The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review

Culturally Congruent Latino-Adapted Telemonitoring of Underrepresented Adults With Type 2 Diabetes: The CULTURA-DM2 Trial

This study reports on the development and testing of a comprehensive diabetes telemonitoring program tailored to meet the needs of underserved Hispanic/Latino patients with diabetes. Individuals participating in the culturally tailored program had significantly better 6-month outcomes than those receiving comprehensive outpatient management for A1C, blood pressure, and diabetes self-efficacy, with no differences between groups in quality of life, medication adherence, emotional functioning, patient activation, or unscheduled physician visits. These findings suggest that culturally congruent diabetes telemonitoring may be effective for this underserved population.

Recruitment, retention and reporting of variables related to ethnic diversity in randomised controlled trials: an umbrella review

OBJECTIVE

This umbrella review synthesises evidence on the methods used to recruit and retain ethnically diverse participants and report and analyse variables related to ethnic diversity in randomised controlled trials.

DESIGN

Umbrella review.

DATA SOURCES

Ovid MEDLINE, Ovid Embase, CINAHL, PsycINFO and Cochrane and Campbell Libraries for review papers published between 1 January 2010 and 13 May 2024.

ELIGIBILITY CRITERIA

English language systematic reviews focusing on inclusion and reporting of ethnicity variables. Methodological quality was assessed using the AMSTAR 2 tool.

RESULTS

Sixty-two systematic reviews were included. Findings point to limited representation and reporting of ethnic diversity in trials. Recruitment strategies commonly reported by the reviews were community engagement, advertisement, face-to-face recruitment, cultural targeting, clinical referral, community presentation, use of technology, incentives and research partnership with communities. Retention strategies highlighted by the reviews included frequent follow-ups on participants to check how they are doing in the study, provision of incentives, use of tailored approaches and culturally appropriate interventions. The findings point to a limited focus on the analysis of variables relevant to ethnic diversity in trials even when they are reported in trials.

CONCLUSION

Significant improvements are required in enhancing the recruitment and retention of ethnically diverse participants in trials as well as analysis and reporting of variables relating to diversity in clinical trials.

PROSPERO REGISTRATION NUMBER

CRD42022325241.

Factors associated with telehealth use among adults in the United States: Findings from the 2020 National Health Interview Survey

INTRODUCTION

During the COVID-19 pandemic, health care shifted to virtual interactions with health professionals. The aim of this study was to examine the determinants of telehealth use in a nationally representative sample of the United States adult population.

METHODS

The study used data from the 2020 National Health Interview Survey of 17,582 respondents aged ≥18. Andersen's model of health services utilization was employed to examine predisposing, enabling, and needs factors associated with past-year telehealth use. Multivariable logistic regression was conducted to examine statistical associations.

RESULTS

32.5% of adults (n = 6402; mean age 51.6, SE = 0.4) reported telehealth use. Predisposing factors: Women and married/partnered adults and those with higher levels of education had greater odds of using telehealth. Adults living in Midwest and South and adults living in medium-small and non-metropolitan areas had decreased odds of using telehealth. Enabling factors: Income and having a usual source of care were positively associated with telehealth use. A negative association was found for those with no insurance and telehealth use, whereas a positive association was found for military insurance. Needs factors: Odds of using telehealth were increased for adults who had well-visits and ER visits in the past 12 months. Mental health services quadrupled the odds of telehealth use. Odds of using telehealth increased with each additional chronic disease, including COVID-19.

CONCLUSION

There are disparities in telehealth use according to sex, education, rurality, access to care, and health needs. Tackling these disparities is pivotal to ensure barriers to telehealth use are not exacerbated post-pandemic.

Barriers to Remote Burn Care Delivery: An Analysis of Burn Center Proximity and Access to Critical Telehealth Infrastructure

ABSTRACT

Mounting evidence supports the use of telehealth to improve burn care access and efficiency. However, barriers to telehealth use remain throughout the United States and may disproportionately affect specific populations, such as rural and non-English-speaking patients. This study analyzes the association between physical proximity to burn care and determinants of telehealth access.The relationship between telehealth-associated measures and proximity to burn care was analyzed with linear regression analysis. County-level data was sourced from the Agency for Healthcare Research and Quality's Social Determinants of Health Database (2020) and the American Community Survey (2021). County-level distances to the nearest American Burn Association (ABA)-verified burn center were calculated based on verified centers listed in the ABA burn center directory (n = 59). A subsequent analysis was performed on income-stratified datasets available for subset counties.Distance was negatively correlated with access to a smartphone (P < 0.0001), broadband internet (P < 0.0001), and cellular data plan (P < 0.0001) and positively correlated with the percent of households with no computing device (P < 0.0001) and no internet access (P < 0.0001). Analysis of income-stratified data revealed similar results. The percent population not speaking English well (P < 0.0001) at all (P = 0.0009) and the proportion of limited English-speaking households (P = 0.0001) decreased as a function of distance.People living furthest from an ABA-verified burn center in the United States are less likely to have adequate access to critical telehealth infrastructure compared to their counterparts living closer to a burn center. However, income impacts overall access and the degree to which access changes with proximity. Conversely, language-associated barriers decrease as distance increases.

Most UK cardiovascular disease trial protocols feature criteria that exclude ethnic minority participants: a systematic review

OBJECTIVES

We systematically reviewed UK cardiovascular disease (CVD) randomized controlled trial (RCT) protocols to identify the proportion featuring eligibility criteria that may disproportionately exclude ethnic minority (EM) participants.

METHODS

We searched MEDLINE, Embase, and Cochrane Library databases, January 2014-June 2022, to identify UK CVD RCT protocols. We extracted nonclinical eligibility criteria from trial protocols and inductively categorized the trials by their language, consent, and broad (ambiguous) criteria. Findings are narratively reported.

RESULTS

Of the seventy included RCT protocols, most (87.1%; 61/70) mentioned consent within the eligibility criteria, with more than two-thirds (68.9%; 42/61) indicating a requirement for 'written' consent. Alternative consent pathways that can aid EM participation were absent. English language requirement was present in 22.9% (16/70) of the studies and 37.1% (26/70) featured broad criteria that are open to interpretation and subject to recruiter bias. Only 4.3% (3/70) protocols mentioned the provision of translation services.

CONCLUSION

Most UK CVD trial protocols feature eligibility criteria that potentially exclude EM groups. Trial eligibility criteria must be situated within a larger inclusive recruitment framework, where ethnicity is considered alongside other intersecting and disadvantaging identities.

Development and validation of a pharmacist-led education model in allergic rhinitis management: a multi-phase study

BACKGROUND

Patient education is identified as one of the core and fundamental management strategies in the management of allergic rhinitis. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed guidance for the management of allergic respiratory disease, and the guidelines are applicable to the international context. The ARIA guidelines for the pharmacy have specifically encouraged the creation of local pharmacist-led intervention in allergic rhinitis management. This study aims to develop a pharmacist-led educational model using a multi-phase study approach.

METHOD

In phase one, we conducted a literature review using four databases to extract relevant articles and clinical practice guidelines published between 2017 and 2022. The information was structured into a questionnaire consisting of patient education material (10 domains with 130 items) and pharmacist counseling scopes (15 domains with 43 items), with each item having a rating scale ranging from 1 (lowest) to 9 (highest) level of agreement. Fifty-two panellists, including otorhinolaryngologists and pharmacists, were invited to complete the questionnaire. A consensus agreement was considered when at least 70% of panellists scored 7 to 9 (critically important). A two-round survey was conducted, and descriptive analysis, inter-rater reliability (≥ 0.5-1 indicate moderate to excellent reliability), variation in the relative interquartile (VRIR < 0.3 indicate good stability), and variation in the coefficient of variation (VCV < 40% considered consensus achieved) were performed. In phase two, patient education material was developed into audio-visual format, and in phase three, patients rated its understandability and actionability using a validated Patient Education Materials Assessment Tool.

RESULTS

In the round one Delphi survey, 43 panellists responded, with 171 out of 173 items achieving "consensus agreement" (75.4-100%). In the second survey, 32 out of 43 panellists responded, with most items (171 out of 173 items) stable across rounds and all items had acceptable internal consistency (VCV: - 12.21-15.81). Two items did not achieve "consensus agreement" (64%) but improved in round two (92.9%), however, instability was observed (VRIR: 0.36). These two items were retained in the model due to achieving the minimum level of agreement and internal consistency (VCV = 15.81). Inter-rater reliability was 0.608 and 0.970 in the respective rounds. Patients rated the educational material as understandable (81.8-100%) and actionable (100%).

CONCLUSION

The validated pharmacist-led education model, with its educational materials tested on end-users, provides structured patient education and pharmaceutical care in assisting patients with allergic rhinitis. The educational material allows the delivery of standardized information by the healthcare providers to the patients. Further research on the effectiveness of this model in improving patients' symptom control and quality of life is warranted.

Mapping two decades of multiple sclerosis rehabilitation trials: A systematic scoping review and call to action to advance the study of race and ethnicity in rehabilitation research

BACKGROUND

Multiple sclerosis (MS), is prevalent across many racial and ethnic groups, and disproportionately impacts racially minoritized populations. Rehabilitation interventions are an important component of comprehensive MS care. Yet, we do not know the extent to which MS rehabilitation trials consider race and ethnicity in defining eligibility criteria, planning recruitment strategies, selecting outcome measures, supporting intervention delivery, and designing approaches to promote adherence and retention.

METHODS

We conducted a scoping review of five databases (MEDLINE, CINAHL, Cochrane Central, EMBASE, and Web of Science) to locate randomized controlled rehabilitation trials published from January 2002 to March 2022. We extracted data from relevant studies, assessed their methodological quality, and narratively summarized results. Reporting of this review is in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

RESULTS

Fifty-six studies of neurorehabilitation (n = 3), cognitive rehabilitation (n = 6), exercise training (n = 9) and self-management (n = 38) interventions were included in this review. The studies were predominantly from North America (n = 44; 73%) or Europe (n = 12; 20%) and included 4280 participants. Most participants (n = 3669; 86%) were Caucasians. Less than 10% of participants were Black (n = 282), Latinx/Hispanic (n = 60), Asian (n = 46), Indigenous (n = 7), or Arab (n = 2). Few studies discussed how race and/or ethnicity were considered in trial planning or execution.

CONCLUSIONS

Without consistent and systematic attention to race and ethnicity, both in terms of trial design and reporting, it is impossible to know how MS rehabilitation interventions will translate into real-world applications. This call to action - to the MS rehabilitation research community to ensure trial and intervention processes that accommodate the needs of diverse racial and ethnic groups - is an important first step in addressing inequities in rehabilitation care for persons with MS.

Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study

BACKGROUND

Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered.

METHODS

We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques.

RESULTS

Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities.

CONCLUSION

This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

Virtual prenatal care: A systematic review of pregnant women's and healthcare professionals' experiences, needs, and preferences for quality care

INTRODUCTION

Exploitation of telehealth in prenatal care has the potential to reduce the access barrier to care and empower women to participate in their own care. This review aims to assess the practical implications of virtual prenatal care and identify the needs and experiences associated with it.

METHODS

A systematic literature review was conducted in four electronic databases: PubMed, Web of Science, Scopus, and Cochrane. The keywords used were "pregnancy", "virtual visit", "prenatal", and others. The search included all relevant studies published from 2011 to 2021 written in English. Articles mentioning virtual prenatal care incorporating synchronous communication between pregnant women and health care professionals were included. Those unrelated to prenatal care or employing asynchronous means of virtual care were excluded. The review was structured following the PRISMA guidelines. Different quality appraisal methods such as JBI, CASP, NOS, and Cochrane were used to assess the methodological quality of the literature. The data were then analyzed based on the categorization of the studies.

RESULTS

Overall, 2863 articles were identified, of which 19 met the inclusion criteria after removing duplicates, screening of abstracts, and full text-four articles identified from hand-searching were incorporated, making a total of 23 eligible articles for the review. The studies' findings revealed the preference for implementing cost-effective virtual care based on the resource set, technological literacy, and consistent accessibility. Further, no significant differences in clinical outcomes were observed between two modes of care, virtual and in-person. The higher satisfaction by pregnant women and healthcare professionals indicated the continuity of the care. In addition, the hybrid model of virtual prenatal care integrated with traditional in-person care was acceptable to both low-risk and high-risk pregnant women. Virtual prenatal care substantially reduced travel time and absences from work, drops in clinic wait time and no-show rate, limited the risk of exposure during a pandemic, and increased self-accountability.

CONCLUSION

Virtual prenatal care offers predominant advantages over in-person when it is carefully designed with the inclusion of pregnant women and healthcare professionals' needs. Evidence showed that providing adequate technology training, proper instruction, and guidelines for initial setup and assurance of a reliable and accessible system is vital in increasing access to care.

The Use of Digital Health Interventions for Cardiometabolic Diseases Among South Asian and Black Minority Ethnic Groups: Realist Review

BACKGROUND

Digital health interventions (DHIs) for the prevention and management of cardiometabolic diseases have become increasingly common. However, there is limited evidence for the suitability of these approaches in minority ethnic populations, who are at an increased risk of these diseases.

OBJECTIVE

This study aimed to investigate the use of DHIs for cardiovascular disease and type 2 diabetes among minority ethnic populations in countries with a majority of White, English-speaking populations, focusing on people who identified as South Asian, Black, or African American.

METHODS

A realist methodology framework was followed. A literature search was conducted to develop context-mechanism-outcome configurations, including the contexts in which DHIs work for the target minority ethnic groups, mechanisms that these contexts trigger, and resulting health outcomes. After systematic searches, a qualitative analysis of the included studies was conducted using deductive and inductive coding.

RESULTS

A total of 15 studies on the uptake of DHIs for cardiovascular disease or diabetes were identified, of which 13 (87%) focused on people with an African-American background. The review found evidence supporting the use of DHIs in minority ethnic populations when specific factors are considered in implementation and design, including patients' beliefs, health needs, education and literacy levels, material circumstances, culture, social networks, and wider community and the supporting health care systems.

CONCLUSIONS

Our context-mechanism-outcome configurations provide a useful guide for the future development of DHIs targeted at South Asian and Black minority ethnic populations, with specific recommendations for improving cultural competency and promoting accessibility and inclusivity of design.

Remotely Delivered Monitoring and Management of Diabetes-Related Foot Disease: An Overview of Systematic Reviews

BACKGROUND

Diabetes-related foot disease (DFD) management requires input from multiple healthcare professionals, and has worse outcomes for people living in remote localities by comparison to urban areas. Remotely delivered healthcare may reduce this disparity. This overview summarizes current evidence on the effectiveness, stakeholder perceptions, and cost-effectiveness of remotely delivered healthcare for DFD.

METHODS

A search of 5 databases was conducted to identify systematic reviews published between January 2000 and June 2020. Eligible reviews were those evaluating remotely delivered monitoring or management of patients at risk of or with active DFD, or clinicians managing these patients. Risk of bias was assessed using the AMSTAR-2 tool.

RESULTS

Eight reviews were eligible for inclusion, including 88 primary studies and 8509 participants, of which 36 studies involving 4357 participants evaluated remotely delivered monitoring or management of DFD. Only one review had a low risk of bias, with most reviews demonstrating limited search strategies and poor reporting of participants. Evidence on effectiveness was mixed, with meta-analyses demonstrating long-term ulcer healing and mortality were not significantly different between telehealth and standard care groups, although the lower-limb amputation rate was significantly decreased in one meta-analysis. Perceptions of telehealth by patients and clinicians were generally positive, whilst acknowledging limitations relating to access and use. Cost-effectiveness data were limited, with poor reporting preventing clear conclusions.

CONCLUSIONS

Remotely delivered healthcare of DFD is well received by patients and clinicians, but its effectiveness is unclear. High quality trials are needed to evaluate the risks and benefits of remotely delivered DFD management.

Barriers to and solutions for representative inclusion across the lifespan and in life course research: The need for structural competency highlighted by the COVID-19 pandemic

Exclusion of special populations (older adults; pregnant women, children, and adolescents; individuals of lower socioeconomic status and/or who live in rural communities; people from racial and ethnic minority groups; individuals from sexual or gender minority groups; and individuals with disabilities) in research is a pervasive problem, despite efforts and policy changes by the National Institutes of Health and other organizations. These populations are adversely impacted by social determinants of health (SDOH) that reduce access and ability to participate in biomedical research. In March 2020, the Northwestern University Clinical and Translational Sciences Institute hosted the "Lifespan and Life Course Research: integrating strategies" "Un-Meeting" to discuss barriers and solutions to underrepresentation of special populations in biomedical research. The COVID-19 pandemic highlighted how exclusion of representative populations in research can increase health inequities. We applied findings of this meeting to perform a literature review of barriers and solutions to recruitment and retention of representative populations in research and to discuss how findings are important to research conducted during the ongoing COVID-19 pandemic. We highlight the role of SDOH, review barriers and solutions to underrepresentation, and discuss the importance of a structural competency framework to improve research participation and retention among special populations.

Almost one in five physiotherapy trials excluded people due to lack of language proficiency: A meta-epidemiological study

OBJECTIVES

The objective of the study was to examine the characteristics of randomized controlled trials (RCTs) evaluating physiotherapy interventions for low back pain (LBP) that specified a language-grounded eligibility criterion and the proportion of people being excluded consequently.

STUDY DESIGN AND SETTING

This is a meta-epidemiological study of RCTs evaluating at least one type of physiotherapy intervention for treatment or prevention of LBP. Records were retrieved from Physiotherapy Evidence Database (PEDro), LILACS, and SciELO from inception to May 2021. We retrieved metadata of each record from PEDro and extracted from included studies: country of recruitment, language-grounded eligibility criterion, and the number of consequent exclusions (if specified).

RESULTS

This study included 2,555 trials. A language-grounded eligibility criterion was specified in 463 trials (18.1%); the proportion was higher in trials conducted in North America and Europe, published after 2000, investigating cognitive and behavioral interventions, and including large sample size. Of these 463 trials, 75 trials (16.2%) reported a total number of 2,152 people being excluded due to lack of language proficiency, equivalent to 12.5% of randomized participants.

CONCLUSION

Nearly one in five physiotherapy clinical trials on LBP excludes people based on language proficiency, compromising the evidence to manage LBP in minority populations.

Trial Forge Guidance 3: randomised trials and how to recruit and retain individuals from ethnic minority groups-practical guidance to support better practice

Randomised trials, especially those intended to directly inform clinical practice and policy, should be designed to reflect all those who could benefit from the intervention under test should it prove effective. This does not always happen. The UK National Institute for Health and Care Research (NIHR) INCLUDE project identified many groups in the UK that are under-served by trials, including ethnic minorities.This guidance document presents four key recommendations for designing and running trials that include the ethnic groups needed by the trial. These are (1) ensure eligibility criteria and recruitment pathway do not limit participation in ways you do not intend, (2) ensure your trial materials are developed with inclusion in mind, (3) ensure staff are culturally competent and (4) build trusting partnerships with community organisations that work with ethnic minority groups. Each recommendation comes with best practice advice, public contributor testimonials, examples of the inclusion problem tackled by the recommendation, or strategies to mitigate the problem, as well as a collection of resources to support implementation of the recommendations.We encourage trial teams to follow the recommendations and, where possible, evaluate the strategies they use to implement them. Finally, while our primary audience is those designing, running and reporting trials, we hope funders, grant reviewers and approvals agencies may also find our guidance useful.

Standardization of the assessment process within telerehabilitation in chronic diseases: a scoping meta-review

BACKGROUND

Telerehabilitation (TR) interventions are receiving increasing attention. They have been evaluated in various scientific areas through systematic reviews. However, there is a lack of data on how to standardize assessment and report on their domains to guide researchers across studies and bring together the best evidence to assess TR for chronic diseases.

AIMS AND OBJECTIVES

The aim of this study was to identify domains of assessment in TR and to qualitatively and quantitatively analyze how and when they are examined to gain an overview of assessment in chronic disease.

METHODS

A scoping meta-review was carried out on 9 databases and gray literature from 2009 to 2019. The keyword search strategy was based on "telerehabilitation", "evaluation", "chronic disease" and their synonyms. All articles were subjected to qualitative analysis using the Health Technology Assessment (HTA) Core Model prior to further analysis and narrative synthesis.

RESULTS

Among the 7412 identified articles, 80 studies met the inclusion criteria and addressed at least one of the noncommunicable diseases (NCD) categories of cardiovascular disease (cardiovascular accidents), cancer, chronic respiratory disease, diabetes, and obesity. Regarding the domains of assessment, the most frequently occurring were "social aspect" (n = 63, 79%) (e.g., effects on behavioral changes) and "clinical efficacy" (n = 53, 66%), and the least frequently occurring was "safety aspects" (n = 2, 3%). We also identified the phases of TR in which the assessment was conducted and found that it most commonly occurred in the pilot study and randomized trial phases and least commonly occurred in the design, pretest, and post-implementation phases.

CONCLUSIONS

Through the HTA model, this scoping meta-review highlighted 10 assessment domains which have not been studied with the same degree of interest in the recent literature. We showed that each of these assessment domains could appear at different phases of TR development and proposed a new cross-disciplinary and comprehensive method for assessing TR interventions. Future studies will benefit from approaches that leverage the best evidence regarding the assessment of TR, and it will be interesting to extend this assessment framework to other chronic diseases.

The Use of Diabetes Technology to Address Inequity in Health Outcomes: Limitations and Opportunities

PURPOSE OF REVIEW

The management of diabetes has been revolutionized by the introduction of novel technological treatments and modalities of care, such as continuous glucose monitoring, insulin pump therapy, and telehealth. While these technologies have demonstrated improvement in health outcomes, it remains unclear whether they have reduced inequities from racial/ethnic minority or socioeconomic status. We review the current literature to discuss evidence of benefit, current limitations, and future opportunities of diabetes technologies.

FINDINGS

While there is ample evidence of the health and psychological benefit of diabetes technologies in large populations of people with type 1 and type 2 diabetes, there remain wide disparities in the use of diabetes technologies, which may be perpetuating or widening inequities. Multilevel barriers include inequitable prescribing practices, lack of support for social determinants of health, mismatch of patient preferences and care models, and cost. We provide a review of disparities in diabetes technology use, possible root causes of continued inequity in outcomes, and insight into ways to overcome remaining gaps.

Challenges and strategies for promoting health equity in virtual care: findings and policy directions from a scoping review of reviews

OBJECTIVE

We sought to understand and synthesize review-level evidence on the challenges associated with accessibility of virtual care among underserved population groups and to identify strategies that can improve access to, uptake of, and engagement with virtual care for these populations.

MATERIALS AND METHODS

A scoping review of reviews was conducted (protocol available at doi: 10.2196/22847). A total of 14 028 records were retrieved from MEDLINE, EMBASE, CINAHL, Scopus, and Epistemonikos databases. Data were abstracted, and challenges and strategies were identified and summarized for each underserved population group and across population groups.

RESULTS

A total of 37 reviews were included. Commonly occurring challenges and strategies were grouped into 6 key thematic areas based on similarities across communities: (1) the person's orientation toward health-related needs, (2) the person's orientation toward health-related technology, (3) the person's digital literacy, (4) technology design, (5) health system structure and organization, and (6) social and structural determinants of access to technology-enabled care. We suggest 4 important directions for policy development: (1) investment in digital health literacy education and training, (2) inclusive digital health technology design, (3) incentivizing inclusive digital health care, and (4) investment in affordable and accessible infrastructure.

DISCUSSION AND CONCLUSION

Challenges associated with accessibility of virtual care among underserved population groups can occur at the individual, technological, health system, and social/structural determinant levels. Although the policy approaches suggested by our review are likely to be difficult to achieve in a given policy context, they are essential to a more equitable future for virtual care.

Can You See My Screen? Virtual Assessment in Speech and Language

PURPOSE

This introduction presents the LSHSS Forum: Can You See My Screen? Virtual Assessment in Speech and Language. The goals of the forum are to document reliability and validity of assessment results conducted virtually, identify characteristics of measures that are suitable for online assessment, and provide clinical and research guidance for interpreting diagnostic results obtained in virtual settings.

METHOD

In this introduction, we provide an overview of the research completed by nine teams, who submitted research articles and notes on a variety of topics pertinent to the theme of telehealth assessments. Of these, seven teams investigated the validity and reliability of 14 different assessment tools, while two teams described training and experience issues.

CONCLUSION

The nine studies presented in this forum will provide speech-language pathologists with insight into a range of issues regarding telehealth assessment, including the breadth of suitable assessment tools; practical strategies for assessing children with a diverse range of ages, languages, skills, and abilities; and the unexpected challenges and opportunities of conducting clinical work and research during a global pandemic.

Effectiveness of Mobile Phone and Web-Based Interventions for Diabetes and Obesity Among African American and Hispanic Adults in the United States: Systematic Review

Background

Mobile health (mHealth) and web-based technological advances allow for new approaches to deliver behavioral interventions for chronic diseases such as obesity and diabetes. African American and Hispanic adults experience a disproportionate burden of major chronic diseases.

Objective

This paper reviews the evidence for mHealth and web-based interventions for diabetes and obesity in African American and Hispanic adults.

Methods

Literature searches of PubMed/Medline, The Cochrane Library, EMBASE, CINAHL Plus, Global Health, Scopus, and Library & Information Science Source were conducted for relevant English-language articles. Articles identified through searches were reviewed by 2 investigators and, if they met the inclusion criteria, were extracted and assessed for risk of bias. Findings were summarized in tabular and narrative format. The overall strength of the evidence was assessed as high, moderate, low, or insufficient on the basis of risk of bias, consistency of findings, directness, precision, and other limitations.

Results

Searches yielded 2358 electronic publications, 196 reports were found to be eligible for inclusion, and 7 studies met the eligibility criteria. All 7 included studies were randomized control trials. Five studies evaluated the effectiveness of an mHealth intervention for weight loss, including one that evaluated the effectiveness for diabetes and two studies focused on diabetes. Of all the studies that focused on weight loss, 3 reported significant differences in weight loss in participants in the intervention group compared with those in the usual care group. Although all studies on diabetes control showed greater improvement in glycemic control for the intervention group compared to that in the control group, only one study showed a significant difference between the 2 groups.

Conclusions

This analysis indicates that there are few published studies that assessed mHealth interventions among minority populations and focused on weight or diabetes. Although the overall strength of evidence was low for diabetes control, it was moderate for weight loss, and our findings suggest that mHealth and web-based interventions may provide a promising approach for interventions among African American and Hispanic adults who have obesity or diabetes.

Telehealth Interventions to Improve Diabetes Management Among Black and Hispanic Patients: a Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews have found that telehealth is an effective strategy for implementing interventions to improve glycemic control and other clinical outcomes for diabetes patients. However, these reviews have not meaningfully focused on Black and Hispanic patients-partly because of the lack of adequate representation of people from racial and ethnic minority groups in clinical trials. It is unclear whether telehealth interventions are effective at improving glycemic control among Black and Hispanic patients given the disproportionate number of barriers they face accessing health care.

OBJECTIVES

A systematic review and meta-analysis of randomized control trials that used telehealth interventions for improving glycemic control among Black and Hispanic diabetes patients.

METHODS

We reviewed PubMed, Embase, Web of Science, CINAHL, PsycINFO, and clinicalTrials.gov from inception to March 2021. We used a narrative summary approach to describe key study characteristics and graded the quality of studies using two reviewers. The pooled net change in HbA1c values was estimated across studies using a random-effects model.

RESULTS

We identified 10 studies that met our inclusion and exclusion criteria. Nine studies were included in the meta-analysis. Only one study was rated as having low bias. Telehealth interventions were primarily delivered by telephone calls, text messages, web-based portals, and virtual visits. Most interventions involved delivering diabetes self-management education. Telehealth intervention pooled across studies with a mix of Black and Hispanic participants (> 50% sample) was associated with a - 0.465 ([CI: - 0.648 to - 0.282], p = 0.000) reduction in HbA1c.

CONCLUSIONS

Our findings suggest telehealth interventions are effective at improving glycemic control among Black and Hispanic diabetes patients.

Telemedicine for Disparity Patients With Diabetes: The Feasibility of Utilizing Telehealth in the Management of Uncontrolled Type 2 Diabetes in Black and Hispanic Disparity Patients; A Pilot Study

BACKGROUND

Non-Hispanic Black (NHB) and Hispanic/Latinx (H/L) patients bear a disproportionate burden of type 2 diabetes and associated complications. Regular visits to a primary care doctor or diabetes specialist are warranted to maintain glycemic control, but for a myriad of reasons disparity populations may have difficulties receiving diabetes care. We seek to determine the feasibility of telehealth added to care as usual and secondarily to improve health outcomes (hemoglobin A1c [HbA1c]) in NHB and H/L with uncontrolled type 2 diabetes managed with two or three noninsulin agents.

METHODS

Twenty-nine patients were randomized to monthly phone calls or weekly to biweekly telehealth visits. Feasibility outcomes were summarized descriptively for the telehealth arm. Differences scores for A1C level and surveys were computed between baseline and three months and compared across arms using a two-sample t test or Mann-Whitney U test.

RESULTS

Patients in the telehealth arm completed a median of eight visits (IQR: 5, 8), and 53% of those in the telephone arm completed 100% of their calls. Change in HbA1c was greater for those in the telephone arm (-2.57 vs -2.07%, P = .70) but the mean baseline HbA1c was higher in the telephone group (11.1% vs 10.3%). Although the change in HbA1c was not statistically different across arms, it was clinically significant.

CONCLUSIONS

Augmenting care as usual with telehealth provided by telephone or tablet can be of benefit in improving glycemic control in NHB and H/L with type 2 diabetes. Larger studies need to explore this further.

Transporting Subgroup Analyses of Randomized Controlled Trials for Planning Implementation of New Interventions

Subgroup analyses of randomized controlled trials guide resource allocation and implementation of new interventions by identifying groups of individuals who are likely to benefit most from the intervention. Unfortunately, trial populations are rarely representative of the target populations of public health or clinical interest. Unless the relevant differences between trial and target populations are accounted for, subgroup results from trials might not reflect which groups in the target population will benefit most from the intervention. Transportability provides a rigorous framework for applying results derived in potentially highly selected study populations to external target populations. The method requires that researchers measure and adjust for all variables that 1) modify the effect of interest and 2) differ between the target and trial populations. To date, applications of transportability have focused on the external validity of overall study results and understanding within-trial heterogeneity; however, this approach has not yet been used for subgroup analyses of trials. Through an example from the Iniciativa Profilaxis Pre-Exposición (iPrEx) study (multiple countries, 2007-2010) of preexposure prophylaxis for human immunodeficiency virus, we illustrate how transporting subgroup analyses can produce target-specific subgroup effect estimates and numbers needed to treat. This approach could lead to more tailored and accurate guidance for resource allocation and cost-effectiveness analyses.

Developing the INCLUDE Ethnicity Framework-a tool to help trialists design trials that better reflect the communities they serve

Background

Ensuring that a trial is designed so that its participants reflect those who might benefit from the results, or be spared harms, is key to the potential benefits of the trial reaching all they should. This paper describes the process, facilitated by Trial Forge, that was used between July 2019 and October 2020 to develop the INCLUDE Ethnicity Framework, part of the wider INCLUDE initiative from the National Institute for Health Research to improve inclusion of under-served groups in clinical research studies.

Methods

Development of the Framework was done in seven phases: (1) outline, (2) initial draft, (3) stakeholder meeting, (4) modify draft, (5) Stakeholder feedback, (6) applying the Framework and (7) packaging. Phases 2 and 3 were face-to-face meetings. Consultation with stakeholders was iterative, especially phases 4 to 6. Movement to the next phase was done once all or most stakeholders were comfortable with the results of the current phase. When there was a version of the Framework that could be considered final, the Framework was applied to six trials to create a set of examples (phase 6). Finally, the Framework, guidance and examples were packaged ready for dissemination (phase 7).

Results

A total of 40 people from stakeholder groups including patient and public partners, clinicians, funders, academics working with various ethnic groups, trial managers and methodologists contributed to the seven phases of development. The Framework comprises two parts. The first part is a list of four key questions:

Who should my trial apply to?

Are the groups identified likely to respond in different ways?

Will my study intervention make it harder for some groups to engage?

Will the way I have designed the study make it harder for some groups to engage?

The second part is a set of worksheets to help trial teams address these questions. The Framework can be used for any stage of trial, for a healthcare intervention in any disease area. The Framework was launched on 1st October 2020 and is available open access at the Trial Forge website: https://www.trialforge.org/trial-forge-centre/include/.

Conclusion

Thinking about the number of people in our trials is not enough: we need to start thinking more carefully about who our participants are.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05276-8.

Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: an acceptability and feasibility study

BACKGROUND

Home telemonitoring is a promising approach to optimizing outcomes for patients with Type 2 Diabetes; however, this care strategy has not been adapted for use with understudied and underserved Hispanic/Latinos (H/L) patients with Type 2 Diabetes.

METHODS

A formative, Community-Based Participatory Research approach was used to adapt a home telemonitoring intervention to facilitate acceptability and feasibility for vulnerable H/L patients. Utilizing the ADAPT-ITT framework, key stakeholders were engaged over an 8-month iterative process using a combination of strategies, including focus groups and structured interviews. Nine Community Advisory Board, Patient Advisory, and Provider Panel Committee focus group discussions were conducted, in English and Spanish, to garner stakeholder input before intervention implementation. Focus groups and structured interviews were also conducted with 12 patients enrolled in a 1-month pilot study, to obtain feedback from patients in the home to further adapt the intervention. Focus groups and structured interviews were approximately 2 hours and 30 min, respectively. All focus groups and structured interviews were audio-recorded and professionally transcribed. Structural coding was used to mark responses to topical questions in the moderator and interview guides.

RESULTS

Two major themes emerged from qualitative analyses of Community Advisory Board/subcommittee focus group data. The first major theme involved intervention components to maximize acceptance/usability. Subthemes included tablet screens (e.g., privacy/identity concerns; enlarging font sizes; lighter tablet to facilitate portability); cultural incongruence (e.g., language translation/literacy, foods, actors "who look like me"); nursing staff (e.g., ensuring accessibility; appointment flexibility); and, educational videos (e.g., the importance of information repetition). A second major theme involved suggested changes to the randomized control trial study structure to maximize participation, including a major restructuring of the consenting process and changes designed to optimize recruitment strategies. Themes from pilot participant focus group/structured interviews were similar to those of the Community Advisory Board such as the need to address and simplify a burdensome consenting process, the importance of assuring privacy, and an accessible, culturally congruent nurse.

CONCLUSIONS

These findings identify important adaptation recommendations from the stakeholder and potential user perspective that should be considered when implementing home telemonitoring for underserved patients with Type 2 Diabetes.

TRIAL REGISTRATION

NCT03960424; ClinicalTrials.gov (US National Institutes of Health). Registered 23 May 2019. Registered prior to data collection. https://www.clinicaltrials.gov/ct2/show/NCT03960424?term=NCT03960424&draw=2&rank=1.

Development and Efficacy of an Electronic, Culturally Adapted Lifestyle Counseling Tool for Improving Diabetes-Related Dietary Knowledge: Randomized Controlled Trial Among Ethnic Minority Adults With Type 2 Diabetes Mellitus

Background

Ethnic minority populations exhibit disproportionately high rates of type 2 diabetes mellitus (T2DM). Electronic health tools have the potential to facilitate the cultural adaptation and tailoring of T2DM education to improve the knowledge and management of diabetes mellitus (DM).

Objective

This study aimed (1) to develop an adaptable Interactive Lifestyle Assessment, Counseling, and Education (I-ACE) software to support dietitian-delivered lifestyle counseling among low-socioeconomic status (SES) ethnic minority patients with T2DM and (2) to evaluate its effect on DM-related dietary knowledge and management compared with standard lifestyle advice (SLA) in a randomized controlled trial (RCT).

Methods

The I-ACE software, developed in consultation with clinical dieticians, incorporates evidence-based dietary and physical activity (PA) recommendations and educational materials. The features and behavioral change techniques include quantitative lifestyle (dietary intake and PA) assessment and simulation, individually tailored education and recommendations, motivational interviewing, and goal setting. For the unblinded pilot RCT, 50 overweight or obese Arab adults (aged 40-62 years) with poorly controlled T2DM were recruited from primary care clinics and randomly assigned to receive 4 in-person, dietician-delivered counseling sessions over 6 months using either (1) the I-ACE tool (experimental arm) or (2) the SLA methods (comparison arm). All outcome assessments were face-to-face. DM-related dietary knowledge (primary outcome) was measured at baseline, 3, 6, and 12 months. Lifestyle and other parameters were measured before, during, and after the intervention. Multiple linear regression and repeated measures linear mixed models were used to compare the changes in study outcomes and explore time trends in between-group and within-group changes.

Results

A total of 25 participants were enrolled in each arm, of whom 24 and 21 completed the final assessment of the primary outcome in the I-ACE and SLA arms, respectively. DM-related lifestyle knowledge increased more rapidly in the I-ACE arm than in the SLA arm (P value for study arm×time interaction=.02). Within the I-ACE arm, the mean (SE) differences in added sugar and dietary fiber intakes from baseline to 12 months were −2.6% (SE 1.0%) of total energy (P=.03) and 2.7 (SE 0.0) g/1000 kcal (P=.003), respectively. The odds of engaging in any leisure PA at 12 months tended to be higher in the I-ACE arm versus SLA arm, but did not reach statistical significance (odds ratio 2.8; 95% CI 0.7-11.6; P=.16). Both arms exhibited significant reductions in HbA_1c (P value for change over time <.001).

Conclusions

The use of the I-ACE software in a 6-month, 4-session dietician-delivered lifestyle counseling intervention improved the efficiency of lifestyle education, compared with SLA, among low-SES, ethnic minority patients with T2DM. This pilot trial provides justification for conducting a large-scale trial to evaluate its effectiveness and applicability in routine clinical care among ethnically diverse populations.

Trial Registration

ClinicalTrials.gov NCT01858506; https://clinicaltrials.gov/ct2/show/NCT01858506.

Associations Between Immigration-Related User Factors and eHealth Activities for Self-Care: Case of First-Generation Immigrants From Pakistan in the Oslo Area, Norway

BACKGROUND

Immigrant populations are often disproportionally affected by chronic diseases, such as type 2 diabetes mellitus (T2DM). Use of information and communication technology (ICT) is one promising approach for better self-care of T2DM to mitigate the social health inequalities, if designed for a wider population. However, knowledge is scarce about immigrant populations' diverse electronic health (eHealth) activities for self-care, especially in European countries.

OBJECTIVE

With a target group of first-generation immigrants from Pakistan in the Oslo area, Norway, we aimed to understand their diverse eHealth activities for T2DM self-care in relation to immigration-related user factors specific to this target group: proficiency in relevant languages (Urdu, Norwegian, English), length of residence in Norway, and diagnosis of T2DM compared with general user factors (age, gender, education and digital skills, and self-rated health status).

METHODS

Data were from a survey among the target population (N=176) conducted in 2015-2016. Using logistic regression, we analyzed associations between user factors and experiences of each of the following eHealth activities for T2DM self-care in the last 12 months: first, information seeking by (1) search engines and (2) Web portals or email subscriptions; second, communication and consultation (1) by closed conversation with a few acquaintances using ICT and (2) on social network services; and third, active decision making by using apps for (1) tracking health information and (2) self-assessment of health status. Using Poisson regression, we also assessed the relationship between user factors and variety of eHealth activities experienced. The Bonferroni correction was used to address the multiple testing problem.

RESULTS

Regression analyses yielded the following significantly positive associations: between Urdu literacy and (1) information seeking by Web portals or email subscriptions (odds ratio [OR] 2.155, 95% CI 1.388-3.344), (2) communication and consultation on social network services (OR 5.697, 95% CI 2.487-13.053), and (3) variety (estimate=0.350, 95% CI 0.148-0.552); between length of residence in Norway and (1) communication and consultation by closed conversation with a few acquaintances using ICT (OR 1.728, 95% CI 1.193-2.503), (2) communication and consultation on social network services (OR 2.098, 95% CI 1.265-3.480), and (3) variety (estimate=0.270, 95% CI 0.117-0.424); between Norwegian language proficiency and active decision making by using apps for self-assessment of health status (OR 2.285, 95% CI 1.294-4.036); between education and digital skills and active decision making by using apps for tracking health information (OR 3.930, 95% CI 1.627-9.492); and between being a female and communication and consultation by closed conversation with a few acquaintances using ICT (OR 2.883, 95% CI 1.335-6.227).

CONCLUSIONS

This study implies immigration-related factors may confound associations between general user factors and eHealth activities. Further studies are needed to explore the influence of immigration-related user factors for eHealth activities in other immigrant groups and countries.

INTERNATIONAL REGISTERED REPORT

RR2-DOI 10.2196/resprot.5468.