedentary time. However, there has been less progress for improving the specificity of sedentary time guidelines. There has been a dramatic increase in the number of studies examining PA mHealth interventions and support for mHealth intervention has generally been positive, though sustaining engagement in mHealth interventions remains a challenge. Promising newer technologies that have been explored more extensively since the prior review including artificial intelligence (AI). Knowledge of how to implement and scale-up effective PA interventions has also increased. Several current trends in PA intervention research that continue to advance the field include examining the moderating effect of the built environment on the effectiveness of behavioral interventions, cultural tailoring of interventions, Just in Time Adaptive Interventions (JITAIs), and exercise snacks (vigorous intensity PA sessions that are less than one minute). Overall, there has been significant progress in the PA intervention field but significant work remains for creating effective interventions that can be readily implemented into real world settings.

Interventions to improve access to cancer care in underserved populations in high income countries: a systematic review

Background

Underserved populations both globally and in Canada face serious cancer inequities that result from systemic economic, environmental, and social conditions. These pose barriers in access to cancer care and lead to suboptimal cancer care experiences and outcomes. Knowledge of effective interventions to improve access to cancer care is needed to inform the design of tailored interventions for these populations.

Aim

To identify interventions and programs to improve access to cancer care for underserved populations in high income countries with universal health coverage (UHC) and the United States (US) throughout the cancer care continuum.

Methods

We conducted a systematic review following the PRISMA standards. We searched Medline, EMBASE, PsycINFO, CINAHL, Scopus, and the Cochrane Library. Inclusion criteria: quantitative and qualitative studies published in English in the last 10 years (2013-2023), describing interventions/programs to improve access to cancer care for underserved populations (18 years and over). We included studies in the US given the body of scholarship on equity in cancer care in that country. Screening, data extraction and analysis were undertaken by two independent reviewers.

Results

Our search yielded 7,549 articles, and 74 met the inclusion criteria. Of these, 56 were conducted in the US, 8 in Australia, 6 in Canada, and 4 in the United Kingdom. Most (90.5%) were quantitative studies and 47.3% were published between 2020-2023. Seven types of interventions were identified: patient navigation, education and counselling, virtual health, service redesign, financial support, improving geographical accessibility and multicomponent interventions. Interventions were mainly designed to mitigate language, distance, financial, lack of knowledge and cultural barriers. Most interventions focused on access to cancer screening, targeted rural populations, racialized groups and people with low socioeconomic status, and were conducted in community-based settings. The majority of interventions or programs significantly improved access to cancer care.

Conclusion

Our systematic review findings suggest that interventions designed to remove specific barriers faced by underserved populations can improve access to cancer care. Few studies came from countries with UHC. Research is required to understand tailored interventions for underserved populations in countries with UHC.

Examining Theoretical Frameworks and Antecedents of Health Apps and Wearables Use: A Scoping Review

The advancement of health apps and wearables has garnered substantial academic attention, particularly in examining why individuals decide to use or not use them. In response to the extensive body of research on this topic, we conducted a scoping review of 61 articles published from 2007 to 2022, aiming to examine the dominant theoretical frameworks and antecedents of health apps and wearables use. The findings demonstrated that the dominant theoretical frameworks within this domain were rooted in the human-computer interaction theories, notably the Technology Acceptance Model and the Unified Theory of Acceptance and Use of Technology. Next, our review identified four levels of antecedents: technological, individual, societal, and policy. At the technological level, emphasis was placed on functionality, reliability, and technological infrastructure. Individual antecedents encompassed socio-demographics, personality traits, cognitive responses to benefits and risks, emotional and affective responses, self-efficacy, and digital literacy. Societal antecedents highlighted the role of social networks and social norms, while policy antecedents elaborated on laws, regulations, and guidelines that encouraged health technology adoption. Our discussion illuminated that the evolving trend of theoretical frameworks in health apps and wearables use research, initially rooted in human-computer interaction, is progressively moving toward more comprehensive perspectives. We further underscored the importance of delving into societal and policy antecedents, which often are overshadowed by the more commonly discussed technological and individual factors. In conclusion, we advocated for a multi-stakeholder collaborative network approach, as this would enable communication researchers to understand the use of health apps and wearables more comprehensively.

Utilization of Mobile Reminders in Improving the Completeness and Timeliness of Routine Childhood Immunization in Kano Metropolis, Nigeria: A Randomized Controlled Trial

INTRODUCTION

This study examined the effectiveness of mobile phone reminders in improving the completeness and timeliness of childhood immunization.

METHOD

We conducted a parallel arm cluster randomized controlled trial in four primary health care facilities in Nigeria. Reminders were sent to eligible participants in the intervention group at specific intervals when their children were scheduled to receive the vaccines administered at the sixth, 10, and 14 weeks after birth. Immunization records of all participants' children were then tracked to assess their immunization status.

RESULTS

The immunization status of the intervention (n = 275) and control (n = 261) arms was analyzed. Completeness and timeliness of the vaccine series were significantly higher (p < .001) among children of participants in the intervention (n = 169, 61.5% and n = 138, 50.2%) than those in the control group (n = 35, 13.4% and n = 13, 5%) arm.

DISCUSSION

Mobile phone reminders were established to be effective in increasing the completeness and timeliness of childhood immunization.

Single or Multiplayer Mode? Examining the Effects of Exergames in Improving Physical Health and Well-Being Among Older Adults

Objective: This study assesses the impact of single-player and multiplayer exergaming modes on improving exercise intentions, reduction of fear of falling, and emotional well-being among older adults, primarily from low socioeconomic status (SES) backgrounds-a group often underrepresented in exergame research. Method: We engaged 48 participants, primarily from low-SES communities in Singapore for a 4-week community-based exergaming intervention. Participants were divided into four groups as follows: (1) conventional exercise alone, (2) exergames alone, (3) exergames with a health coach, and (4) exergames with a peer. Using two-way repeated-measures ANOVA, we analyzed the effects of these interventions. Results: The findings revealed that all exergaming modes positively influenced exercise intentions, fear of falling, and emotional well-being to varying extents. Notably, exergaming with a health coach significantly improved participants' exercise intentions and emotional well-being, underscoring the value of expert guidance in motivating and supporting older adults in adopting healthier lifestyles. Exergaming with a peer was most effective in reducing fear of falling, highlighting the importance of social support and peer interaction in addressing physical health concerns among this population. Conclusion: This study emphasizes the potential of tailored exergame interventions incorporating various social interactions to improve health outcomes for older adults, contributing to more inclusive health promotion strategies.

Mobile Health Interventions for Substance Use Disorders

Substance use disorders (SUDs) have an enormous negative impact on individuals, families, and society as a whole. Most individuals with SUDs do not receive treatment because of the limited availability of treatment providers, costs, inflexible work schedules, required treatment-related time commitments, and other hurdles. A paradigm shift in the provision of SUD treatments is currently underway. Indeed, with rapid technological advances, novel mobile health (mHealth) interventions can now be downloaded and accessed by those that need them anytime and anywhere. Nevertheless, the development and evaluation process for mHealth interventions for SUDs is still in its infancy. This review provides a critical appraisal of the significant literature in the field of mHealth interventions for SUDs with a particular emphasis on interventions for understudied and underserved populations. We also discuss the mHealth intervention development process, intervention optimization, and important remaining questions.

The Helping Hand in Ukraine: feasibility and potential impact

BACKGROUND

New services are needed to prevent the mental health consequences of the war in Ukraine. Ten adolescents self-recruited to use and evaluate the Ukrainian version of the Helping Hand (HH) in Odesa, Ukraine. From April to June 2023, they participated in a 10-session group program where they played the cognitive behavioral game app, shared stories, and engaged in activities to enhance their coping skills.

METHODS

A mixed-method, quantitative-qualitative design was used to get insight into the feasibility and potential impact of the HH on Ukrainian adolescents' mental health and well-being during the war. A questionnaire to the adolescents assessed the feasibility of the intervention; anxiety and depression symptoms were assessed before and after the intervention by a standardized and validated adolescent-completed questionnaire. An interview with the psychologist who implemented the intervention was used to interpret the data completed by the adolescents.

RESULTS

Eight of 10 adolescents completed the HH intervention, and the psychologist found the HH helpful and culturally appropriate. The average anxiety and depression symptoms decreased from before the intervention (M = 20.4) to after (M = 15.0), showing a moderate effect size.

CONCLUSION

The results indicated that the HH has a high potential to prevent mental health consequences in Ukraine.

Remote Inclusion of Vulnerable Users in mHealth Intervention Design: Retrospective Case Analysis

BACKGROUND

Mobile health (mHealth) interventions that promote healthy behaviors or mindsets are a promising avenue to reach vulnerable or at-risk groups. In designing such mHealth interventions, authentic representation of intended participants is essential. The COVID-19 pandemic served as a catalyst for innovation in remote user-centered research methods. The capability of such research methods to effectively engage with vulnerable participants requires inquiry into practice to determine the suitability and appropriateness of these methods.

OBJECTIVE

In this study, we aimed to explore opportunities and considerations that emerged from involving vulnerable user groups remotely when designing mHealth interventions. Implications and recommendations are presented for researchers and practitioners conducting remote user-centered research with vulnerable populations.

METHODS

Remote user-centered research practices from 2 projects involving vulnerable populations in Norway and Australia were examined retrospectively using visual mapping and a reflection-on-action approach. The projects engaged low-income and unemployed groups during the COVID-19 pandemic in user-based evaluation and testing of interactive, web-based mHealth interventions.

RESULTS

Opportunities and considerations were identified as (1) reduced barriers to research inclusion; (2) digital literacy transition; (3) contextualized insights: a window into people's lives; (4) seamless enactment of roles; and (5) increased flexibility for researchers and participants.

CONCLUSIONS

Our findings support the capability and suitability of remote user methods to engage with users from vulnerable groups. Remote methods facilitate recruitment, ease the burden of research participation, level out power imbalances, and provide a rich and relevant environment for user-centered evaluation of mHealth interventions. There is a potential for a much more agile research practice. Future research should consider the privacy impacts of increased access to participants' environment via webcams and screen share and how technology mediates participants' action in terms of privacy. The development of support procedures and tools for remote testing of mHealth apps with user participants will be crucial to capitalize on efficiency gains and better protect participants' privacy.

Developing a Tailored eHealth Self-Management Intervention for Patients With Chronic Kidney Disease in China: Intervention Mapping Approach

BACKGROUND

Chronic kidney disease (CKD) is a major public health concern. Adequate self-management skills are vital to reduce CKD burden, optimize patient health outcomes, and control health care expenditures. Using eHealth to support CKD self-management has the potential to promote healthy behaviors and improve health outcomes of patients with CKD. However, knowledge of the implementation of such interventions in general, and in China specifically, is still limited.

OBJECTIVE

This study aims to develop a tailored eHealth self-management intervention for patients with CKD in China based on the Dutch Medical Dashboard (MD) eHealth self-management intervention.

METHODS

We used an intervention mapping approach. In phase 1, a systematic review and 2 qualitative studies were conducted to examine the needs, beliefs, and perceptions of patients with CKD and health care professionals regarding CKD self-management and eHealth interventions. Afterward, key factors gathered from the aforementioned studies were categorized following the 5 domains of the Consolidated Framework for Implementation Research (CFIR). In phase 2, we specified program outcomes, performance objectives, determinants, theory-based methods, and practical strategies. Knowledge obtained from previous results was combined to complement core components of the MD self-management intervention and adapt them for Chinese patients with CKD. Additionally, the CFIR-Expert Recommendations for Implementing Change Matching Tool was pragmatically used to generate a list of potential implementation strategies to address the key factors influencing the implementation of eHealth CKD self-management interventions, and implementation strategies were discussed and finalized with the intervention monitoring group.

RESULTS

An overview of the CFIR domains showed the essential factors influencing the implementation of eHealth CKD self-management interventions in Chinese settings, including "knowledge and beliefs" in the domain "individual characteristics," "quality and advantage of eHealth intervention" in the domain "intervention characteristics," "compatibility" in the domain "inner setting," and "cultural context" in the domain "outer setting." To ensure the effectiveness of the Dutch MD-based self-management intervention, we did not change the core self-management intervention components of MD that underlie its effectiveness, such as self-monitoring. We identified surface-level cultural adaptations involving customizing intervention content, messages, and approaches to the observable cultural characteristics of the local population to enhance the intervention's appeal, receptivity, and feasibility, such as providing video or voice call options to support interactions with health care professionals. Furthermore, the adapted modules such as Knowledge Center and My Self-Monitoring were developed in a mobile health app.

CONCLUSIONS

Our study resulted in the delivery of a culturally tailored, standardized eHealth self-management intervention for patients with CKD in China that has the potential to optimize patients' self-management skills and improve health status and quality of life. Moreover, our study's research approach and results can inform future research on the tailoring and translation of evidence-based, eHealth self-management interventions to various contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04212923; https://classic.clinicaltrials.gov/ct2/show/NCT04212923.

The effectiveness of visual-based interventions on health literacy in health care: a systematic review and meta-analysis

BACKGROUND

Limited Health Literacy (HL) is an obstacle to accessing and receiving optimal health care and negatively impacts patients' quality of life, thus making it an urgent issue in the health care system. Visual-based interventions are a promising strategy to improve HL through the use of visual aids and pictorial materials to explain health-related concepts. However, a comprehensive summary of the literature on the topic is still scarce.

METHODS

To fill this gap, we carried out a systematic review and meta-analysis with the aim to determine the effectiveness of visual-based interventions in improving comprehension of health related material in the clinical population. Independent studies evaluating the effectiveness of visual-based interventions on adults (> 18 years) and whose primary outcome was either health literacy (HL) or comprehension were eligible for the review. After a systematic literature search was carried out in five databases, 28 studies met the inclusion criteria and thus were included. Most of the studies were randomized controlled trials and they focused on HL and health knowledge as outcomes.

RESULTS

The review and meta-analysis showed that visual-based interventions were most effective in enhancing the comprehension of health-related material compared to traditional methods. According to meta-analytic results, videos are more effective than traditional methods (Z = 5.45, 95% CI [0.35, 0.75], p < 0.00001) and than the employment of written material (Z = 7.59, 95% CI [0.48, 0.82], p < 0.00001). Despite this, no significant difference was found between video and oral discussion (Z = 1.70, 95% CI [-0.46, 0.53], p = 0.09).

CONCLUSIONS

We conclude that visual-based interventions, particularly the ones using videos, are effective for improving HL and the comprehension of health-related material.

App Engagement as a Predictor of Weight Loss in Blended-Care Interventions: Retrospective Observational Study Using Large-Scale Real-World Data

BACKGROUND

Early weight loss is an established predictor for treatment outcomes in weight management interventions for people with obesity. However, there is a paucity of additional, reliable, and clinically actionable early predictors in weight management interventions. Novel blended-care weight management interventions combine coach and app support and afford new means of structured, continuous data collection, informing research on treatment adherence and outcome prediction.

OBJECTIVE

Against this backdrop, this study analyzes app engagement as a predictor for weight loss in large-scale, real-world, blended-care interventions. We hypothesize that patients who engage more frequently in app usage in blended-care treatment (eg, higher logging activity) lose more weight than patients who engage comparably less frequently at 3 and 6 months of intervention.

METHODS

Real-world data from 19,211 patients in obesity treatment were analyzed retrospectively. Patients were treated with 3 different blended-care weight management interventions, offered in Switzerland, the United Kingdom, and Germany by a digital behavior change provider. The principal component analysis identified an overarching metric for app engagement based on app usage. A median split informed a distinction in higher and lower engagers among the patients. Both groups were matched through optimal propensity score matching for relevant characteristics (eg, gender, age, and start weight). A linear regression model, combining patient characteristics and app-derived data, was applied to identify predictors for weight loss outcomes.

RESULTS

For the entire sample (N=19,211), mean weight loss was -3.24% (SD 4.58%) at 3 months and -5.22% (SD 6.29%) at 6 months. Across countries, higher app engagement yielded more weight loss than lower engagement after 3 but not after 6 months of intervention (P3 months<.001 and P6 months=.59). Early app engagement within the first 3 months predicted percentage weight loss in Switzerland and Germany, but not in the United Kingdom (PSwitzerland<.001, PUnited Kingdom=.12, and PGermany=.005). Higher age was associated with stronger weight loss in the 3-month period (PSwitzerland=.001, PUnited Kingdom=.002, and PGermany<.001) and, for Germany, also in the 6-month period (PSwitzerland=.09, PUnited Kingdom=.46, and PGermany=.03). In Switzerland, higher numbers of patients' messages to coaches were associated with higher weight loss (P3 months<.001 and P6 months<.001). Messages from coaches were not significantly associated with weight loss (all P>.05).

CONCLUSIONS

Early app engagement is a predictor of weight loss, with higher engagement yielding more weight loss than lower engagement in this analysis. This new predictor lends itself to automated monitoring and as a digital indicator for needed or adapted clinical action. Further research needs to establish the reliability of early app engagement as a predictor for treatment adherence and outcomes. In general, the obtained results testify to the potential of app-derived data to inform clinical monitoring practices and intervention design.

Examining health apps and wearable use in improving physical and mental well-being across U.S., China, and Singapore

Health apps and wearables are touted to improve physical health and mental well-being. However, it is unclear from existing research the extent to which these health technologies are efficacious in improving physical and mental well-being at a population level, particularly for the underserved groups from the perspective of health equity and social determinants. Also, it is unclear if the relationship between health apps and wearables use and physical and mental well-being differs across individualistic, collectivistic, and a mix of individual-collectivistic cultures. A large-scale online survey was conducted in the U.S. (individualist culture), China (collectivist culture), and Singapore (mix of individual-collectivist culture) using quota sampling after obtaining ethical approval from the Institutional Review Board (IRB-2021-262) of Nanyang Technological University (NTU), Singapore. There was a total of 1004 respondents from the U.S., 1072 from China, and 1017 from Singapore. Data were analyzed using multiple regression and negative binomial regression. The study found that income consistently had the strongest relationship with physical and mental well-being measures in all three countries, while the use of health apps and wearables only had a moderate association with psychological well-being only in the US. Health apps and wearables were associated with the number of times people spent exercising and some mental health outcomes in China and Singapore, but they were only positively associated with psychological well-being in the US. The study emphasizes the importance of considering the social determinants, social-cultural context of the population, and the facilitating conditions for the effective use of digital health technologies. The study suggests that the combined use of both health apps and wearables is most strongly associated with better physical and mental health, though this association is less pronounced when individuals use only apps or wearables.

Addressing Data Absenteeism and Technology Chauvinism in the Use of Gamified Wearable Gloves Among Older Adults: Moderated Usability Study

BACKGROUND

Digital health technologies have the potential to improve health outcomes for older adults, especially for those recovering from stroke. However, there are challenges to developing these technologies, such as data absenteeism (where older adults' views are often underrepresented in research and development) and technology chauvinism (the belief that sophisticated technology alone is the panacea to addressing health problems), which hinder their effectiveness.

OBJECTIVE

In this study, we aimed to address these challenges by developing a wearable glove integrated with culturally relevant exergames to motivate older adults to exercise and, for those recovering from stroke, to adhere to rehabilitation.

METHODS

We conducted a moderated usability study with 19 older adults, of which 11 (58%) had a history of stroke. Our participants engaged in a 30-minute gameplay session with the wearable glove integrated with exergames, followed by a quantitative survey and an in-depth interview. We used descriptive analysis to compare responses to the System Usability Scale between those who had a history of stroke and those who did not. In addition, we analyzed the qualitative interviews using a bottom-up thematic analysis to identify key themes related to the motivations and barriers regarding the use of wearable gloves for rehabilitation and exercise.

RESULTS

Our study generated several key insights. First, making the exergames exciting and challenging could improve exercise and rehabilitation motivation, but it could also have a boomerang effect, where participants may become demotivated if the games were very challenging. Second, the comfort and ease of use of the wearable gloves were important for older adults, regardless of their stroke history. Third, for older adults with a history of stroke, the functionality and purpose of the wearable glove were important in helping them with specific exercise movements.

CONCLUSIONS

Our findings highlight the importance of providing contextual support for the effective use of digital technologies, particularly for older adults recovering from stroke. In addition to technology and usability factors, other contextual factors such as gamification and social support (from occupational therapists or caregivers) should be considered to provide a comprehensive approach to addressing health problems. To overcome data absenteeism and technology chauvinism, it is important to develop digital health technologies that are tailored to the needs of underserved communities. Our study provides valuable insights for the development of digital health technologies that can motivate older adults recovering from stroke to exercise and adhere to rehabilitation.

Characterizing perceived usability and its correlation with smoking cessation: An analysis of user assessments of the smoking cessation app quitSTART

Background

As smartphone ownership has become common in all demographic groups in the United States, smartphone applications (apps) for smoking cessation have grown in popularity due to their potential for supporting the diverse populations in the United States who are attempting to quit smoking. Usability is commonly assessed in mobile health (mHealth) technology as an important aspect of the user experience that could influence users' adherence to a health app and health outcomes. However, the variation of perceived usability across demographic groups, and the implications of that variation for app success, have not been well studied.

Objective

The aims of this study were to characterize variation in the perceived usability of the National Cancer Institute Smokefree.gov Initiative smoking cessation app quitSTART across demographic groups, and to assess the correlation between perceived usability and short-term smoking cessation.

Methods

We conducted a secondary analysis of data from a randomized controlled trial conducted from 2020 to 2021, which used a 16-item modified version of the mHealth App Usability Questionnaire (MAUQ) to quantify perceived usability four weeks after app download among 131 smokers attempting to quit. Responses were coded on a 5-point Likert-type scale ranging from strongly disagree (1) to strongly agree (5) and total perceived usability was calculated as the sum of all 16 items (range: 16-80). Associations between participant demographic characteristics (gender, race, education level, age, etc.) and total usability were determined using an ANCOVA model. A multivariable logistic regression model was used to assess the association between usability and smoking cessation, also assessed 4 weeks after app download.

Results

The ANCOVA model demonstrated that race was associated with perceived usability, with participants from a racial minority group reporting higher total usability than White participants (p < 0.001). White participants had an adjusted mean total usability of 55.8 (95 % CI: 52.8, 58.8) while racial minority group participants had an adjusted mean total usability of 66.5 (95 % CI: 61.2, 71.6). Other participant demographic characteristics, such as gender and sexual minority status, were not associated with mean total usability. Total usability was positively associated with smoking cessation (OR: 1.04, 95 % CI: 1.00, 1.08, p = 0.031).

Conclusions

Total perceived usability of quitSTART was higher among adults from a racial minority group compared to White adults, and perceived usability was positively associated with cessation success. These findings emphasize the importance of ensuring high usability of mHealth smoking cessation apps for diverse populations.

Facilitators and barriers for implementing screening brief intervention and referral for health promotion in a rural hospital in Alberta: using consolidated framework for implementation research

BACKGROUND

Screening, brief intervention, and referral (SBIR) is an evidence-based, comprehensive health promotion approach commonly implemented to reduce alcohol and substance use. Implementation research on SBIR demonstrate that patients find it acceptable, reduces hospital costs, and it is effective. However, SBIR implementation in hospital settings for multiple risk factors (fruit and vegetable consumption, physical activity, alcohol and tobacco use) is still emergent. More evidence is needed to guide SBIR implementation for multiple risk factors in hospital settings.

OBJECTIVE

To explore the facilitators and barriers of SBIR implementation in a rural hospital using the Consolidated Framework for Implementation Research (CFIR).

METHODS

We conducted a descriptive qualitative investigation consisting of both inductive and deductive analyses. We conducted virtual, semi-structured interviews, guided by the CFIR framework. All interviews were audio-recorded, and transcribed verbatim. NVivo 12 Pro was used to organize and code the raw data.

RESULTS

A total of six key informant semi-structured interviews, ranging from 45 to 60 min, were carried out with members of the implementation support team and clinical implementers. Implementation support members reported that collaborating with health departments facilitated SBIR implementation by helping (a) align health promotion risk factors with existing guidelines; (b) develop training and educational resources for clinicians and patients; and (c) foster leadership buy-in. Conversely, clinical implementers reported several barriers to SBIR implementation including, increased and disrupted workflow due to SBIR-related documentation, a lack of knowledge on patients' readiness and motivation to change, as well as perceived patient stigma in relation to SBIR risk factors.

CONCLUSION

The CFIR provided a comprehensive framework to gauge facilitators and barriers relating to SBIR implementation. Our pilot investigation revealed that future SBIR implementation must address organizational, clinical implementer, and patient readiness to implement SBIR at all phases of the implementation process in a hospital.

Effective elements of eHealth interventions for mental health and well-being in children and adolescents: A systematic review

Background

Mental health problems among children and adolescents increased in recent years, while mental health services are overburdened with long waiting lists. eHealth interventions, that is, interventions delivered digitally via apps or websites, offer a promising approach to prevent and efficiently treat emerging mental health problems in youth. Over the past years, rapid technological progress has led to diverse eHealth interventions for youth mental health. However, a structured overview of effective eHealth elements and mechanisms through which interventions aim to improve mental health is lacking. The aim of this pre-registered systematic review is to identify elements of eHealth interventions that improve mental health and well-being in children and adolescents aged 10-25 from both clinical and general populations.

Methods

This systematic review conducted in April 2023 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines identified 108 studies and 103 distinct interventions between 2011-2023. The overall sample size was 33,435 participants (30.7% male, mean age = 18.4 years, SD = 2.5). Most studies (64.8%) were randomized controlled trials (RCTs) to test the interventions. The remaining studies utilized a pre-post or group-comparison design (non-RCTs).

Results

The interventions were heterogeneous in design, method of delivery, target group and outcome measures. Overall, 77.7% of the studies showed a positive significant association between eHealth intervention and mental health or well-being. Elements that were often related to improved mental health and well-being were cognitive behavioural therapy (CBT) or self-monitoring as therapeutic principles, blended approaches combining eHealth with traditional therapy, peer/parental involvement and technological gamification elements, such as rewards.

Conclusions

Elements of youth eHealth interventions that appear to positively impact mental health or well-being are (a) CBT-based, (b) self-monitoring (c) blended interventions, (d) peer or parental involvement or (e) gamification. Future directions for the development and implementation of eHealth interventions for youth are discussed.

Guide Development for eHealth Interventions Targeting People With a Low Socioeconomic Position: Participatory Design Approach

BACKGROUND

People with a low socioeconomic position (SEP) are less likely to benefit from eHealth interventions, exacerbating social health inequalities. Professionals developing eHealth interventions for this group face numerous challenges. A comprehensive guide to support these professionals in their work could mitigate these inequalities.

OBJECTIVE

We aimed to develop a web-based guide to support professionals in the development, adaptation, evaluation, and implementation of eHealth interventions for people with a low SEP.

METHODS

This study consisted of 2 phases. The first phase involved a secondary analysis of 2 previous qualitative and quantitative studies. In this phase, we synthesized insights from the previous studies to develop the guide's content and information structure. In the second phase, we used a participatory design process. This process included iterative development and evaluation of the guide's design with 11 professionals who had experience with both eHealth and the target group. We used test versions (prototypes) and think-aloud testing combined with semistructured interviews and a questionnaire to identify design requirements and develop and adapt the guide accordingly.

RESULTS

The secondary analysis resulted in a framework of recommendations for developing the guide, which was categorized under 5 themes: development, reach, adherence, evaluation, and implementation. The participatory design process resulted in 16 requirements on system, content, and service aspects for the design of the guide. For the system category, the guide was required to have an open navigation strategy leading to more specific information and short pages with visual elements. Content requirements included providing comprehensible information, scientific evidence, a user perspective, information on practical applications, and a personal and informal tone of voice. Service requirements involved improving suitability for different professionals, ensuring long-term viability, and a focus on implementation. Based on these requirements, we developed the final version of "the inclusive eHealth guide."

CONCLUSIONS

The inclusive eHealth guide provides a practical, user-centric tool for professionals aiming to develop, adapt, evaluate, and implement eHealth interventions for people with a low SEP, with the aim of reducing health disparities in this population. Future research should investigate its suitability for different end-user goals, its external validity, its applicability in specific contexts, and its real-world impact on social health inequality.

Experiencing (Shared) Decision Making: Results from a Qualitative Study of People with Mental Illness and Their Family Members

(1) Background: There is a fundamental shift in healthcare toward shared decision making (SDM). This study explores SDM from the perspective of individuals affected by mental illness and their family members and investigates factors which promote and hinder the process. (2) Methods: We conducted N = 15 telephone interviews (n = 4 adults affected by mental illness, n = 5 family members, n = 6 both applicable, the majority reporting experiences with affective and anxiety disorders). Data were recorded, transcribed, and analyzed according to procedures established by Mayring. (3) Results: Individuals affected by mental illness and their family members have a strong desire to be involved in treatment decisions and to participate in finding a diagnosis. Often these stakeholders are denied the opportunity to participate; sometimes enabling behaviors impede participation. The stigmatization of mental illnesses is a major barrier. There are also structural barriers to SDM within the healthcare system. Peer support, self-help associations, and psychosocial counseling services are important to empowering individuals and promoting SDM. (4) Conclusions: SDM has the potential to improve the quality of mental healthcare. Barriers can be mitigated and new approaches for interventions in the psychiatric sector have been identified. This study has also shown the importance of understanding SDM as a process that should begin at the diagnostic phase.

Effectiveness of mHealth consultation services for preventing postpartum depressive symptoms: a randomized clinical trial

BACKGROUND

Although many conventional healthcare services to prevent postpartum depression are provided face-to-face, physical and psychosocial barriers remain. These barriers may be overcome by using mobile health services (mHealth). To examine the effectiveness of mHealth professional consultation services in preventing postpartum depressive symptoms in real-world settings, we conducted this randomized controlled trial in Japan, where universal free face-to-face perinatal care is available.

METHODS

This study included 734 pregnant women living in Yokohama city who could communicate in Japanese, recruited at public offices and childcare support facilities. The participants were randomized to the mHealth group (intervention, n = 365), where they could use a free app-based mHealth consultation service with gynecologists/obstetricians, pediatricians, and midwives whenever and as many times as they wanted between 6 p.m. and 10 p.m. on weekdays throughout their pregnancy and postpartum periods (funded by the City of Yokohama government) or the usual care group (control, n = 369). The primary outcome was the risk of elevated postpartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale score ≥ 9. Secondary outcomes were self-efficacy, loneliness, perceived barriers to healthcare access, number of clinic visits, and ambulance usage. All outcomes were collected three months post-delivery. We also conducted subgroup analyses assessing the differences in the treatment effect by sociodemographic status.

RESULTS

Most women completed all questionnaires (n = 639 of 734, response rate: 87%). The mean baseline age was 32.9 ± 4.2 years, and 62% were primipara. Three months post-delivery, women in the mHealth group had a lower risk of elevated postpartum depressive symptoms (47/310 [15.2%]) compared to the usual care group (75/329 [22.8%], risk ratio: 0.67 [95% confidence interval: 0.48-0.93]). Compared with the usual care group, women in the mHealth group had higher self-efficacy, less loneliness, and fewer perceived barriers to healthcare access. No differences were observed in the frequency of clinic visits or ambulance usage. Furthermore, in the subgroup analyses, we did not find differences in the treatment effect by sociodemographic status.

CONCLUSIONS

Local government-funded mHealth consultation services have a preventive effect on postpartum depressive symptoms, removing physical and psychological barriers to healthcare access in real-world settings.

TRIAL REGISTRATION

UMIN-CTR identifier: UMIN000041611. Registered 31 August 2021.

Effectiveness of internet-based and mobile-based interventions for adults with overweight or obesity experiencing symptoms of depression: a systematic review protocol

INTRODUCTION

Internet-based and mobile-based interventions (IMIs) provide innovative low-threshold and cost-effective prevention and self-management options for mental health problems complementary to standard treatment. The objective of this systematic review is to summarise the effectiveness and to critically evaluate studies on IMIs addressing comorbid depressive symptoms in adults with overweight or obesity.

METHODS AND ANALYSIS

The study authors will systematically search the databases MEDLINE, Cochrane Library, PsycINFO, Web of Science, Embase and Google Scholar (for grey literature) for randomised controlled trials (RCTs) of IMIs for individuals with overweight or obesity and comorbid depressive symptoms without restrictions on publication date (planned inception 1 June 2023 to 1 December 2023). Two reviewers will independently extract and evaluate data from studies eligible for inclusion by assessing quality of evidence and qualitatively synthesising results. Preferred Reporting Items for Systematic reviews Meta-Analyses (PRISMA) standards and the revised Cochrane Risk of Bias tool in RCTs (RoB 2) will be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data will be collected. Study results will be disseminated through publication in a peer-reviewed journal and presentations on conferences.

PROSPERO REGISTRATION NUMBER

CRD42023361771.

Perceptions and Usability of PREVENTION: A Breast Cancer Risk Assessment e-Platform

BACKGROUND

The PREVENTION e-platform was developed to provide accessible and evidence-based health information tailored to different Breast Cancer (BC) risk levels. The demonstration study objectives were to (1) assess the usability and perceived impact of PREVENTION on women with assigned hypothetical BC risk levels (i.e., near population, intermediate or high) and (2) explore perceptions and recommendations for e-platform improvement.

METHODS

Thirty women with no history of cancer were recruited through social media, commercial centers, health clinics, and community settings in Montreal, Qc, Canada. Participants accessed e-platform content tailored to their assigned hypothetical BC risk level, and then completed study e-questionnaires including the user Mobile Application Rating Scale (uMARS), an e-platform quality scale (i.e., in terms of engagement, functionality, aesthetics, and information). A subsample (n = 18) was randomly selected for an individual follow-up semi-structured interview.

RESULTS

The e-platform overall quality was high, with mean M = 4.01 (out of 5) and SD = 0.50. A total of 87% (n = 26) agreed or strongly agreed that PREVENTION increased their knowledge and awareness of BC risk, and 80% would recommend it to others while reporting likelihood of following lifestyle recommendations to decrease their BC risk. Follow up interviews indicated that participants perceived the e-platform as a trusted source of BC information and a promising means to connect with peers. They also reported that while the e-platform was easy to navigate, improvements were needed for connectivity, visuals, and the organization of scientific resources.

CONCLUSION

Preliminary findings support PREVENTION as a promising means to provide personalized BC information and support. Efforts are underway to further refine the platform, assess its impact in larger samples and gather feedback from BC specialists.

An Assessment of Perspectives and Concerns Among Research Participants of Childbearing Age Regarding the Health-Relatedness of Data, Online Data Privacy, and Donating Data to Researchers: Survey Study

BACKGROUND

The June 2022 US Supreme Court decision to ban abortion care in Dobbs v Jackson Women's Health Organization sparked ominous debate about the privacy and safety of women and families of childbearing age with digital footprints who actively engage in family planning, including abortion and miscarriage care.

OBJECTIVE

To assess the perspectives of a subpopulation of research participants of childbearing age regarding the health-relatedness of their digital data, their concerns about the use and sharing of personal data online, and their concerns about donating data from various sources to researchers today or in the future.

METHODS

An 18-item electronic survey was developed using Qualtrics and administered to adults (aged ≥18 years) registered in the ResearchMatch database in April 2021. Individuals were invited to participate in the survey regardless of health status, race, gender, or any other mutable or immutable characteristics. Descriptive statistical analyses were conducted using Microsoft Excel and manual queries (single layer, bottom-up topic modeling) and used to categorize illuminating quotes from free-text survey responses.

RESULTS

A total of 470 participants initiated the survey and 402 completed and submitted the survey (for an 86% completion rate). Nearly half the participants (189/402, 47%) self-reported to be persons of childbearing age (18 to 50 years). Most participants of childbearing age agreed or strongly agreed that social media data, email data, text message data, Google search history data, online purchase history data, electronic medical record data, fitness tracker and wearable data, credit card statement data, and genetic data are health-related. Most participants disagreed or strongly disagreed that music streaming data, Yelp review and rating data, ride-sharing history data, tax records and other income history data, voting history data, and geolocation data are health-related. Most (164/189, 87%) participants were concerned about fraud or abuse based on their personal information, online companies and websites sharing information with other parties without consent, and online companies and websites using information for purposes that are not explicitly stated in their privacy policies. Free-text survey responses showed that participants were concerned about data use beyond scope of consent; exclusion from health care and insurance; government and corporate mistrust; and data confidentiality, security, and discretion.

CONCLUSIONS

Our findings in light of Dobbs and other related events indicate there are opportunities to educate research participants about the health-relatedness of their digital data. Developing strategies and best privacy practices for discretion regarding digital-footprint data related to family planning should be a priority for companies, researchers, families, and other stakeholders.

Wearable Devices in Cardiovascular Medicine

Wearable devices, such as smartwatches and activity trackers, are commonly used by patients in their everyday lives to manage their health and well-being. These devices collect and analyze long-term continuous data on measures of behavioral or physiologic function, which may provide clinicians with a more comprehensive view of a patients' health compared with the traditional sporadic measures captured by office visits and hospitalizations. Wearable devices have a wide range of potential clinical applications ranging from arrhythmia screening of high-risk individuals to remote management of chronic conditions such as heart failure or peripheral artery disease. As the use of wearable devices continues to grow, we must adopt a multifaceted approach with collaboration among all key stakeholders to effectively and safely integrate these technologies into routine clinical practice. In this Review, we summarize the features of wearable devices and associated machine learning techniques. We describe key research studies that illustrate the role of wearable devices in the screening and management of cardiovascular conditions and identify directions for future research. Last, we highlight the challenges that are currently hindering the widespread use of wearable devices in cardiovascular medicine and provide short- and long-term solutions to promote increased use of wearable devices in clinical care.