How Veterans With Post-Traumatic Stress Disorder and Comorbid Health Conditions Utilize eHealth to Manage Their Health Care Needs: A Mixed-Methods Analysis

Association of Digital Engagement With Relaxation Tools and Stress Level Reduction: Retrospective Cohort Study

BACKGROUND

Stress is an emotional response caused by external triggers and is a high-prevalence global problem affecting mental and physical health. Several different digital therapeutic solutions are effective for stress management. However, there is limited understanding of the association between relaxation components and stress levels when using a digital app.

OBJECTIVE

This study investigated the contribution of relaxation tools to stress levels over time. We hypothesized that participation in breathing exercises and cognitive behavioral therapy-based video sessions would be associated with a reduction in stress levels. We also hypothesized a significant reduction specifically in participants' perceived sense of burden and lack of productivity when engaged with breathing exercises and video sessions.

METHODS

Stress levels were evaluated in a real-world data cohort using a behavioral health app for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform-based treatment followed users (N=490) who started with moderate and above levels of stress and completed at least 2 stress assessments. The levels of stress were tracked throughout the first 10 weeks. A piecewise mixed effects model was applied to model the trajectories of weekly stress mean scores in 2 time segments (1-6 weeks and 6-10 weeks). Next, a simple slope analysis was used for interpreting interactions probing the moderators: breathing exercises and video sessions. Piecewise mixed-effects models were also used to model the trajectories of specific perceived stress item rates in the stress questionnaire in the 2 segments (1-6 weeks and 6-10 weeks) and whether they are moderated by the relaxation engagements. Simple slope analysis was also used here for the interpretation of the interactions.

RESULTS

Analysis revealed a significant decrease in stress symptoms (β=-.25; 95% CI -0.32 to -0.17; P<.001) during the period of 1-6 weeks of app use that was maintained during the period of 6-10 weeks. Breathing exercises significantly moderated the reduction in stress symptoms during the period of 1-6 weeks (β=-.07; 95% CI -0.13 to -0.01; P=.03), while engagement in digital video sessions did not moderate stress scores. Engagement in digital video sessions, as well as breathing exercises, significantly moderated the reduction in perceived sense of burden and lack of productivity during weeks 1-6 and remained stable during weeks 6-10 on both items.

CONCLUSIONS

This study sheds light on the association between stress level reduction and specific components of engagement in a digital health app, breathing exercises, and cognitive behavioral therapy-based video sessions. Our findings provide a basis for further investigation of current and moderating factors that contribute to the personalization of digital intervention. In addition, results may aid in developing a more comprehensive understanding of how digital intervention tools work for mental health and for whom they are most effective.

Validation of the eHEALTH Literacy Scale (Eheals) With Military Service Members

INTRODUCTION

Medical readiness of individual service members (SMs) is an integral component of operational readiness. Electronic Health (eHealth) literacy, here defined as the ability to seek out, find, evaluate, and appraise, integrate, and apply what is gained in electronic environments toward solving a health problem, is a key skill to enhance individual medical readiness. The World Health Organization (WHO) has identified health literacy as an important social determinant of health. The Internet enables individuals to access information virtually anywhere, at any place, any time, which is especially beneficial for SMs who serve around the globe, often isolated from modern health care facilities.

MATERIALS AND METHODS

This study examined the utility of the eHealth literacy scale (eHeals) as a potentially valuable tool to assist commanders and medical teams for assessing the health literacy of SMs. The main objective of our study was to examine the validity of the three-factor eHEALS measure for an active duty sample, using confirmatory factorial analysis.

RESULTS

Our findings support the validity of the eHEALS measure of electronic health literacy among military SMs, potentially identifying a means of measuring SMs' health literacy, and a target for intervention to increase medical readiness, well-being, and overall quality of life for individual SMs.

CONCLUSIONS

The study highlights a brief 6-item assessment tool that can quickly and efficiently be added to the current validated health and well-being measures for military personnel. This brief assessment can provide a measure of knowledge, skills, and confidence regarding ehealth information leading to better-informed health care decisions in the military context. These findings are especially relevant given the military's current emphasis on modernization and the need to put people first in order to build the overall team and improve unit effectiveness.

Evaluating the efficacy of NoteAid on EHR note comprehension among US Veterans through Amazon Mechanical Turk

OBJECTIVE

Low health literacy is a concern among US Veterans. In this study, we evaluated NoteAid, a system that provides lay definitions to medical jargon terms in EHR notes to help Veterans comprehend EHR notes. We expected that low initial scores for Veterans would be improved by using NoteAid.

MATERIALS AND METHODS

We recruited Veterans from the Amazon Mechanical Turk crowd work platform (MTurk). We also recruited non-Veterans from MTurk as a control group for comparison. We randomly split recruited MTurk Veteran participants into control and intervention groups. We recruited non-Veteran participants into mutually exclusive control or intervention tasks on the MTurk platform. We showed participants de-identified EHR notes and asked them to answer comprehension questions related to the notes. We provided participants in the intervention group with EHR note content processed with NoteAid, while NoteAid was not available for participants in the control group.

RESULTS

We recruited 94 Veterans and 181 non-Veterans. NoteAid leads to a significant improvement for non-Veterans but not for Veterans. Comparing Veterans recruited via MTurk with non-Veterans recruited via MTurk, we found that without NoteAid, Veterans have significantly higher raw scores than non-Veterans. This difference is not significant with NoteAid.

DISCUSSION

That Veterans outperform a comparable population of non-Veterans is a surprising outcome. Without NoteAid, scores on the test are already high for Veterans, therefore, minimizing the ability of an intervention such as NoteAid to improve performance. With regards to Veterans, understanding the health literacy of Veterans has been an open question. We show here that Veterans score higher than a comparable, non-Veteran population.

CONCLUSION

Veterans on MTurk do not see improved scores when using NoteAid, but they already score high on the test, significantly higher than non-Veterans. When evaluating NoteAid, population specifics need to be considered, as performance may vary across groups. Future work investigating the effectiveness of NoteAid on improving comprehension with local Veterans and developing a more difficult test to assess groups with higher health literacy is needed.

The Use of Digital Health Services Among Patients and Citizens Living at Home: Scoping Review

BACKGROUND

The development of digital health services reflects not only the technical development of services but also a change in attitude and the way of thinking. It has become a cornerstone for engaging and activating patients and citizens in health management while living at home. Digital health services are also aimed at enhancing the efficiency and quality of services, while simultaneously providing services more cost-effectively. In 2020, the COVID-19 pandemic accelerated worldwide the development and use of digital services in response to requirements for social distancing and other regulations.

OBJECTIVE

The aim of this review is to identify and summarize how digital health services are being used among patients and citizens while living at home.

METHODS

The Joanna Briggs Institute (JBI) methodology for scoping reviews was used as guidance. A search conducted in 3 databases (CINAHL, PubMed, Scopus) resulted in 419 papers. The reporting was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review (PRISMA-ScR), and the analysis of the included papers was performed using a framework consisting of 5 clusters describing the use of digital health services. After screening and excluding papers that did not match the inclusion criteria, 88 (21%) papers from 2010 to 2022 were included in the final analysis.

RESULTS

Results indicated that digital health services are used in different situations and among different kinds of populations. In most studies, digital health services were used in the form of video visits or consultations. The telephone was also used regularly for consultations. Other services, such as remote monitoring and transmitting of recorded information and the use the of internet or portals for searching information, were observed as well. Alerts, emergency systems, and reminders were observed to offer possibilities of use, for example, among older people. The digital health services also showed to have potential for use in patient education.

CONCLUSIONS

The development of digital services reflects a shift toward the provision of care regardless of time and place. It also reflects a shift toward emphasis on patient-centered care, meaning activating and engaging patients in their own care as they use digital services for various health-related purposes. Despite the development of digital services, many challenges (eg, adequate infrastructure) still prevail worldwide.

Automated Text Messaging During COVID-19: Patient Feedback to Increase Adoption

Automated text messaging interventions can effectively improve self-care and were used to support the U.S. Veterans Health Administration's (VHA) public health outreach during the COVID pandemic. Currently, significant gaps exist in knowledge about VHA patients' texting protocol preferences that may impact user receptivity, engagement, and effectiveness. This study qualitatively evaluated patient suggestions to improve two VHA Covid-related texting interventions and preferences for future text message protocols. We reviewed cross-sectional type-written survey responses from patients receiving either the "Coronavirus Precautions" or the "Coping During COVID" multi-week text protocols. Two team members independently and inductively coded all responses allowing for an upward abstraction of qualitative data. Nine hundred five patients (72.8% male) responded to the open-response item questions targeted by this research. An item that sought feedback to improve protocol acceptability generated thirteen distinct descriptive categories (inter-rater reliability 83.5%). Codable feedback showed, for example, that patients desired to manipulate message frequency and to have a more sophisticated interaction with messages. Patients' suggestions for future automated text messaging protocols yielded nine distinct topic areas. Patients offered suggestions that may impact receptivity and engagement of future automated text message protocols, particularly as they relate to outreach during a public health crisis. In addition, patients offered specific topics they would like to see in future text message protocols. We discuss how the findings can be used to increase engagement in current and post-pandemic public health interventions.

Digital Health Skillsets and Digital Preparedness: Comparison of Veterans Health Administration Users and Other Veterans Nationally

Background

As health care systems shift to greater use of telemedicine and digital tools, an individual’s digital health literacy has become an important skillset. The Veterans Health Administration (VA) has invested resources in providing digital health care; however, to date, no study has compared the digital health skills and preparedness of veterans receiving care in the VA to veterans receiving care outside the VA.

Objective

The goal of the research was to describe digital health skills and preparedness among veterans who receive care within and outside the VA health care system and examine whether receiving care in the VA is associated with digital preparedness (reporting more than 2 digital health skills) after accounting for demographic and social risk factors.

Methods

We used cross-sectional data from the 2016-2018 National Health Interview Survey to identify veterans (aged over 18 years) who obtain health care either within or outside the VA health care system. We used multivariable logistic regression models to examine the association of sociodemographic (age, sex, race, ethnicity), social risk factors (economic instability, disadvantaged neighborhood, low educational attainment, and social isolation), and health care delivery location (VA and non-VA) with digital preparedness.

Results

Those who received health care within the VA health care system (n=3188) were younger (age 18-49 years: 33.3% [95% CI 30.7-36.0] vs 24.2% [95% CI 21.9-26.5], P<.01), were more often female (34.7% [95% CI 32.0-37.3] vs 6.6% [95% CI 5.5-7.6], P<.01) and identified as Black (13.1% [95% CI 11.2-15.0] vs 10.2% [95% CI 8.7-11.8], P<.01), and reported greater economic instability (8.3% [95% CI 6.9-9.8] vs 5.5% [95% CI 4.6-6.5], P<.01) and social isolation (42.6% [95% CI 40.3-44.9] vs 35.4% [95% CI 33.4-37.5], P<.01) compared to veterans who received care outside the VA (n=3393). Veterans who obtained care within the VA reported more digital health skills than those who obtained care outside the VA, endorsing greater rates of looking up health information on the internet (51.8% [95% CI 49.2-54.4] vs 45.0% [95% CI 42.6-47.3], P<.01), filling a prescription using the internet (16.2% [95% CI 14.5-18.0] vs 11.3% [95% CI 9.6-13.0], P<.01), scheduling a health care appointment on the internet (14.1% [95% CI 12.4-15.8] vs 11.6% [95% CI 10.1-13.1], P=.02), and communicating with a health care provider by email (18.0% [95% CI 16.1-19.8] vs 13.3% [95% CI 11.6-14.9], P<.01). Following adjustment for sociodemographic and social risk factors, receiving health care from the VA was the only characteristic associated with higher odds (adjusted odds ratio [aOR] 1.36, 95% CI 1.12-1.65) of being digitally prepared.

Conclusions

Despite these demographic disadvantages to digital uptake, veterans who receive care in the VA reported more digital health skills and appear more digitally prepared than veterans who do not receive care within the VA, suggesting a positive, system-level influence on this cohort.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

Background

Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.

Objective

This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.

Methods

A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.

Results

A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.

Conclusions

Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

Relationship between eHealth literacy and psychological status during COVID-19 pandemic: A survey of Chinese residents

Aims

To investigate the eHealth literacy and the psychological status of Chinese residents during the COVID‐19 pandemic and explore their interrelationship.

Background

The COVID‐19 outbreak has placed intense psychological pressure on community residents. Their psychological status may be affected by eHealth literacy due to home isolation during this rampant pandemic.

Methods

This is a Web‐based cross‐sectional survey conducted on the JD Health platform, which resulted in 15,000 respondents having participated in this survey. The eHealth Literacy Questionnaire (EHLQ), Patient Health Questionnaire‐9 (PHQ‐9), Insomnia Severity Index (ISI) and Impact of Event Scale‐Revised (IES‐R) were used. The Pearson correlation was used to analyse the relationship between eHealth literacy and depression, insomnia and post‐traumatic stress disorder.

Results

The score of eHealth literacy was 48.88 ± 8.46, and 11.4%, 6.8% and 20.1% of respondents experienced moderate to severe depression, insomnia and post‐traumatic stress disorder. eHealth literacy negatively correlated with depression (r = −0.331), insomnia (r = −0.366) and post‐traumatic stress disorder (r = −0.320).

Conclusion

eHealth literacy is closely related to psychological status. Improving eHealth literacy may contribute to maintaining good psychological well‐being.

Implications for Nursing Management

It is necessary to strengthen the education of primary health care providers to enhance their ability to help community residents effectively use eHealth information.

Public implementation of a web-based program for veterans with risky alcohol use and PTSD: A RE-AIM evaluation of VetChange

BACKGROUND

Evidence-based web and mobile interventions are available for a range of mental health concerns. Little is known about how self-administered web interventions are used outside of controlled research trials, and there is a critical need to empirically examine real-world public implementation of such programs. To this end, the aim of the current study was to evaluate and describe outcomes of a nationwide public implementation of VetChange, a self-administered web intervention for veterans with problematic alcohol use and symptoms of PTSD.

METHOD

The study used the RE-AIM framework to organize outcomes along five key dimensions: reach, effectiveness, adoption, implementation, and maintenance. This naturalistic observation study included program use information for all who registered an account with VetChange during the 2-year study period and who self-identified as a returning veteran. We collected program use data automatically via normal website operation; a subset of program users provided additional self-report outcome data. The study used linear multilevel mixed modeling to evaluate changes in alcohol use and PTSD symptoms over a six-month postregistration period.

RESULTS

VetChange successfully reached a large, geographically diverse sample of returning veterans with risky drinking and PTSD symptoms. Despite variable, overall modest, rates of intervention use over time, registered users demonstrated significant improvements in drinking, PTSD, and quality of life, and participants maintained these outcomes at a six-month follow-up.

CONCLUSIONS

Given the observed low cost per acquisition, positive clinical outcomes, and the potential to produce long-term cost savings through reduced health care burden associated with chronic alcohol use disorder and PTSD, this study demonstrates how web-based interventions can provide public health benefits and reduce long-term health care costs.

Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods

The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31-40.].

The architecture of co-morbidity networks of physical and mental health conditions in military veterans

Co-morbidity between medical and psychiatric conditions is commonly considered between individual pairs of conditions. However, an important alternative is to consider all conditions as part of a co-morbidity network, which encompasses all interactions between patients and a healthcare system. Analysis of co-morbidity networks could detect and quantify general tendencies not observed by smaller-scale studies. Here, we investigate the co-morbidity network derived from longitudinal healthcare records from approximately 1 million United States military veterans, a population disproportionately impacted by psychiatric morbidity and psychological trauma. Network analyses revealed marked and heterogenous patterns of co-morbidity, including a multi-scale community structure composed of groups of commonly co-morbid conditions. Psychiatric conditions including posttraumatic stress disorder were strong predictors of future medical morbidity. Neurological conditions and conditions associated with chronic pain were particularly highly co-morbid with psychiatric conditions. Across conditions, the degree of co-morbidity was positively associated with mortality. Co-morbidity was modified by biological sex and could be used to predict future diagnostic status, with out-of-sample prediction accuracy of 90-92%. Understanding complex patterns of disease co-morbidity has the potential to lead to improved designs of systems of care and the development of targeted interventions that consider the broader context of mental and physical health.

Proposal for the User-Centered Design Approach for Health Apps Based on Successful Experiences: Integrative Review

Background

Different strategies encompassed within mHealth have shown themselves to be effective for maintaining good health or controlling certain diseases. However, there is usually a very high rate of abandonment of health apps. Therefore, it would seem obvious that there is a need for involving the end users (whether they are health professionals, patients, or both) in the design process from the early stages in order to enable their needs and characteristics to be identified. In this sense, it is common knowledge that focusing on the user permits the consideration of valuable details aimed at making the correct adjustment between the patient, the technology, and the organization of attention.

Objective

The goal of the research was to propose a methodology based on the review of previous successful user experiences in setting up health apps by using qualitative techniques (focus groups and discussion groups) that includes the participation of information technology and health professionals and the patients themselves.

Methods

An integrative review was made of studies in which a qualitative methodology was employed mainly through focus and/or discussion groups for the design and development of health apps, consulting diverse databases (PubMed, Scopus, and Proquest) with the following search strategy: “mHealth AND apps AND focus group OR discussion group.” A total of 69 papers were included in the review.

Results

A proposal structured in 4 sessions of variable duration was made in which information technology and health professionals and patients take part: composing, preparing, and organizing contents (session 1); testing structure and usability (session 2); does the app fit the needs of end users? (session 3); and last testing—keep on improving (session 4). Throughout the sessions, we propose studying aspects like previous user experiences in mHealth, barriers to the adoption of mHealth, interface contents, management and browsability, usability, perceived quality, security and privacy, capacity to self-manage disease with the app, ergonomics, and glanceability, etc. Specific tools that have proved useful in previous research for measuring these aspects are presented.

Conclusions

These work sessions would be based on predominantly qualitative methodologies although, as they evolve, validated questionnaires permitting the assessment of the objectivity of certain technical aspects could be incorporated. With this proposal, a project centered on end users could be effected, responding to their needs. However, this requires validation that will be made via implementation in the development of health apps, with the subsequent measurement of results in terms of adherence and improvement in the clinical variables of the end users.

Patient Perspectives to Inform a Health Literacy Educational Program: A Systematic Review and Thematic Synthesis of Qualitative Studies

Patient-centred care is tailored to the needs of patients and is necessary for better health outcomes, especially for individuals with limited health literacy (LHL). However, its implementation remains challenging. The key to effectively address patient-centred care is to include perspectives of patients with LHL within the curricula of (future) healthcare providers (HCP). This systematic review aimed to explore and synthesize evidence on the needs, experiences and preferences of patients with LHL and to inform an existing educational framework. We searched three databases: PsychInfo, Medline and Cinahl, and extracted 798 articles. One-hundred and three articles met the inclusion criteria. After data extraction and thematic synthesis, key themes were identified. Patients with LHL and chronic diseases encounter multiple problems in the care process, which are often related to a lack of person-centeredness. Patient perspectives were categorized into four key themes: (1) Support system; (2) Patient self-management; (3) Capacities of HCPs; (4) Barriers in healthcare systems. "Cultural sensitivity" and "eHealth" were identified as recurring themes. A set of learning outcomes for (future) HCPs was developed based on our findings. The perspectives of patients with LHL provided valuable input for a comprehensive and person-centred educational framework that can enhance the relevance and quality of education for (future) HCPs, and contribute to better person-centred care for patients with LHL.

Provider Perspectives on Integrating Sensor-Captured Patient-Generated Data in Mental Health Care

The increasing ubiquity of health sensing technology holds promise to enable patients and health care providers to make more informed decisions based on continuously-captured data. The use of sensor-captured patient-generated data (sPGD) has been gaining greater prominence in the assessment of physical health, but we have little understanding of the role that sPGD can play in mental health. To better understand the use of sPGD in mental health, we interviewed care providers in an intensive treatment program (ITP) for veterans with post-traumatic stress disorder. In this program, patients were given Fitbits for their own voluntary use. Providers identified a number of potential benefits from patients' Fitbit use, such as patient empowerment and opportunities to reinforce therapeutic progress through collaborative data review and interpretation. However, despite the promise of sensor data as offering an "objective" view into patients' health behavior and symptoms, the relationships between sPGD and therapeutic progress are often ambiguous. Given substantial subjectivity involved in interpreting data from commercial wearables in the context of mental health treatment, providers emphasized potential risks to their patients and were uncertain how to adjust their practice to effectively guide collaborative use of the FitBit and its sPGD. We discuss the implications of these findings for designing systems to leverage sPGD in mental health care.

Dual Use of a Patient Portal and Clinical Video Telehealth by Veterans with Mental Health Diagnoses: Retrospective, Cross-Sectional Analysis

Background

Access to mental health care is challenging. The Veterans Health Administration (VHA) has been addressing these challenges through technological innovations including the implementation of Clinical Video Telehealth, two-way interactive and synchronous videoconferencing between a provider and a patient, and an electronic patient portal and personal health record, My HealtheVet.

Objective

This study aimed to describe early adoption and use of My HealtheVet and Clinical Video Telehealth among VHA users with mental health diagnoses.

Methods

We conducted a retrospective, cross-sectional analysis of early My HealtheVet adoption and Clinical Video Telehealth engagement among veterans with one or more mental health diagnoses who were VHA users from 2007 to 2012. We categorized veterans into four electronic health (eHealth) technology use groups: My HealtheVet only, Clinical Video Telehealth only, dual users who used both, and nonusers of either. We examined demographic characteristics and mental health diagnoses by group. We explored My HealtheVet feature use among My HealtheVet adopters. We then explored predictors of My HealtheVet adoption, Clinical Video Telehealth engagement, and dual use using multivariate logistic regression.

Results

Among 2.17 million veterans with one or more mental health diagnoses, 1.51% (32,723/2,171,325) were dual users, and 71.72% (1,557,218/2,171,325) were nonusers of both My HealtheVet and Clinical Video Telehealth. African American and Latino patients were significantly less likely to engage in Clinical Video Telehealth or use My HealtheVet compared with white patients. Low-income patients who met the criteria for free care were significantly less likely to be My HealtheVet or dual users than those who did not. The odds of Clinical Video Telehealth engagement and dual use decreased with increasing age. Women were more likely than men to be My HealtheVet or dual users but less likely than men to be Clinical Video Telehealth users. Patients with schizophrenia or schizoaffective disorder were significantly less likely to be My HealtheVet or dual users than those with other mental health diagnoses (odds ratio, OR 0.50, CI 0.47-0.53 and OR 0.75, CI 0.69-0.80, respectively). Dual users were younger (53.08 years, SD 13.7, vs 60.11 years, SD 15.83), more likely to be white, and less likely to be low-income than the overall cohort. Although rural patients had 17% lower odds of My HealtheVet adoption compared with urban patients (OR 0.83, 95% CI 0.80-0.87), they were substantially more likely than their urban counterparts to engage in Clinical Video Telehealth and dual use (OR 2.45, 95% CI 1.95-3.09 for Clinical Video Telehealth and OR 2.11, 95% CI 1.81-2.47 for dual use).

Conclusions

During this study (2007-2012), use of these technologies was low, leaving much potential for growth. There were sociodemographic disparities in access to My HealtheVet and Clinical Video Telehealth and in dual use of these technologies. There was also variation based on types of mental health diagnosis. More research is needed to ensure that these and other patient-facing eHealth technologies are accessible and effectively used by all vulnerable patients.

Facilitators and Barriers to Seeking Mental Health Care Among Primary Care Veterans With Posttraumatic Stress Disorder

Although posttraumatic stress disorder (PTSD) is common in primary care patients, many do not seek mental health treatment. Existing research on barriers and facilitators to receiving PTSD treatment are not specific to primary care patients. In this study, we sought to understand the psychosocial concerns, treatment barriers, and treatment facilitators among non-treatment-seeking primary care veterans with PTSD who reside in both rural and urban settings. Using a concurrent triangulation design, we collected qualitative focus group and quantitative self-report data concurrently, analyzed them separately, and merged the results for interpretation. In total, 27 veteran primary care patients with PTSD participated in 1 of 4 focus groups. A modified conventional content analysis approach was used. Team-based coding began with three broad primary codes (psychosocial concerns, barriers, and facilitators) and subcodes were allowed to emerge from the data. Self-report measures were used to collect clinical characteristics and barriers to care. The results expanded upon existing models of PTSD treatment initiation by (a) specifying treatment preferences, such as patient-centered care, peer support services, and open access scheduling, and (b) presenting concerns, such as anger and core symptoms of PTSD. Results also indicated that a commonly used quantitative barriers measure may offer an incomplete picture of why veterans do not seek treatment as it does not assess how past negative treatment experiences may affect utilization. Strategies to help veterans overcome barriers to care may benefit from a focus on negative treatment-seeking beliefs and tailoring based on a veteran's rural or urban status.

Veterans' Attitudes Toward Smartphone App Use for Mental Health Care: Qualitative Study of Rurality and Age Differences

Background

Mental health smartphone apps provide support, skills, and symptom tracking on demand and come at minimal to no additional cost to patients. Although the Department of Veterans Affairs has established itself as a national leader in the creation of mental health apps, veterans’ attitudes regarding the use of these innovations are largely unknown, particularly among rural and aging populations who may benefit from increased access to care.

Objective

The objective of our study was to examine veterans’ attitudes toward smartphone apps and to assess whether openness toward this technology varies by age or rurality.

Methods

We conducted semistructured qualitative interviews with 66 veterans from rural and urban areas in Maine, Arkansas, and California. Eligible veterans aged 18 to 70 years had screened positive for postraumatic stress disorder (PTSD), alcohol use disorder, or major depressive disorder, but a history of mental health service utilization was not required. Interviews were digitally recorded, professionally transcribed, and coded by a research team using an established codebook. We then conducted a thematic analysis of segments pertaining to smartphone use, informed by existing theories of technology adoption.

Results

Interviews revealed a marked division regarding openness to mental health smartphone apps, such that veterans either expressed strongly positive or negative views about their usage, with few participants sharing ambivalent or neutral opinions. Differences emerged between rural and urban veterans’ attitudes, with rural veterans tending to oppose app usage, describe smartphones as hard to navigate, and cite barriers such as financial limitations and connectivity issues, more so than urban populations. Moreover, rural veterans more often described smartphones as being opposed to their values. Differences did not emerge between younger and older (≥50) veterans regarding beliefs that apps could be effective or compatible with their culture and identity. However, compared with younger veterans, older veterans more often reported not owning a smartphone and described this technology as being difficult to use.

Conclusions

Openness toward the use of smartphone apps in mental health treatment may vary based on rurality, and further exploration of the barriers cited by rural veterans is needed to improve access to care. In addition, findings indicate that older patients may be more open to integrating technology into their mental health care than providers might assume, although such patients may have more trouble navigating these devices and may benefit from simplified app designs or smartphone training. Given the strong opinions expressed either for or against smartphone apps, our findings suggest that apps may not be an ideal adjunctive treatment for all patients, but it is important to identify those who are open to and may greatly benefit from this technology.

Veterans' Perspectives on Fitbit Use in Treatment for Post-Traumatic Stress Disorder: An Interview Study

BACKGROUND

The increase in availability of patient data through consumer health wearable devices and mobile phone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues, but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact integration including patients' motivations to use wearables and their subsequent data.

OBJECTIVE

The aim of this study was to gain an understanding of patients' motivations to use or not to use wearables devices during an intensive treatment program for post-traumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and nonuse of the Fitbit?

METHODS

We conducted semistructured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis.

RESULTS

We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship.

CONCLUSIONS

To integrate wearable data into mental health treatment programs, it is important to understand the patient's perspectives and motivations in using wearables. We also discuss how the military culture and PTSD may have contributed to our participants' behaviors and attitudes toward Fitbit usage. We conclude with possible approaches for integrating patient-generated data into mental health treatment settings that may address the challenges we identified.

Help-Seeking on Facebook Versus More Traditional Sources of Help: Cross-Sectional Survey of Military Veterans

BACKGROUND

The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help or how it compares to other sources of potential support for mental health problems.

OBJECTIVE

This study aimed to evaluate the degree to which military veterans with depression use social media for help-seeking in comparison to other more traditional sources of help.

METHODS

Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and nonusers were compared via t tests, Chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models.

RESULTS

The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and nonusers, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (eg, psychologists), informal (eg, friends), or phone helpline sources of support were significantly higher. Results did not substantially change when examining users of other social media, women, or younger adults.

CONCLUSIONS

In its current form, the social media platform Facebook is not seen as a venue to seek help for emotional problems or suicidality among veterans with major depression in the United States.

eHealth literacy research-Quo vadis?

The concept of electronic health (eHealth) literacy evolved from the social and information sciences and describes competencies necessary to use electronic health services. As it is a rather new topic, and as there is no current overview of the state of the art in research, it is not possible to identify research gaps. Therefore, the objective of this viewpoint article is to increase knowledge on the current state of the art of research in eHealth literacy and to identify gaps in scientific research which should be focused on by the research community in the future. The article provides a current viewpoint of the concept of eHealth literacy and related research. Gaps can be found in terms of a missing "gold standard" regarding both the definition and the measurement of eHealth literacy. Furthermore, there is a need for identifying the implications on eHealth developers, which evolve from the measurement of eHealth literacy in eHealth users. Finally, a stronger inclusion of health professionals, both in the evolving concept and in the measurement of eHealth literacy, is needed in the future.

Diverse veterans' pre- and post-intervention perceptions of home telemental health for posttraumatic stress disorder delivered via tablet

Objectives Home telemental health services have the potential to overcome many individual and systemic barriers to care facing military veterans with posttraumatic stress disorder. However, little is known about the home telemental health-related attitudes and experiences of highly underserved rural or ethnically, racially diverse veterans. This study evaluated whether ethnically/racially diverse U.S. veterans residing in the rural Pacific Islands would find the delivery of evidence-based treatment for posttraumatic stress disorder via home telemental health tablet devices useful and helpful. Method Clinicians located in a central urban location delivered Cognitive Processing Therapy for posttraumatic stress disorder directly into patients' homes via a tablet device and secure WiFi connection. Pre- and post-treatment measures were collected from a clinical sample of 47 veterans (average age: 49.3 years). Most (74.4%) self-identified as being of ethnic/racial minority background. Attitudinal, satisfaction, and usability scales were collected from home telemental health engaging ( n = 29) and non-engaging ( n = 18) veterans. Results Ratings on measures of home telemental health comfort, satisfaction with care, and usability were uniformly positive. Veterans were equally open to receiving mental health services at home via home telemental health or in the clinic. In the case of services for a physical problem, however, veterans preferred in-clinic care. Following treatment, veterans' attitudinal scores increased on items such as "There is enough therapist contact in home telemental health interventions." However, a small portion of veterans (7%) reported having technical or privacy concerns. Conclusion The provision of evidence-based posttraumatic stress disorder treatment directly into the patients' homes proved feasible and was well received by the large majority of rural ethnically/racially diverse veterans.