Views of People With High and Low Levels of Health Literacy About a Digital Intervention to Promote Physical Activity for Diabetes: A Qualitative Study in Five Countries

Hotspots and trends in health-oriented physical literacy research: a visual analysis based on the WOS database

BACKGROUND

The World Health Organization has proposed that physical activity is a meaningful way to improve the quality of human life and reduce the probability of chronic non-communicable diseases and that humans should change their mindset from the actual effectiveness of physical activity in promoting health to the new view that "physical activity makes life more meaningful." The introduction and development of physical literacy reveal the critical role of physical activity in improving human health and the importance of human initiative in physical activity for healthy development. Therefore, the objectives of this paper are (1) to conduct a bibliometric analysis of the literature on physical literacy, assessing the scope, frequency, and geographical distribution of research publications from various countries and institutions from 2015 to 2023; (2) to visualize keywords in articles on the topic of Physical literacy to analyze whether there is a link between physical literacy and health, and (3) based on the results of the visual analysis, we propose that proper health is built on the sense of physical literacy and further construct the circular path of physical literacy, physical activity, and physical health improvement.

METHODS

Using VOSviewer software v.1.6.18, this study searched the core collection of the Web of Science database from 2015 to April 15, 2023, using "physical literacy" as a keyword to explore the current international research on physical literacy.

RESULTS

A total of 3,446 articles were included, and a correlation map was derived based on the co-occurrence frequency of keywords, which showed that physical literacy was highly correlated with six concepts: health literacy, physical activity, health, children, adolescents, and prevention.

CONCLUSION

Based on the analysis of literature visualization techniques, there is a high correlation between physical literacy and health, and international physical literacy research is in a trend of multi-point amplification, with research hotspots gradually shifting from the field of sports to the field of health and closely related to the field of health, indicating that physical literacy aims to promote the achievement of individual health by driving humans to increase physical activity.

Identifying app components that promote physical activity: a group concept mapping study

Background

Digital interventions are a promising avenue to promote physical activity in healthy adults. Current practices recommend to include end-users early on in the development process. This study focuses on the wishes and needs of users regarding an a mobile health (mHealth) application that promotes physical activity in healthy adults, and on the differences between participants who do or do not meet the World Health Organization's recommendation of an equivalent of 150 minutes of moderate intensity physical activity.

Methods

We used a mixed-method design called Group Concept Mapping. In a first phase, we collected statements completing the prompt "In an app that helps me move more, I would like to see/ do/ learn the following…" during four brainstorming sessions with physically inactive individuals (n = 19). The resulting 90 statements were then sorted and rated by a new group of participants (n = 46). Sorting data was aggregated, and (dis)similarity matrices were created using multidimensional scaling. Hierarchical clustering was applied using Ward's method. Analyses were carried out for the entire group, a subgroup of active participants and a subgroup of inactive participants. Explorative analyses further investigated ratings of the clusters as a function of activity level, gender, age and education.

Results

Six clusters of statements were identified, namely 'Ease-of-use and Self-monitoring', 'Technical Aspects and Advertisement', 'Personalised Information and Support', 'Motivational Aspects', 'Goal setting, goal review and rewards', and 'Social Features'. The cluster 'Ease-of-use and Self-monitoring' was rated highest in the overall group and the active subgroup, whereas the cluster 'Technical Aspects and Advertisement' was scored as most relevant in the inactive subgroup. For all groups, the cluster 'Social Features' was scored the lowest. Explorative analysis revealed minor between-group differences.

Discussion

The present study identified priorities of users for an mHealth application that promotes physical activity. First, the application should be user-friendly and accessible. Second, the application should provide personalized support and information. Third, users should be able to monitor their behaviour and compare their current activity to their past performance. Fourth, users should be provided autonomy within the app, such as over which and how many notifications they would like to receive, and whether or not they want to engage with social features. These priorities can serve as guiding principles for developing mHealth applications to promote physical activity in the general population.

Intervention development of 'Diabetes Together' using the person-based approach: a couples-focused intervention to support self-management of type 2 diabetes in South Africa

OBJECTIVES

Type 2 diabetes (T2D) is a growing concern in South Africa, where many find self-management challenging. Behaviour-change health interventions are enhanced by involving partners of patients. We aimed to develop a couples-focused intervention to improve self-management of T2D among adults in South Africa.

DESIGN

We used the person-based approach (PBA): synthesising evidence from existing interventions; background research; theory; and primary qualitative interviews with 10 couples to ascertain barriers and facilitators to self-management. This evidence was used to formulate guiding principles that directed the intervention design. We then prototyped the intervention workshop material, shared it with our public and patient involvement group and ran iterative co-discovery think-aloud sessions with nine couples. Feedback was rapidly analysed and changes formulated to improve the intervention, optimising its acceptability and maximising its potential efficacy.

SETTING

We recruited couples using public-sector health services in the area of Cape Town, South Africa, during 2020-2021.

PARTICIPANTS

The 38 participants were couples where one person had T2D.

INTERVENTION

We developed the 'Diabetes Together' intervention to support self-management of T2D among couples in South Africa, focussing on: improved communication and shared appraisal of T2D; identifying opportunities for better self-management; and support from partners. Diabetes Together combined eight informational and two skills-building sections over two workshops.

RESULTS

Our guiding principles included: providing equal information on T2D to partners; improving couples' communication; shared goal-setting; discussion of diabetes fears; discussing couples' roles in diabetes self-management; and supporting couples' autonomy to identify and prioritise diabetes self-management strategies.Participants viewing Diabetes Together valued the couples-focus of the intervention, especially communication. Feedback resulted in several improvements throughout the intervention, for example, addressing health concerns and tailoring to the setting.

CONCLUSIONS

Using the PBA, our intervention was developed and tailored to our target audience. Our next step is to pilot the workshops' feasibility and acceptability.

Evaluation of prototype risk prediction tools for clinicians and people living with type 2 diabetes in North West London using the think aloud method

The prevalence of type 2 diabetes in North West London (NWL) is relatively high compared to other parts of the United Kingdom with outcomes suboptimal. This presents a need for more effective strategies to identify people living with type 2 diabetes who need additional support. An emerging subset of web-based interventions for diabetes self-management and population management has used artificial intelligence and machine learning models to stratify the risk of complications from diabetes and identify patients in need of immediate support. In this study, two prototype risk prediction tools on the MyWay Diabetes and MyWay Clinical platforms were evaluated with six clinicians and six people living with type 2 diabetes in NWL using the think aloud method. The results of the sessions with people living with type 2 diabetes showed that the concept of the tool was intuitive, however, more instruction on how to correctly use the risk prediction tool would be valuable. The feedback from the sessions with clinicians was that the data presented in the tool aligned with the key diabetes targets in NWL, and that this would be useful for identifying and inviting patients to the practice who are overdue for tests and at risk of complications. The findings of the evaluation have been used to support the development of the prototype risk predictions tools. This study demonstrates the value of conducting usability testing on web-based interventions designed to support the targeted management of type 2 diabetes in local communities.

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

Background

Digital interventions offer a potentially cost-effective means to support patient self-management in primary care, but evidence for the feasibility, acceptability and cost-effectiveness of digital interventions remains mixed. This programme focused on the potential for self-management digital interventions to improve outcomes in two common, contrasting conditions (i.e. hypertension and asthma) for which care is currently suboptimal, leading to excess deaths, illness, disability and costs for the NHS.

Objectives

The overall purpose was to address the question of how digital interventions can best provide cost-effective support for patient self-management in primary care. Our aims were to develop and trial digital interventions to support patient self-management of hypertension and asthma. Through the process of planning, developing and evaluating these interventions, we also aimed to generate a better understanding of what features and methods for implementing digital interventions could make digital interventions acceptable, feasible, effective and cost-effective to integrate into primary care.

Design

For the hypertension strand, we carried out systematic reviews of quantitative and qualitative evidence, intervention planning, development and optimisation, and an unmasked randomised controlled trial comparing digital intervention with usual care, with a health economic analysis and nested process evaluation. For the asthma strand, we carried out a systematic review of quantitative evidence, intervention planning, development and optimisation, and a feasibility randomised controlled trial comparing digital intervention with usual care, with nested process evaluation.

Setting

General practices (hypertension, n = 76; asthma, n = 7) across Wessex and Thames Valley regions in Southern England.

Participants

For the hypertension strand, people with uncontrolled hypertension taking one, two or three antihypertensive medications. For the asthma strand, adults with asthma and impaired asthma-related quality of life.

Interventions

Our hypertension intervention (i.e. HOME BP) was a digital intervention that included motivational training for patients to self-monitor blood pressure, as well as health-care professionals to support self-management; a digital interface to send monthly readings to the health-care professional and to prompt planned medication changes when patients’ readings exceeded recommended targets for 2 consecutive months; and support for optional patient healthy behaviour change (e.g. healthy diet/weight loss, increased physical activity and reduced alcohol and salt consumption). The control group were provided with a Blood Pressure UK (London, UK) leaflet for hypertension and received routine hypertension care. Our asthma intervention (i.e. My Breathing Matters) was a digital intervention to improve the functional quality of life of primary care patients with asthma by supporting illness self-management. Motivational content intended to facilitate use of pharmacological self-management strategies (e.g. medication adherence and appropriate health-care service use) and non-pharmacological self-management strategies (e.g. breathing retraining, stress reduction and healthy behaviour change). The control group were given an Asthma UK (London, UK) information booklet on asthma self-management and received routine asthma care.

Main outcome measures

The primary outcome for the hypertension randomised controlled trial was difference between intervention and usual-care groups in mean systolic blood pressure (mmHg) at 12 months, adjusted for baseline blood pressure, blood pressure target (i.e. standard, diabetic or aged > 80 years), age and general practice. The primary outcome for the asthma feasibility study was the feasibility of the trial design, including recruitment, adherence, intervention engagement and retention at follow-up. Health-care utilisation data were collected via notes review.

Review methods

The quantitative reviews included a meta-analysis. The qualitative review comprised a meta-ethnography.

Results

A total of 622 hypertensive patients were recruited to the randomised controlled trial, and 552 (89%) were followed up at 12 months. Systolic blood pressure was significantly lower in the intervention group at 12 months, with a difference of –3.4 mmHg (95% confidence interval –6.1 to –0.8 mmHg), and this gave an incremental cost per unit of systolic blood pressure reduction of £11 (95% confidence interval £5 to £29). Owing to a cost difference of £402 and a quality-adjusted life-year (QALY) difference of 0.044, long-term modelling puts the incremental cost per QALY at just over £9000. The probability of being cost-effective was 66% at willingness to pay £20,000 per quality-adjusted life-year, and this was higher at higher thresholds. A total of 88 patients were recruited to the asthma feasibility trial (target n = 80; n = 44 in each arm). At 3-month follow-up, two patients withdrew and six patients did not complete outcome measures. At 12 months, two patients withdrew and four patients did not complete outcome measures. A total of 36 out of 44 patients in the intervention group engaged with My Breathing Matters [with a median of four (range 0–25) logins].

Limitations

Although the interventions were designed to be as accessible as was feasible, most trial participants were white and participants of lower socioeconomic status were less likely to take part and complete follow-up measures. Challenges remain in terms of integrating digital interventions with clinical records.

Conclusions

A digital intervention using self-monitored blood pressure to inform medication titration led to significantly lower blood pressure in participants than usual care. The observed reduction in blood pressure would be expected to lead to a reduction of 10–15% in patients suffering a stroke. The feasibility trial of My Breathing Matters suggests that a fully powered randomised controlled trial of the intervention is warranted. The theory-, evidence- and person-based approaches to intervention development refined through this programme enabled us to identify and address important contextual barriers to and facilitators of engagement with the interventions.

Future work

This research justifies consideration of further implementation of the hypertension intervention, a fully powered randomised controlled trial of the asthma intervention and wide dissemination of our methods for intervention development. Our interventions can also be adapted for a range of other health conditions.

Trial and study registration

The trials are registered as ISRCTN13790648 (hypertension) and ISRCTN15698435 (asthma). The studies are registered as PROSPERO CRD42013004773 (hypertension review) and PROSPERO CRD42014013455 (asthma review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 11. See the NIHR Journals Library website for further information.

Digital Health Literacy: Bibliometric Analysis

Background

Digital health is growing at a rapid pace, and digital health literacy has attracted increasing attention from the academic community.

Objective

The purposes of this study are to conduct a systematic bibliometric analysis on the field of digital health literacy and to understand the research context and trends in this field.

Methods

Methods: A total of 1955 scientific publications were collected from the Web of Science core collection. Institutional co-operation, journal co-citation, theme bursting, keyword co-occurrence, author co-operation, author co-citation, literature co-citation, and references in the field of digital health literacy were analyzed using the VOSviewer and CiteSpace knowledge mapping tools.

Results

The results demonstrate that the United States has the highest number of publications and citations in this field. The University of California System was first in terms of institutional contributions. The Journal of Medical Internet Research led in the number of publications, citations, and co-citations. Research areas of highly cited articles in the field of digital health literacy mainly include the definition and scale of health literacy, health literacy and health outcomes, health literacy and the digital divide, and the influencing factors of health literacy.

Conclusions

We summarized research progress in the field of digital health literacy and reveal the context, trends, and trending topics of digital health literacy research through statistical analysis and network visualization. We found that digital health literacy has a significant potential to improve health outcomes, bridge the digital divide, and reduce health inequalities. Our work can serve as a fundamental reference and directional guide for future research in this field.

Enrollment and retention of participants in remote digital health studies: a scoping review and framework proposal (Preprint)

Background

Objective

Methods

Results

Conclusions

A qualitative study exploring the barriers to attending structured education programmes among adults with type 2 diabetes

BACKGROUND

Diabetes self-management education, a universally recommended component of diabetes care, aims to support self-management in people with type 2 diabetes. However, attendance is low (approx. 10%). Previous research investigating the reasons for low attendance have not yet linked findings to theory, making it difficult to translate findings into practice. This study explores why some adults with type 2 diabetes do not attend diabetes self-management education and considers how services can be adapted accordingly, using Andersen's Behavioural Model of Health Service Utilisation as a framework.

METHODS

A cross-sectional semi-structured qualitative interview study was carried out. Semi-structured interviews were conducted by telephone with 14 adults with type 2 diabetes who had verbally declined their invitation to attend diabetes self-management education in Bath and North East Somerset, UK, within the last 2 years. Data were analysed using inductive thematic analysis before mapping the themes onto the factors of Andersen's Behavioural Model.

RESULTS

Two main themes were identified: 'perceived need' and 'practical barriers'. The former theme explored participants' tendency to decline diabetes education when they perceived they did not need the programme. This perception tended to arise from participants' high self-efficacy to manage their type 2 diabetes, the low priority they attributed to their condition and limited knowledge about the programme. The latter theme, 'practical barriers', explored the notion that some participants wanted to attend but were unable to due to other commitments and/or transportation issues in getting to the venue.

CONCLUSIONS

All sub-themes resonated with one or more factors of Andersen's Behavioural Model indicating that the model may help to elucidate attendance barriers and ways to improve services. To fully understand low attendance to diabetes education, the complex and individualised reasons for non-attendance must be recognised and a person-centred approach should be taken to understand people's experience, needs and capabilities.

Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis

Background

For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation.

Objective

To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool.

Methods

The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool.

Results

Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context.

Conclusions

These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-04464-2

Digital Health Intervention Design and Deployment for Engaging Demographic Groups Likely to Be Affected by the Digital Divide: Protocol for a Systematic Scoping Review

Background

Digital health interventions refer to interventions designed to support health-related knowledge transfer and are delivered via digital technologies, such as mobile apps. Digital health interventions are a double-edged sword: they have the potential to reduce health inequalities, for example, by making treatments available remotely to rural populations underserved by health care facilities or by helping to overcome language barriers via in-app translation services; however, if not designed and deployed with care, digital health interventions also have the potential to increase health inequalities and exacerbate the effects of the digital divide.

Objective

The aim of this study is to review ways to mitigate the digital divide through digital health intervention design, deployment, and engagement mechanisms sensitive to the needs of digitally excluded populations.

Methods

This protocol outlines the procedure for a systematic scoping review that follows the methodology recommended by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidance. The following databases will be searched for primary research studies published in English from October 1, 2011, to October 1, 2021: Cochrane Library, Epistemonikos, NICE Evidence, PROSPERO, PubMed (with MEDLINE and Europe PMC), and Trip. In addition, the following sources of gray literature will be searched: Conference Proceedings Citation Index, Health Management Information Consortium, International HTA Database, OpenGrey, The Grey Literature Report, Google Scholar Basic Search UK, MedNar Deep Web Search Engine, and Carrot2. We will select publications that meet the following inclusion criteria: primary research papers that evaluated digital health interventions that describe features of digital health intervention design and deployment that enable or hinder access to and engagement with digital health interventions by adults from demographic groups likely to be affected by the digital divide (eg, older age, minority ethnic groups, lower income, and lower education level). A random selection of 25 publications identified from the search will be double screened by four reviewers. If there is >75% agreement for included/excluded publications, the team will continue to screen all the identified publications. For all included publications, study characteristics will be extracted by one author and checked for agreement by a second author, with any disagreements resolved by consensus among the study team. Consultation digital health intervention design and deployment, and digital health intervention users will also be conducted in parallel.

Results

The review is underway and is anticipated to be completed by September 2022.

Conclusions

The results will have implications for researchers and policy makers using digital health interventions for health improvement peripandemic and post pandemic, and will inform best practices in the design and delivery of digital health interventions.

International Registered Report Identifier (IRRID)

PRR1-10.2196/32538

Digital healthcare in COPD management: a narrative review on the advantages, pitfalls, and need for further research

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality despite current treatment strategies which focus on smoking cessation, pulmonary rehabilitation, and symptomatic relief. A focus of COPD care is to encourage self-management, particularly during COVID-19, where much face-to-face care has been reduced or ceased. Digital health solutions may offer affordable and scalable solutions to support COPD patient education and self-management, such solutions could improve clinical outcomes and expand service reach for limited additional cost. However, optimal ways to deliver digital medicine are still in development, and there are a number of important considerations for clinicians, commissioners, and patients to ensure successful implementation of digitally augmented care. In this narrative review, we discuss advantages, pitfalls, and future prospects of digital healthcare, which offer a variety of tools including self-management plans, education videos, inhaler training videos, feedback to patients and healthcare professionals (HCPs), exacerbation monitoring, and pulmonary rehabilitation. We discuss the key issues with sustaining patient and HCP engagement and limiting attrition of use, interoperability with devices, integration into healthcare systems, and ensuring inclusivity and accessibility. We explore the essential areas of research beyond determining safety and efficacy to understand the acceptability of digital healthcare solutions to patients, clinicians, and healthcare systems, and hence ways to improve this and sustain engagement. Finally, we explore the regulatory challenges to ensure quality and engagement and effective integration into current healthcare systems and care pathways, while maintaining patients' autonomy and privacy. Understanding and addressing these issues and successful incorporation of an acceptable, simple, scalable, affordable, and future-proof digital solution into healthcare systems could help remodel global chronic disease management and fractured healthcare systems to provide best patient care and optimisation of healthcare resources to meet the global burden and unmet clinical need of COPD.

Cocreation of Massive Open Online Courses to Improve Digital Health Literacy in Diabetes: Pilot Mixed Methods Study

Background

Self-management education is a fundamental aspect in the health care of people with diabetes to develop the necessary skills for the improvement of health outcomes. Patients are required to have the competencies to manage electronic information resources—that is, an appropriate level of digital health literacy. The European project IC-Health aimed to improve digital health literacy among people with diabetes through the cocreation of massive open online courses (MOOCs).

Objective

We report the preliminary results obtained in 3 participating countries in the IC-Health project (Italy, Spain, and Sweden) regarding (1) experience of the participants during the cocreation process of MOOCs, (2) perceived changes in their digital health literacy level after using MOOCs, and (3) a preliminary assessment of the acceptability of MOOCs.

Methods

The cocreation of the MOOCs included focus groups with adults and adolescents with diabetes and the creation of independent communities of practice for type 1 diabetes and type 2 diabetes participants aimed to co-design the MOOCs. Quantitative measures of the acceptability of MOOCs, experience in the cocreation process, and increase in digital health literacy (dimensions of finding, understanding, and appraisal) were assessed.

Results

A total of 28 participants with diabetes participated in focus groups. Adults and adolescents agreed that the internet is a secondary source of health-related information. A total of 149 participants comprised the diabetes communities of practice. A total of 9 MOOCs were developed. Acceptability of the MOOCs and the cocreation experience were positively valued. There was a significant improvement in digital health literacy in both adults and adolescents after using MOOCs (P<.001).

Conclusions

Although the results presented on self-perceived digital health literacy are preliminary and exploratory, this pilot study suggests that IC-Health MOOCs represent a promising tool for the medical care of diabetes, being able to help reduce the limitations associated with low digital health literacy and other communication barriers in the diabetes population.

Facing the Growing COVID-19 Infodemic: Digital Health Literacy and Information-Seeking Behaviour of University Students in Slovenia

The entire world is faced with the COVID-19 pandemic, which is also accompanied by an infodemic. This refers to the rapid spread of (accurate and false) information, mainly through internet usage increasing. Digital health literacy (DHL) is therefore important for addressing challenges related to online health information and services, as well as for navigation through the complex information landscape with huge amounts of different (and conflicting) information about COVID-19. The aim of this study is to examine the level of DHL in relation to COVID-19 in Slovenian university students and to determine online information-seeking behaviour in order to plan and prepare effective communication interventions for this sub-population. A cross-sectional survey, administered by an online questionnaire, was conducted to collect data on DHL. A total of 3621 students participated, of whom 70% were female and the average age was 22.65 years (SD = 4.65). Bivariate analyses were performed to assess the association of key characteristics with DHL. Overall, the results show that the level of DHL among students is sufficient. Most difficulties were reported in assessing the reliability of information (n = 1484, 49.3%). Approximately one third of the students (n = 847, 27.9%) reported having problems in finding information of their interest, and somewhat more (n = 900, 29.6%) reported difficulties in making a selection among all the information found. Students with a sufficient level of DHL are more likely to seek information through search engines and websites of official institutions, while students with a limited level of DHL more frequently reported using social media for health information searches. It is necessary to establish interventions for a systematic lift of the DHL and health literacy (HL) of all population groups.

Effectiveness of Colorectal Cancer Screening Promotion Using E-Media Decision Aids: A Systematic Review and Meta-Analysis

Colorectal cancer (CRC)-screening reduces mortality, yet remains underutilized. The use of electronic media (e-media) decision aids improves saliency and fosters informed decision-making. This systematic review aimed to determine the effectiveness of CRC-screening promotion, using e-media decision aids in primary healthcare (PHC) settings. Three databases (MEDLINE, Web of Science, and the Cochrane Library) were searched for eligible studies. Studies that evaluated e-media decision aids compared to usual care or other conditions were selected. Quality was assessed by using Cochrane tools. Their effectiveness was measured by CRC-screening completion rates, and meta-analysis was conducted to calculate the pooled estimates. Ten studies involving 9393 patients were included in this review. Follow-up durations spanned 3–24 months. The two types of decision-aid interventions used were videos and interactive multimedia programs, with durations of 6–15 min. Data from nine feasible studies with low or some risk of bias were synthesized for meta-analysis. A random-effects model revealed that CRC-screening promotion using e-media decision aids were almost twice as likely to have screening completion than their comparisons (OR 1.62, 95% CI: 1.03–2.62, p < 0.05). CRC-screening promotion through e-media has great potential for increasing screening participation in PHC settings. Thus, its development should be prioritized, and it should be integrated into existing programs.

Optimizing a digital intervention for managing blood pressure in stroke patients using a diverse sample: Integrating the person-based approach and patient and public involvement

BACKGROUND

Having a stroke or transient ischaemic attack increases the risk of a subsequent one, especially with high blood pressure (BP). Home-based BP management can be effective at maintaining optimal BP.

OBJECTIVE

To describe the optimization of a digital intervention for stroke patients and the value of participant diversity, using the person-based approach (PBA) and integral patient and public involvement (PPI).

SETTING AND PARTICIPANTS

Stroke patients recruited from primary care and community settings, and health-care professionals in primary care, in England and Ireland.

DESIGN

Three linked qualitative studies conducted iteratively to develop an intervention using the PBA, with integral PPI.

INTERVENTION

The BP: Together intervention, adapted from existing BP self-monitoring interventions, is delivered via mobile phone or web interface to support self-monitoring of BP at home. It alerts patients and their clinicians when a change in antihypertensive medication is needed.

FINDINGS

Feedback from a diverse range of participants identified potential barriers, which were addressed to improve the intervention accessibility, feasibility and persuasiveness. Easy-to-read materials were developed to improve usability for patients with aphasia and lower literacy. The importance of including family members who support patient care was also highlighted. Feedback messages regarding medication change were refined to ensure usefulness for patients and clinicians.

DISCUSSION

Input from PPI alongside qualitative research with a diverse study sample allowed the creation of a simple and equitable BP management intervention for stroke patients.

PATIENT INVOLVEMENT

Two PPI co-investigators contributed to design, conduct of study, data interpretation and manuscript preparation; community PPI sessions informed early planning. Study participants were stroke patients and family members.

Su salud a la mano (your health at hand): patient perceptions about a bilingual patient portal in the Los Angeles safety net

OBJECTIVES

Driven by beneficial patient-centered outcomes associated with patient portal use and the Affordable Care Act, portal implementation has expanded into safety nets-health systems that offer access to care to a large share of uninsured, Medicaid, and other vulnerable populations. However, little attention has been paid to the factors that affect portal accessibility by the vulnerable patients served by these health systems-including those who are limited English proficient (LEP).

MATERIALS AND METHODS

The Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net system in the nation, launched its first patient portal, and one of the few bilingual English-Spanish interfaces in existence, in March of 2015. To explore portal awareness and perceptions, we conducted focus groups with LAC DHS patients, in English and Spanish (LEP). The Technology Acceptance Model was used to guide thematic analysis of focus group data.

RESULTS

Of the 46 participants, 37 were patients and 9 were caretakers; 23 were English-speaking and 23 Spanish-speaking LEP. All patients had diabetes or hypertension. Over half had an annual household income <$10 000, yet 78% of English-speaking and 65% of Spanish-speaking LEP participants reported at-home Internet access. Participants' discussion centered around 3 major thematic narratives: (1) participants' awareness or attitudes about the LAC DHS portal; (2) role of culture, language, or community with regard to portal accessibility and utility; and (3) perceived needs for successful portal implementation.

CONCLUSIONS

Safety net participants identified concrete benefits to the portal and emphasized the need for portal engagement that offered accessible education, support, and resources in clinical and community settings. The portal offers an additional opportunity to engage the patient and family with trusted and validated health information, and should be further developed in this capacity. This study provides a better understanding of preferred improvements of patient portal engagement that guide broader health technology efforts to address electronic health disparities.

Development and Feasibility of a Digital Acceptance and Commitment Therapy-Based Intervention for Generalized Anxiety Disorder: Pilot Acceptability Study

Background

Generalized anxiety disorder (GAD) is characterized by excessive worry that is difficult to control and has high comorbidity with mood disorders including depression. Individuals experience long wait times for diagnosis and often face accessibility barriers to treatment. There is a need for a digital solution that is accessible and acceptable to those with GAD.

Objective

This paper aims to describe the development of a digital intervention prototype of acceptance and commitment therapy (ACT) for GAD that sits within an existing well-being app platform, BioBase. A pilot feasibility study evaluating acceptability and usability is conducted in a sample of adults with a diagnosis of GAD, self-referred to the study.

Methods

Phase 1 applied the person-based approach (creation of guiding principles, intervention design objectives, and the key intervention features). In Phase 2 participants received the app-based therapeutic and paired wearable for 2 weeks. Self-report questionnaires were obtained at baseline and posttreatment. The primary outcome was psychological flexibility (Acceptance and Action Questionnaire-II [AAQ-II]) as this is the aim of ACT. Mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) and symptoms of anxiety (7-item Generalized Anxiety Disorder Assessment [GAD-7]) and depression (9-item Patient Health Questionnaire [PHQ-9]) were also assessed. Posttreatment usability was assessed via self-report measures (System Usability Scale [SUS]) in addition to interviews that further explored feasibility of the digital intervention in this sample.

Results

The app-based therapeutic was well received. Of 13 participants, 10 (77%) completed the treatment. Results show a high usability rating (83.5). Participants found the digital intervention to be relevant, useful, and helpful in managing their anxiety. Participants had lower anxiety (d=0.69) and depression (d=0.84) scores at exit, and these differences were significantly different from baseline (P=.03 and .008 for GAD-7 and PHQ-9, respectively). Participants had higher psychological flexibility and well-being scores at exit, although these were not significantly different from baseline (P=.11 and .55 for AAQ-II and WEMWBS, respectively).

Conclusions

This ACT prototype within BioBase is an acceptable and feasible digital intervention in reducing symptoms of anxiety and depression. This study suggests that this intervention warrants a larger feasibility study in adults with GAD.

The Active Brains Digital Intervention to Reduce Cognitive Decline in Older Adults: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Increasing physical activity, improving diet, and performing brain training exercises are associated with reduced cognitive decline in older adults.

OBJECTIVE

In this paper, we describe a feasibility trial of the Active Brains intervention, a web-based digital intervention developed to support older adults to make these 3 healthy behavior changes associated with improved cognitive health. The Active Brains trial is a randomized feasibility trial that will test how accessible, acceptable, and feasible the Active Brains intervention is and the effectiveness of the study procedures that we intend to use in the larger, main trial.

METHODS

In the randomized controlled trial (RCT), we use a parallel design. We will be conducting the intervention with 2 populations recruited through GP practices (family practices) in England from 2018 to 2019: older adults with signs of cognitive decline and older adults without any cognitive decline. Trial participants were randomly allocated to 1 of 3 study groups: usual care, the Active Brains intervention, or the Active Brains website plus brief support from a trained coach (over the phone or by email). The main outcomes are performance on cognitive tasks, quality of life (using EuroQol-5D 5 level), Instrumental Activities of Daily Living, and diagnoses of dementia. Secondary outcomes (including depression, enablement, and health care costs) and process measures (including qualitative interviews with participants and supporters) will also be collected. The trial has been approved by the National Health Service Research Ethics Committee (reference 17/SC/0463).

RESULTS

Results will be published in peer-reviewed journals, presented at conferences, and shared at public engagement events. Data collection was completed in May 2020, and the results will be reported in 2021.

CONCLUSIONS

The findings of this study will help us to identify and make important changes to the website, the support received, or the study procedures before we progress to our main randomized phase III trial.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number 23758980; http://www.isrctn.com/ISRCTN23758980.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18929.

Supporting patients to be involved in decisions about their health and care: Development of a best practice health literacy App for Australian adults living with Chronic Kidney Disease

ISSUE ADDRESSED

Inadequate health literacy is common in those with chronic kidney disease (CKD), especially among culturally and linguistically diverse groups. Patient information for people with CKD, including those with kidney failure requiring dialysis, is often written beyond their literacy level, and many CKD-related apps are not accurate or evidence based. These represent important barriers to health care decision-making and equity in access to health care.

METHODS

We developed a cross-platform application (the "SUCCESS app") to support Australian adults with kidney failure requiring dialysis to actively participate in self-management and decision-making. App content was informed by health literacy theory which recognises the importance of reducing the complexity of health information as well as equipping consumers with the skills necessary to access, understand and act on this information. The development team comprised members of diverse backgrounds and expertise, including nursing, allied health, psychology, epidemiology, nephrology and IT, as well as consumer representatives.

RESULTS

Content areas included diet, fluids, medicine, physical activity, emotional well-being and supportive care, chosen as they represent important decision points in the CKD trajectory. To support functional health literacy, a four-step process to simplify written content was used including calculating readability statistics, applying the Patient Education Materials Assessment Tool, supplementing written information with video and audio content, and incorporating micro-learning and interactive quizzes. To develop communicative and critical health literacy skills, question prompt lists and evidence-based volitional help sheets were included in each module to support question-asking and behaviour change. We also developed animated skills training related to communication, shared decision-making and critical appraisal of health information.

CONCLUSIONS

This is the first health literacy informed app developed to promote active patient participation in CKD management and decision-making. Ongoing evaluation of the SUCCESS app through analysis of quantitative and qualitative data will provide valuable insights into the feasibility of implementing the app with dialysis patients, and the impact of the intervention of psychosocial and clinical outcomes. SO WHAT?: Digital health solutions have been found to improve self-management for chronic conditions, and could optimise the use of health care services and patient outcomes.

Patients’ and healthcare professionals’ perspectives towards technology-assisted diabetes self-management education. A qualitative systematic review

Introduction

Diabetes self-management education is a key aspect in the long-term management of type 2 diabetes. The patient and healthcare professional (HCP) perspective on the use of technology-assisted DSME has yet to be studied. Hence, the objective of this study was to better understand the factors that facilitate or hinder the adoptions of such education by adults with type 2 diabetes and their HCPs.

Methods

We systematically searched five databases (Medline, Embase, CINAHL, Web of Science Core Collection, and PsycINFO) until August 2019. The search included qualitative and mixed-method studies that reported the views of patients and HCPs regarding features, uses, and implementations of technology-assisted DSME. Data were synthesized through an inductive thematic analysis.

Results

A total of 13 articles were included, involving 242 patients, ranging from 18 to 81 years and included web-based, mobile application, digital versatile disc (DVD), virtual reality or telehealth interventions. Patients and HCPs had mixed views towards features of the technology-assisted interventions, with patients’ personal qualities and HCPs’ concerns affecting uses of the interventions. Patients generally preferred technologies that were easy to access, use, and apply and that had reliable information. Patients’ ambitions motivated them, and personal attributes such as poor competence with technology, poor literacy, and language barriers acted as barriers. Patients especially liked the peer support that they received but did not like it when there was no regulation of advice on these platforms. HCPs believed that while the interventions were useful to patients, they faced difficulties with integration into their clinical workflows.

Conclusion

This review explored the features of technology-assisted diabetes self-management education interventions that enhanced positive patient engagements and the negative aspects of both the platforms and the target groups. Technical support and training will be effective in managing these concerns and ensuring meaningful use of these platforms.

Discontinuously supervised aerobic training vs. physical activity promotion in the self-management of type 2 diabetes in older Italian patients: design and methods of the 'TRIPL-A' randomized controlled trial

Background

Physical activity (PA) has health benefits for people with type 2 diabetes (T2D). Indeed, regular PA is considered an important part of any T2D management plan, yet most patients adopt a sedentary lifestyle.

Exercise referral schemes (ERS) have the potential to effectively promote physical activity among T2D patients, and their effectiveness may be enhanced when they are supported by computer-based technologies.

The ‘TRIPL-A’ study (i.e., a TRIal to promote PhysicaL Activity among patients in the young-old age affected by T2D) aims to assess if realizing an innovative ERS, based on a strong partnership among general practitioners, specialist physicians, exercise specialists, and patients, and supported by a web-based application (WBA), can effectively lead sedentary older T2D patients to adopt an active lifestyle.

Methods

A randomized controlled design will be used, and an ERS, supported by a WBA, will be implemented. 300 physically inactive T2D patients (aged 65–74 years) will be assigned to either an intervention or control arm. Control arm patients will only receive behavioral counseling on physical activity and diet, while intervention arm patients will also undergo an 18-month (3 day/week), discontinuously supervised aerobic exercise training program. The trial will be divided into six three-month periods: during first, third and fifth period, an exercise specialist will supervise the training sessions and, using the WBA, prescribe exercise progression and monitor exercise adherence. Patients will exercise on their own in the other periods.

Patients’ sedentary behaviors (primary outcome), PA level, fitness status, metabolic profile, psychological well-being, quality of life, and use of health care services (secondary outcomes) will be assessed at baseline and at 6, 12, and 18 months from baseline.

Repeated measure ANCOVAs will be used to compare the intervention and control arm with respect to each study outcome measure.

Discussion

Primary and secondary outcome results will allow us to evaluate the effectiveness of an ERS, specifically designed for the management of T2D clinical conditions and supported by a WBA, in promoting PA within Italian primary care settings.

Trial registration

This trial is retrospectively registered under the Australian New Zealand Clinical Trials Registry (reference number: ACTRN12618001164280; registered 13 July 2018).

Factors influencing self-management in patients with type 2 diabetes in general practice: a qualitative study

Many Australian adults with type 2 diabetes mellitus (T2DM) do not follow recommended self-management behaviours that could prevent or delay complications. This exploratory study aimed to investigate the factors influencing self-management of T2DM in general practice. Semi-structured qualitative interviews were conducted with patients with T2DM (n = 10) and their GPs (n = 4) and practice nurses (n = 3) in a low socioeconomic area of Sydney, New South Wales, Australia. The interviews were analysed thematically using the socio-ecological model as a framework for coding. Additional themes were derived inductively based on the explicitly stated meaning of the text. Factors influencing self-management occurred on four levels of the socio-ecological model: individual (e-health literacy, motivation, time constraints); interpersonal (family and friends, T2DM education, patient-provider relationship); organisational (affordability, multidisciplinary care); and community levels (culture, self-management resources). Multi-level strategies are needed to address this wide range of factors that are beyond the scope of single services or organisations. These could include tailoring health education and resources to e-health literacy and culture; attention to social networks and the patient–provider relationship; and facilitating access to affordable on-site allied health services.

Health Literacy in Web-Based Health Information Environments: Systematic Review of Concepts, Definitions, and Operationalization for Measurement

Background

Health literacy research seems to lack a consensus on what aspects to include into literacy in the context of health and on how to operationalize these concepts for measurement purposes. In addition to health literacy, several other concepts, such as electronic health (eHealth) literacy and mental health literacy, have been developed across disciplines. This study examines how these different concepts are used when studying health-related competencies in Web contexts.

Objective

This study systematically reviews health literacy concepts and definitions and their operationalization in studies focused on Web-based health information environments.

Methods

A systematic literature search was conducted in April 2016 in 6 electronic databases with a limitation to articles in English published between January 2011 and April 2016. Altogether, 1289 unique records were identified and screened according to the predefined inclusion criteria: (1) original, peer-reviewed research articles written in English; (2) the topic of the article concerned literacy in the context of health; (3) informants of the study were lay people, not health professionals or students of the field; and (4) the focus of the study was placed on an Web-based information environment. In total, 180 full texts were screened, of which 68 were included in the review. The studies were analyzed with an emphasis on the used health literacy concepts and measures.

Results

On the basis of the included studies, several concepts are in use when studying health-related literacy in Web environments, eHealth literacy and health literacy being the most common ones. The reviewed studies represent a variety of disciplines, but mostly medical sciences. Typically, quantitative research methods are used. On the basis of the definitions for health literacy, 3 thematic categories were identified: general and skill-based, multidimensional, and domain-specific health literacy. Most studies adopted a domain-specific concept, followed by the ones that used a general and skill-based concept. Multidimensional concepts occurred least frequently. The general health literacy concepts were usually operationalized with reading comprehension measures, the domain-specific concepts with self-efficacy measures, and multidimensional concepts with several types of measures. However, inconsistencies in operationalization were identified.

Conclusions

The results show that in studies conducted in Web-based information environments, several different health literacy concepts are in use, and there is no clear consensus on the definitions for these concepts. Future studies should place emphasis on the conceptual development of health literacy in Web contexts to gain better results on operationalization for measurement. Researchers are encouraged to provide clear operational definitions for the concepts they use to ensure transparency in reporting.

Crossing the Digital Divide in Online Self-Management Support: Analysis of Usage Data From HeLP-Diabetes

BACKGROUND

Digital health is increasingly recognized as a cost-effective means to support patient self-care. However, there are concerns about whether the "digital divide," defined as the gap between those who do and do not make regular use of digital technologies, will lead to increased health inequalities. Access to the internet, computer literacy, motivation to use digital health interventions, and fears about internet security are barriers to use of digital health interventions. Some of these barriers disproportionately affect people of older age, black or minority ethnic background, and low socioeconomic status. HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a theoretically informed online self-management program for adults with type 2 diabetes, was developed to meet the needs of people from a broad demographic background.

OBJECTIVE

This study aimed to determine whether there was evidence of a digital divide when HeLP-Diabetes was integrated into routine care. This was achieved by (1) comparing the characteristics of people who registered for the program against the target population (people with type 2 diabetes in inner London), (2) comparing the characteristics of people who registered for the program and used it with those who did not use it, and (3) comparing sections of the website visited by different demographic groups.

METHODS

A retrospective analysis of data on the use of HeLP-Diabetes in routine clinical practice in 4 inner London clinical commissioning groups was undertaken. Data were collected from patients who registered for the program as part of routine health services.. Data on gender, age, ethnicity, and educational attainment were collected at registration, and data on webpage visits (user identification number, date, time, and page visited) were collected automatically by software on the server side of the website.

RESULTS

The characteristics of people who registered for the program were found to reflect those of the target population. The mean age was 58.4 years (SD=28.0), over 50.0% were from black and minority ethnic backgrounds, and nearly a third (29.8%) had no qualifications beyond school leaving age. There was no association between demographic characteristics and use of the program, apart from weak evidence of less use by the mixed ethnicity group. There was no evidence of the differential use of the program by any demographic group, apart from weak evidence for people with degrees and school leavers being more likely to use the "Living and working with diabetes" (P=.03) and "Treating diabetes" (P=.04) sections of the website.

CONCLUSIONS

This study is one of the first to provide evidence that a digital health intervention can be integrated into routine health services without widening health inequalities. The relative success of the intervention may be attributed to integration into routine health care, and careful design with extensive user input and consideration of literacy levels. Developers of digital health interventions need to acknowledge barriers to access and use, and collect data on the demographic profile of users, to address inequalities.

Intervention planning for the REDUCE maintenance intervention: a digital intervention to reduce reulceration risk among patients with a history of diabetic foot ulcers

OBJECTIVES

To develop a comprehensive intervention plan for the REDUCE maintenance intervention to support people who have had diabetic foot ulcers (DFUs) to sustain behaviours that reduce reulceration risk.

METHODS

Theory-based, evidence-based and person-based approaches to intervention development were used. In phase I of intervention planning, evidence was collated from a scoping review of the literature and qualitative interviews with patients who have had DFUs (n=20). This was used to identify the psychosocial needs and challenges of this population and barriers and facilitators to the intervention's target behaviours: regular foot checking, rapid self-referral in the event of changes in foot health, graded and regular physical activity and emotional management. In phase II, this evidence was combined with expert consultation to develop the intervention plan. Brief 'guiding principles' for shaping intervention development were created. 'Behavioural analysis' and 'logic modelling' were used to map intervention content onto behaviour change theory to comprehensively describe the intervention and its hypothesised mechanisms.

RESULTS

Key challenges to the intervention's target behaviours included patients' uncertainty regarding when to self-refer, physical limitations affecting foot checking and physical activity and, for some, difficulties managing negative emotions. Important considerations for the intervention design included a need to increase patients' confidence in making a self-referral and in using the maintenance intervention and a need to acknowledge that some intervention content might be relevant to only some patients (emotional management, physical activity). The behavioural analysis identified the following processes hypothesised to facilitate long-term behaviour maintenance including increasing patients' skills, self-efficacy, knowledge, positive outcome expectancies, sense of personal control, social support and physical opportunity.

CONCLUSIONS

This research provides a transparent description of the intervention planning for the REDUCE maintenance intervention. It provides insights into potential barriers and facilitators to the target behaviours and potentially useful behaviour change techniques to use in clinical practice.

Using an Analysis of Behavior Change to Inform Effective Digital Intervention Design: How Did the PRIMIT Website Change Hand Hygiene Behavior Across 8993 Users?

Background

In designing digital interventions for healthcare, it is important to understand not just whether interventions work but also how and for whom—including whether individual intervention components have different effects, whether a certain usage threshold is required to change behavior in each intervention and whether usage differs across population subgroups.

Purpose

We investigated these questions using data from a large trial of the digital PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory tract infection Transmission) (PRIMIT) intervention, which aimed to reduce respiratory tract infections (RTIs) by increasing hand hygiene behavior.

Method

Baseline and follow-up questionnaires measured behaviors, intentions and attitudes in hand hygiene. In conjunction with objective measures of usage of the four PRIMIT sessions, we analysed these observational data to examine mechanisms of behavior change in 8993 intervention users.

Results

We found that the PRIMIT intervention changed behavior, intentions and attitudes, and this change was associated with reduced RTIs. The largest hand hygiene change occurred after the first session, with incrementally smaller changes after each subsequent session, suggesting that engagement with the core behavior change techniques included in the first session was necessary and sufficient for behavior change. The intervention was equally effective for men and women, older and younger people and was particularly effective for those with lower levels of education.

Conclusions

Our well-powered analysis has implications for intervention development. We were able to determine a ‘minimum threshold’ of intervention engagement that is required for hand hygiene change, and we discuss the potential implications this (and other analyses of this type) may have for further intervention development. We also discuss the application of similar analyses to other interventions.

Digital Health Interventions for Adults With Type 2 Diabetes: Qualitative Study of Patient Perspectives on Diabetes Self-Management Education and Support

BACKGROUND

The prevalence of type 2 diabetes is increasing globally, and health services in many countries are struggling with the morbidity, mortality, and costs associated with the complications of this long-term condition. Diabetes self-management education (DSME) and behavioral support can reduce the risks of developing diabetes-related complications and improve glycemic control. However, their uptake is low. Digital health interventions (DHI) can provide sustained support and may overcome challenges associated with attending diabetes self-management sessions. They have the potential for delivery at multiple locations at convenient times, anonymity, and presentation of content in attractive and tailored formats. This study investigates the needs and wants of patients with type 2 diabetes to inform the development of digital self-management education and support.

OBJECTIVE

The objective of this study was to explore patient perspectives on unmet needs for self-management and support and the role of DHI in adults living with type 2 diabetes.

METHODS

This study used a qualitative approach based on data generated from 4 focus groups with 20 patients.

RESULTS

The data generated by the focus groups illustrated the significant burden that the diagnosis of diabetes places on many patients and the negative impacts on their emotional well-being, work, social life, and physical health. Although patients' experiences of the health care services varied, there was agreement that even the best services were unable to meet all users' needs to support the emotional regulation, psychological adjustment, and behavioral changes needed for successful self-management.

CONCLUSIONS

By focusing on medical management and information provision, existing health care services and education programs may not be adequately meeting all the needs of patients with type 2 diabetes. DHIs have the potential to improve access to DSME and behavioral support and extend the range of content offered by health services to fit with a wider range of patient needs. Features that could help DHIs address some of the unmet needs described by participants in this study included placing an emphasis on emotional and role management, being available at all times, having up-to-date evidence-based guidance for patients, and providing access to peer-generated and professional advice.

Comparative analysis of diabetes self-management education programs in the European Union Member States

Diabetes self-management education (DSME) is generally considered as an integral part of diabetes care. The availability of different types of self-management in the European Union Member States (EUMS) remains uncertain. The aim of this study is to perform a comparative analysis of existing DSME programs (DSMEP) implemented in EUMS. Unpublished data regarding DSME in the EUMS was assessed with Diabetes Literacy Survey using wiki tool (WT) targeting patients and different stakeholders. An additional literature review (LR) was performed in PubMed to identify published studies regarding DSMEP in the EUMS from 2004 to 2014. A total of 102 DSMEP implemented in EUMS were reported in the WT and 154 programs were identified from the LR. Comparative analysis of the data indicated that a majority of programs are aimed at adults and only a minority at children and elderly. Only a small percentage of the programs utilize information technology for teaching and learning, and only one out of five programs pay attention to depression. The identified DSMEP aimed primarily to empower patients through increasing knowledge and changing attitudes and beliefs towards diabetes. This study provides an overview of the present state-of-the-art on diabetes self-management education programs in the 28 EUMS. To increase participation, existing DSMEP should be made more accessible to the patients as well as tailored to specific patient groups.

Web-based self-management support for people with type 2 diabetes (HeLP-Diabetes): randomised controlled trial in English primary care

OBJECTIVE

To determine the effectiveness of a web-based self-management programme for people with type 2 diabetes in improving glycaemic control and reducing diabetes-related distress.

METHODS AND DESIGN

Individually randomised two-arm controlled trial.

SETTING

21 general practices in England.

PARTICIPANTS

Adults aged 18 or over with a diagnosis of type 2 diabetes registered with participating general practices.

INTERVENTION AND COMPARATOR

Usual care plus either Healthy Living for People with Diabetes (HeLP-Diabetes), an interactive, theoretically informed, web-based self-management programme or a simple, text-based website containing basic information only.

OUTCOMES AND DATA COLLECTION

Joint primary outcomes were glycated haemoglobin (HbA1c) and diabetes-related distress, measured by the Problem Areas in Diabetes (PAID) scale, collected at 3 and 12 months after randomisation, with 12 months the primary outcome point. Research nurses, blind to allocation collected clinical data; participants completed self-report questionnaires online.

ANALYSIS

The analysis compared groups as randomised (intention to treat) using a linear mixed effects model, adjusted for baseline data with multiple imputation of missing values.

RESULTS

Of the 374 participants randomised between September 2013 and December 2014, 185 were allocated to the intervention and 189 to the control. Final (12 month) follow-up data for HbA1c were available for 318 (85%) and for PAID 337 (90%) of participants. Of these, 291 (78%) and 321 (86%) responses were recorded within the predefined window of 10-14 months. Participants in the intervention group had lower HbA1c than those in the control (mean difference -0.24%; 95% CI -0.44 to -0.049; p=0.014). There was no significant overall difference between groups in the mean PAID score (p=0.21), but prespecified subgroup analysis of participants who had been more recently diagnosed with diabetes showed a beneficial impact of the intervention in this group (p = 0.004). There were no reported harms.

CONCLUSIONS

Access to HeLP-Diabetes improved glycaemic control over 12 months.

TRIAL REGISTRATION NUMBER

ISRCTN02123133.

Telemonitoring and Health Counseling for Self-Management Support of Patients With Type 2 Diabetes: A Randomized Controlled Trial

Background

The prevalence of diabetes is increasing among adults globally, and there is a need for new models of health care delivery. Research has shown that self-management approaches encourage persons with chronic conditions to take a primary role in managing their daily care.

Objective

The objective of this study was to investigate whether the introduction of a health technology-supported self-management program involving telemonitoring and health counseling had beneficial effects on glycated hemoglobin (HbA_1c), other clinical variables (height, weight, body mass index, blood pressure, blood lipid profile), and health-related quality of life (HRQoL), as measured using the Short Form Health Survey (SF-36) version 2 in patients with type 2 diabetes.

Methods

This was a pragmatic randomized controlled trial of patients with type 2 diabetes. Both the control and intervention groups received usual care. The intervention group also participated in additional health promotion activities with the use of the Prescribed Healthcare Web application for self-monitoring of blood glucose and blood pressure. About every second month or when needed, the general practitioner or the diabetes nurse reviewed the results and the health care activity plan.

Results

A total of 166 patients with type 2 diabetes were randomly assigned to the intervention (n=87) or control (n=79) groups. From the baseline to follow-up, 36 patients in the intervention group and 5 patients in the control group were lost to follow-up, and 2 patients died. Additionally, HbA_1c was not available at baseline in one patient in the intervention group. A total of 122 patients were included in the final analysis after 19 months. There were no significant differences between the groups in the primary outcome HbA_1c level (P=.33), and in the secondary outcome HRQoL as measured using SF-36. A total of 80% (67/87) of the patients in the intervention group at the baseline, and 98% (47/50) of the responders after 19-month intervention were familiar with using a personal computer (P=.001). After 19 months, nonresponders (ie, data from baseline) reported significantly poorer mental health in social functioning and role emotional subscales on the SF-36 (P=.03, and P=.01, respectively).

Conclusions

The primary outcome HbA_1c level and the secondary outcome HRQoL did not differ between groups after the 19-month follow-up. Those lost to follow-up reported significantly poorer mental health than did the responders in the intervention group.

Trial Registration

Clinicaltrials.gov NCT01478672; https://clinicaltrials.gov/ct2/show/NCT01478672 (Archived by WebCite at http://www.webcitation.org/6r4eILeyu)

Using Community Engagement to Develop a Web-Based Intervention for Latinos about the HPV Vaccine

Human papillomavirus (HPV) infection is pervasive among sexually active women and men, and Hispanic women are at particularly high risk as they have higher rates of invasive cervical cancer compared to other racial or ethnic groups in the United States. There is a need for interventions to increase HPV vaccination among this high-risk population. This study investigated how to modify a previously developed web-based intervention that provided individually tailored information about HPV to improve its use among the Latino population. A community-oriented modification approach incorporated feedback from a community advisory committee, and focus groups among the Latino population, to modify the intervention. Several themes emerged including a need for basic information about HPV and HPV vaccination, changes to make the intervention appear less clinical, and incorporation of information addressing barriers specific to the Latino community. This work was done in preparation for a randomized trial to assess the impact of this modified intervention on HPV vaccination attitudes and uptake among Latino young adults and parents of adolescents. If effective, our intervention could be a resource for reducing HPV vaccination concerns, improving immunization rates, and educating Latinos about HPV and the HPV vaccine outside of the time boundaries of the traditional clinical encounter.

Effects on Engagement and Health Literacy Outcomes of Web-Based Materials Promoting Physical Activity in People With Diabetes: An International Randomized Trial

Background

Developing accessible Web-based materials to support diabetes self-management in people with lower levels of health literacy is a continuing challenge.

Objective

The objective of this international study was to develop a Web-based intervention promoting physical activity among people with type 2 diabetes to determine whether audiovisual presentation and interactivity (quizzes, planners, tailoring) could help to overcome the digital divide by making digital interventions accessible and effective for people with all levels of health literacy. This study also aimed to determine whether these materials can improve health literacy outcomes for people with lower levels of health literacy and also be effective for people with higher levels of health literacy.

Methods

To assess the impact of interactivity and audiovisual features on usage, engagement, and health literacy outcomes, we designed two versions of a Web-based intervention (one interactive and one plain-text version of the same content) to promote physical activity in people with type 2 diabetes. We randomly assigned participants from the United Kingdom, Austria, Germany, Ireland, and Taiwan to either an interactive or plain-text version of the intervention in English, German, or Mandarin. Intervention usage was objectively recorded by the intervention software. Self-report measures were taken at baseline and follow-up (immediately after participants viewed the intervention) and included measures of health literacy, engagement (website satisfaction and willingness to recommend the intervention to others), and health literacy outcomes (diabetes knowledge, enablement, attitude, perceived behavioral control, and intention to undertake physical activity).

Results

In total, 1041 people took part in this study. Of the 1005 who completed health literacy information, 268 (26.67%) had intermediate or low levels of health literacy. The interactive intervention overall did not produce better outcomes than did the plain-text version. Participants in the plain-text intervention group looked at significantly more sections of the intervention (mean difference –0.47, 95% CI –0.64 to –0.30, P<.001), but this did not lead to better outcomes. Health literacy outcomes, including attitudes and intentions to engage in physical activity, significantly improved following the intervention for participants in both intervention groups. These improvements were similar across higher and lower health literacy levels and in all countries. Participants in the interactive intervention group had acquired more diabetes knowledge (mean difference 0.80, 95% CI 0.65-0.94, P<.001). Participants from both groups reported high levels of website satisfaction and would recommend the website to others.

Conclusions

Following established practice for simple, clear design and presentation and using a person-based approach to intervention development, with in-depth iterative feedback from users, may be more important than interactivity and audiovisual presentations when developing accessible digital health interventions to improve health literacy outcomes.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 43587048; http://www.isrctn.com/ISRCTN43587048. (Archived by WebCite at http://www.webcitation.org/6nGhaP9bv)

Understanding and Promoting Effective Engagement With Digital Behavior Change Interventions

This paper is one in a series developed through a process of expert consensus to provide an overview of questions of current importance in research into engagement with digital behavior change interventions, identifying guidance based on research to date and priority topics for future research. The first part of this paper critically reflects on current approaches to conceptualizing and measuring engagement. Next, issues relevant to promoting effective engagement are discussed, including how best to tailor to individual needs and combine digital and human support. A key conclusion with regard to conceptualizing engagement is that it is important to understand the relationship between engagement with the digital intervention and the desired behavior change. This paper argues that it may be more valuable to establish and promote "effective engagement," rather than simply more engagement, with "effective engagement" defined empirically as sufficient engagement with the intervention to achieve intended outcomes. Appraisal of the value and limitations of methods of assessing different aspects of engagement highlights the need to identify valid and efficient combinations of measures to develop and test multidimensional models of engagement. The final section of the paper reflects on how interventions can be designed to fit the user and their specific needs and context. Despite many unresolved questions posed by novel and rapidly changing technologies, there is widespread consensus that successful intervention design demands a user-centered and iterative approach to development, using mixed methods and in-depth qualitative research to progressively refine the intervention to meet user requirements.

Individuals With Disabilities Who Have Diabetes: Do We Have Targeted Interventions?

According to 2010 data from the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. It is assumed that various diabetes interventions are available to help individuals manage this chronic disease, but that is not the case. The literature is scant regarding interventions focused on people with disabilities who have diabetes. The purpose of this article is to review interventions specifically focused on people with disabilities who have diabetes and to discuss the effect of these interventions on this population.