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

Digitally mediated relationships: How social representation in technology influences the therapeutic relationship in primary care

Relationships, built on trust, knowledge, regard, and loyalty, have been demonstrated to be fundamental to health care delivery. Strong relationships between patients and providers have been linked to more compassionate care delivery, and better patient experience and outcomes, and may be particularly important in primary care. The rapid adoption of digital technologies since the onset of COVID-19 has led health care systems to seriously consider a "digital-first" primary care delivery model. Questions remain regarding what impact this transformation will have on the therapeutic relationship. Using a rapid ethnographic approach this study explores how patient and provider understandings of therapeutic relationships and digital health technologies may influence relationship-building or maintenance between patients with complex care needs and their care providers. Three team-based primary care sites in Toronto, Ontario, Canada were included in the study. Across the three sites 9 patients with chronic health conditions, 1 caregiver, and 10 healthcare providers (including family physicians, family medicine residents, social workers, and nurse practitioners) participated. Interviews were conducted with all participants and 8 observations of virtual clinical encounters (phone and video visits) were conducted. Using social representation theory as a lens, analysis revealed that participants' constructions of therapeutic relationships and digital technologies were informed by their identities, experiences, and expectations. For participants to see technologies as enabling to the therapeutic relationship, there needed to be alignment between how participants viewed the role of technology in care and in their lives, and how they recognized (or constructed) a good therapeutic relationship. This exploratory work suggests the need to think about how both patients' and providers' views of technology may determine whether digital technologies can be leveraged to meet patient needs while maintaining, or building, strong therapeutic relationships.

Unveiling the adoption of metaverse technology in Bangkok metropolitan areas: A UTAUT2 perspective with social media marketing and consumer engagement

As the metaverse emerges as a transformative digital realm, its adoption and integration into various aspects of society are subjects of increasing scholarly and practical interest. This research investigated the factors influencing the intention to use metaverse technology (IU) in Bangkok metropolitan areas, with a particular focus on the extended Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) framework, alongside the role of social media marketing (SMM) and consumer engagement (CE). To verify behavioral intention, gender, age, and experience are proposed as moderating factors affecting the constructs on individuals' behavioral intention of metaverse technology usage. The study collected data from 403 Thai internet users living in Bangkok and its surrounding areas using an online questionnaire. Subsequently, the PLS-SEM method was employed to validate the research model's robustness and reliability. Structural model analysis revealed significant relationships among constructs, highlighting SMM's direct influence on UTAUT2 (β = 0.787) and CE (β = 0.211). Serial mediation analyzes demonstrated a fully mediating role of SMM influencing UI through CE (β = 0.572) and UTAUT2 (β = 0.306). Moderation analyzes revealed the association between SMM and IU, mediated through UTAUT2 and CE, is moderated by age and experience. Additionally, the integration of PLS-SEM and artificial neural network (ANN) models underscored the accuracy and predictive power of the proposed framework. The findings of this study not only contribute to academic literature but also offer practical implications for marketers aiming to navigate the metaverse landscape effectively. They emphasize the pivotal role of UTAUT2 constructs and the subtle interplay between SMM, CE, and IU in shaping successful marketing strategies.

Access, Readiness and Willingness to Engage in Allied Health Telerehabilitation Services for Adults: Does Cultural and Linguistic Diversity Make a Difference?

Telerehabilitation is an appealing service delivery option for optimising recovery. Internationally, the equity of telerehabilitation services for people from culturally and linguistically diverse (CALD) backgrounds has been questioned. Using a 31-item survey, our study explored the access, readiness and willingness of 260 patients receiving allied health services from a large tertiary health service located in Sydney, Australia, to use telerehabilitation for adults. Overall, 72% patients reported having access to technology, 38% met our readiness criteria and 53% reported willingness to engage in telerehabilitation. There were no differences in access, readiness and willingness to engage in telerehabilitation between patients from CALD and non-CALD backgrounds. Age was the only factor that influenced access (OR = 0.94, 95% CI 0.90 to 0.97), readiness (OR = 0.95, 95% CI 0.92 to 0.98) and willingness (OR = 0.97, 95% CI 0.95 to 1.00) to engage in telerehabilitation. Past experience of telerehabilitation was related to willingness (OR = 2.73, 95% CI 1.55-4.79) but not access (OR = 1.79, 95% CI 0.87 to 3.68) or readiness (OR = 1.90, 95% CI 0.93 to 3.87). Our findings highlight the importance of ensuring positive patient experiences to promote ongoing willingness to use telerehabilitation. Efforts are needed to improve patients' digital health literacy, especially patients from older age groups, to ensure equitable engagement in telerehabilitation services.

Person-Generated Health Data in Women's Health: Scoping Review

BACKGROUND

The increased pervasiveness of digital health technology is producing large amounts of person-generated health data (PGHD). These data can empower people to monitor their health to promote prevention and management of disease. Women make up one of the largest groups of consumers of digital self-tracking technology.

OBJECTIVE

In this scoping review, we aimed to (1) identify the different areas of women's health monitored using PGHD from connected health devices, (2) explore personal metrics collected through these technologies, and (3) synthesize facilitators of and barriers to women's adoption and use of connected health devices.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews, we searched 5 databases for articles published between January 1, 2015, and February 29, 2020. Papers were included if they targeted women or female individuals and incorporated digital health tools that collected PGHD outside a clinical setting.

RESULTS

We included a total of 406 papers in this review. Articles on the use of PGHD for women steadily increased from 2015 to 2020. The health areas that the articles focused on spanned several topics, with pregnancy and the postpartum period being the most prevalent followed by cancer. Types of digital health used to collect PGHD included mobile apps, wearables, websites, the Internet of Things or smart devices, 2-way messaging, interactive voice response, and implantable devices. A thematic analysis of 41.4% (168/406) of the papers revealed 6 themes regarding facilitators of and barriers to women's use of digital health technology for collecting PGHD: (1) accessibility and connectivity, (2) design and functionality, (3) accuracy and credibility, (4) audience and adoption, (5) impact on community and health service, and (6) impact on health and behavior.

CONCLUSIONS

Leading up to the COVID-19 pandemic, the adoption of digital health tools to address women's health concerns was on a steady rise. The prominence of tools related to pregnancy and the postpartum period reflects the strong focus on reproductive health in women's health research and highlights opportunities for digital technology development in other women's health topics. Digital health technology was most acceptable when it was relevant to the target audience, was seen as user-friendly, and considered women's personalization preferences while also ensuring accuracy of measurements and credibility of information. The integration of digital technologies into clinical care will continue to evolve, and factors such as liability and health care provider workload need to be considered. While acknowledging the diversity of individual needs, the use of PGHD can positively impact the self-care management of numerous women's health journeys. The COVID-19 pandemic has ushered in increased adoption and acceptance of digital health technology. This study could serve as a baseline comparison for how this field has evolved as a result.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/26110.

Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada

OBJECTIVES

Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada.

DESIGN

We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis.

RESULTS

Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices.

CONCLUSION

Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

Bridging the digital health divide-patient experiences with mobile integrated health and facilitated telehealth by community-level indicators of health disparity

OBJECTIVE

Evaluate the impact of community tele-paramedicine (CTP) on patient experience and satisfaction relative to community-level indicators of health disparity.

MATERIALS AND METHODS

This mixed-methods study evaluates patient-reported satisfaction and experience with CTP, a facilitated telehealth program combining in-home paramedic visits with video visits by emergency physicians. Anonymous post-CTP visit survey responses and themes derived from directed content analysis of in-depth interviews from participants of a randomized clinical trial of mobile integrated health and telehealth were stratified into high, moderate, and low health disparity Community Health Districts (CHD) according to the 2018 New York City (NYC) Community Health Survey.

RESULTS

Among 232 CTP patients, 55% resided in high or moderate disparity CHDs but accounted for 66% of visits between April 2019 and October 2021. CHDs with the highest proportion of CTP visits were more adversely impacted by social determinants of health relative to the NYC average. Satisfaction surveys were completed in 37% of 2078 CTP visits between February 2021 and March 2023 demonstrating high patient satisfaction that did not vary by community-level health disparity. Qualitative interviews conducted with 19 patients identified differing perspectives on the value of CTP: patients in high-disparity CHDs expressed themes aligned with improved health literacy, self-efficacy, and a more engaged health system, whereas those from low-disparity CHDs focused on convenience and uniquely identified redundancies in at-home services.

CONCLUSIONS

This mixed-methods analysis suggests CTP bridges the digital health divide by facilitating telehealth in communities negatively impacted by health disparities.

A Self-Guided Web-Based App (MyDiaMate) for Enhancing Mental Health in Adults With Type 1 Diabetes: Insights From a Real-World Study in the Netherlands

BACKGROUND

MyDiaMate is a web-based intervention specifically designed for adults with type 1 diabetes (T1D) that aims to help them improve and maintain their mental health. Prior pilot-testing of MyDiaMate verified its acceptability, feasibility, and usability.

OBJECTIVE

This study aimed to investigate the real-world uptake and usage of MyDiaMate in the Netherlands.

METHODS

Between March 2021 and December 2022, MyDiaMate was made freely available to Dutch adults with T1D. Usage (participation and completion rates of the modules) was tracked using log data. Users could volunteer to participate in the user profile study, which required filling out a set of baseline questionnaires. The usage of study participants was examined separately for participants scoring above and below the cutoffs of the "Problem Areas in Diabetes" (PAID-11) questionnaire (diabetes distress), the "World Health Organization Well-being Index" (WHO-5) questionnaire (emotional well-being), and the fatigue severity subscale of the "Checklist Individual Strength" (CIS) questionnaire (fatigue). Two months after creating an account, study participants received an evaluation questionnaire to provide us with feedback.

RESULTS

In total, 1008 adults created a MyDiaMate account, of whom 343 (34%) participated in the user profile study. The mean age was 43 (SD 14.9; 18-76) years. Most participants were female (n=217, 63.3%) and higher educated (n=198, 57.6%). The majority had been living with T1D for over 5 years (n=241, 73.5%). Of the study participants, 59.1% (n=199) of them reported low emotional well-being (WHO-5 score≤50), 70.9% (n=239) of them reported elevated diabetes distress (PAID-11 score≥18), and 52.4% (n=178) of them reported severe fatigue (CIS score≥35). Participation rates varied between 9.5% (n=19) for social environment to 100% (n=726) for diabetes in balance, which opened by default. Completion rates ranged from 4.3% (n=1) for energy, an extensive cognitive behavioral therapy module, to 68.6% (n=24) for the shorter module on hypos. There were no differences in terms of participation and completion rates of the modules between study participants with a more severe profile, that is, lower emotional well-being, greater diabetes distress, or more fatigue symptoms, and those with a less severe profile. Further, no technical problems were reported, and various suggestions were made by study participants to improve the application, suggesting a need for more personalization.

CONCLUSIONS

Data from this naturalistic study demonstrated the potential of MyDiaMate as a self-help tool for adults with T1D, supplementary to ongoing diabetes care, to improve healthy coping with diabetes and mental health. Future research is needed to explore engagement strategies and test the efficacy of MyDiaMate in a randomized controlled trial.

An assessment of ten popular pregnancy applications (Apps) available for women in Australia

OBJECTIVE

Given the growing popularity of health Apps, this study aimed to evaluate popular pregnancy Apps among Australian women.

DESIGN

Ten popular pregnancy mobile device Apps accessible within Australia were assessed using the Deakin Health E-technologies Assessment Lab (HEAL) framework, the Australian Privacy Principles (APP) and other context-specific criteria.

RESULTS

Most Apps were robust in use and user-friendly in terms of design. Based on the HEAL assessment, all the Apps scored between 70 and 89 out of 120. Only two of the ten Apps were locally hosted and operated. Only one App could search local health services using Victorian postcodes. All ten Apps were aligned with various privacy policy guidelines, but only one was reported to be fully aligned with the APP as it is locally hosted and operated. None of the Apps had accessibility features such as for visual or hearing difficulties. Only one App could be assessed as able to interface with the electronic medical record system in Australia due to a lack of publicly available information on this capability.

CONCLUSIONS

Due to privacy concerns, pregnancy Apps accessible in Australia should be used with caution unless care is taken to select an App that fully complies with local requirements or international equivalents. All Apps were subjectively rated as moderate in quality, and more attention to accessibility and privacy features by App developers is recommended, along with the focus on integration with Australian digital health services.

Moving Toward Online-Based Sexually Transmitted Infection Testing and Treatment Services for Young People: Who Will Use It and What Do They Want?

BACKGROUND

The market for online sexually transmitted infection (STI) services is rapidly expanding. Online health services often have unequal uptake among different demographics of the population. There is a need to understand how different online delivery options for STI testing may appeal to different groups of young people, particularly young people who have higher rates of STI diagnoses.

METHODS

An online survey of young Australians aged 16 to 29 years was conducted to understand service preferences regarding consultation (telehealth, fully automated questionnaire), testing (electronic pathology form, at-home self-sampling), and treatment (e-prescriptions, mailed oral tablets). Multivariable multinomial logistic regression examined associations between user characteristics and service preferences, and adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs) are presented.

RESULTS

Among 905 respondents, rural youth were more likely to prefer fully automated questionnaires (aRRR, 1.9; 95% CI, 1.0-3.5) over telehealth consultations, whereas culturally and linguistically diverse (CALD) youth were less likely (aRRR, 0.4; 95% CI, 0.2-0.7). Rural youth preferred at-home self-sampling kits (aRRR, 1.9; 95% CI, 1.3-2.7) over electronic forms for on-site collection at pathology centers, with the opposite for CALD youth (aRRR, 0.7; 95% CI, 0.5-1.0). Receiving oral antibiotics by mail was preferred by rural youth (aRRR, 2.3; 95% CI, 1.1-4.6) over for in-clinic treatment, but not for CALD youth (aRRR, 0.5; 95% CI, 0.4-0.8).

CONCLUSIONS

Our findings suggest that rural youth tend to prefer self-navigated and automated options, whereas CALD prefer options with greater provider engagement. Online STI service providers should consider how different service options may affect equitable uptake across the population and implications for addressing disparities in testing and treatment.

Lifestyle Interventions to Prevent Type 2 Diabetes in Women with a History of Gestational Diabetes: A Systematic Review and Meta-Analysis through the Lens of Health Equity

BACKGROUND

Type 2 diabetes mellites is one of the health problems disproportionally affecting people with low socioeconomic statuses. Gestational diabetes mellites increases the risk of type 2 diabetes by up to ten-fold for women. Lifestyle interventions prevent type 2 diabetes in women with prior gestational diabetes. However, it is unknown if similar effectiveness can be expected for all population subgroups.

OBJECTIVE

This study aims to assess the prevention of type 2 diabetes in women with prior gestational diabetes using population characteristics according to the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) criteria.

METHODS

MEDLINE, CINAHL, EMBASE, PubMed, PsycINFO, Web of Science, and EBM Reviews databases were searched for interventional studies of diet, physical activity, or behavioural interventions published up to 21 February 2023. Random effects subgroup meta-analysis was conducted to evaluate the association of population characteristics and intervention effects.

RESULTS

All studies were conducted in high-income countries or middle-income countries. Two-thirds of the studies reported on race/ethnicity and education level. Less than one-third reported on place (urban/rural), occupation, and socioeconomic status. None reported on religion or social capital. Studies from high-income countries (MD = -1.46; 95% CI: -2.27, -0.66, I2 = 70.46, p < 0.001) showed a greater reduction in bodyweight compared with the studies conducted in middle-income countries (MD = -0.11; 95% CI: -1.12, 0.89, I2 = 69.31, p < 0.001) (p for subgroup difference = 0.04).

CONCLUSION

There are significant equity gaps in the evidence for the prevention of type 2 diabetes in women with prior gestational diabetes due to reports on population characteristics being poor. Interventions may be less effective in reducing bodyweight in women from middle-income countries compared to high-income countries. Collecting and analysing data related to equity is needed to understand the effect of lifestyle interventions on type 2 diabetes for different population subgroups.

The Use of mHealth Apps for the Assessment and Management of Diabetes-Related Foot Health Outcomes: Systematic Review

BACKGROUND

Globally, diabetes affects approximately 500 million people and is predicted to affect up to 700 million people by 2045. In Australia, the ongoing impact of colonization produces inequity in health care delivery and inequality in health care outcomes for First Nations Peoples, with diabetes rates 4 times those of non-Indigenous Australians. Evidence-based clinical practice has been shown to reduce complications of diabetes-related foot disease, including ulceration and amputation, by 50%. However, factors such as a lack of access to culturally safe care, geographical remoteness, and high costs associated with in-person care are key barriers for First Nations Peoples in accessing evidence-based care, leading to the development of innovative mobile health (mHealth) apps as a way to increase access to health services and improve knowledge and self-care management for people with diabetes.

OBJECTIVE

This study aims to evaluate studies investigating the use of mHealth apps for the assessment and management of diabetes-related foot health in First Nations Peoples in Australia and non-Indigenous populations globally.

METHODS

PubMed, Informit's Indigenous Collection database, Ovid MEDLINE, Embase, CINAHL Complete, and Scopus were searched from inception to September 8, 2022. Hand searches of gray literature and reference lists of included studies were conducted. Studies describing mHealth apps developed for the assessment and management of diabetes-related foot health were eligible. Studies must include an evaluation (qualitative or quantitative) of the mHealth app. No language, publication date, or publication status restrictions were used. Quality appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and the Health Evidence Bulletins Wales checklists for observational, cohort, and qualitative studies.

RESULTS

No studies specifically including First Nations Peoples in Australia were identified. Six studies in non-Indigenous populations with 361 participants were included. Foot care education was the main component of all mHealth apps. Of the 6 mHealth apps, 2 (33%) provided functionality for participants to enter health-related data; 1 (17%) included a messaging interface. The length of follow-up ranged from 1-6 months. Of the 6 studies, 1 (17%) reported high levels of acceptability of the mHealth app content for self-care by people with diabetes and diabetes specialists; the remaining 5 (83%) reported that participants had improved diabetes-related knowledge and self-management skills after using their mHealth app.

CONCLUSIONS

The findings from this systematic review provide an overview of the features deployed in mHealth apps and indicate that this type of intervention can improve knowledge and self-care management skills in non-Indigenous people with diabetes. Future research needs to focus on mHealth apps for populations where there is inadequate or ineffective service delivery, including for First Nations Peoples and those living in geographically remote areas, as well as evaluate direct effects on diabetes-related foot disease outcomes.

TRIAL REGISTRATION

PROSPERO CRD42022349087; https://tinyurl.com/35u6mmzd.

Migrants face Barriers to Obtaining Electronic Identification: A population-based Study Among Older Russian-speakers in Finland

As digital technologies continue to transform health care and health systems, they will continue to have a lasting impact on health services. Many health and social care services have rapidly become 'digital by default'. The electronic identification (e-ID) technology is needed for secure authentication to digital services. Recent studies have shown that the 'digital divide' is prominent between ethnic minorities and the majority populations and between older and younger adults. Inequalities related to not having an e-ID, which is in many countries required to access digital health services, remain under-researched. Moreover, there is a lack of knowledge of the use of digital services among older migrants. This study analyses general socio-demographic as well as migration specific factors that may be associated with not having an e-ID among older migrants. We used the Care, Health and Ageing of Russian-speaking Minority in Finland (CHARM) study, which is a nationally representative survey of community-dwelling Russian-speaking adults aged ≥ 50 years living in Finland (N = 1082, 57% men, mean age 63.2 years, standard deviation 8.4 years, response rate 36%). Our results showed that 21% of older Russian-speakers did not have an e-ID. Our regression analysis showed that older age and poorer economic situation were associated with a lower probability of having an e-ID. In addition, we found an association between not speaking local languages and not having an e-ID. This may relate to private banks regulating the requirements for obtaining the most common e-ID method, online banking ID. We argue that for individuals who are already in vulnerable positions, current e-ID practices might pose yet another obstacle to obtaining the health services they need and are entitled to.