Designing, Implementing, and Evaluating Mobile Health Technologies for Managing Chronic Conditions in Older Adults: A Scoping Review

Technology Use for Home-Based Stroke Rehabilitation in Switzerland From the Perspectives of Persons Living With Stroke, Informal Caregivers, and Therapists: Qualitative Interview and Focus Group Study

BACKGROUND

Stroke is a leading cause for long-term disability, requiring both inpatient and outpatient rehabilitation and self-training in the home environment. Technology-based tools are gradually gaining acceptance as additional and suitable options for extending the rehabilitation process. While the experiences of persons living with stroke, therapists, and informal caregivers with respect to technology use have already been investigated in other countries, this topic is underexplored in the Swiss context.

OBJECTIVE

We aimed to explore the experiences and needs of persons living with stroke, informal caregivers, and therapists in using technology-based tools in a home environment for stroke rehabilitation in Switzerland.

METHODS

This study followed a qualitative descriptive methodology, including semistructured interviews and focus group discussions. We applied a deductive template analysis alongside the accessibility, adaptability, accountability, and engagement framework to analyze the qualitative data sets for technology-assisted solutions for poststroke rehabilitation.

RESULTS

We collected the experiences and needs of persons living with stroke (7/23, 30%), informal caregivers (4/23, 17%), and therapists (occupational and physical therapists; 12/23, 52%). The 4 categories we used to organize the analysis and results were accessibility to quality rehabilitation, adaptability to patient differences, accountability or compliance with rehabilitation, and engagement with rehabilitation. Persons living with stroke stated that they use various tools within their rehabilitation process depending on their specific needs. They felt that there is a plethora of tools available but sometimes felt overwhelmed with the selection process. Informal caregivers indicated that they generally felt underserved and insufficiently informed throughout the rehabilitation process. They reported that they use technology-based tools to support their relatives affected by stroke in becoming more independent. Therapists appreciate the numerous possible applications of technology-based tools in rehabilitation. At the same time, however, they express dissatisfaction with the lack of clarity in Switzerland regarding cost coverage, recommendations, and training opportunities.

CONCLUSIONS

Persons living with stroke, informal caregivers, and therapists in Switzerland reported varied and unique experiences and needs with the use of technology-based tools in outpatient stroke rehabilitation. Written recommendations, the assumption of financial costs, and the provision of information and education could foster increased confidence in the use of technology-based tools for patients and therapists.

mHealth Apps for Dementia, Alzheimer Disease, and Other Neurocognitive Disorders: Systematic Search and Environmental Scan

BACKGROUND

Lifestyle behaviors including exercise, sleep, diet, stress, mental stimulation, and social interaction significantly impact the likelihood of developing dementia. Mobile health (mHealth) apps have been valuable tools in addressing these lifestyle behaviors for general health and well-being, and there is growing recognition of their potential use for brain health and dementia prevention. Effective apps must be evidence-based and safeguard user data, addressing gaps in the current state of dementia-related mHealth apps.

OBJECTIVE

This study aims to describe the scope of available apps for dementia prevention and risk factors, highlighting gaps and suggesting a path forward for future development.

METHODS

A systematic search of mobile app stores, peer-reviewed literature, dementia and Alzheimer association websites, and browser searches was conducted from October 19, 2022, to November 2, 2022. A total of 1044 mHealth apps were retrieved. After screening, 152 apps met the inclusion criteria and were coded by paired, independent reviewers using an extraction framework. The framework was adapted from the Silberg scale, other scoping reviews of mHealth apps for similar populations, and background research on modifiable dementia risk factors. Coded elements included evidence-based and expert credibility, app features, lifestyle elements of focus, and privacy and security.

RESULTS

Of the 152 apps that met the final selection criteria, 88 (57.9%) addressed modifiable lifestyle behaviors associated with reducing dementia risk. However, many of these apps (59/152, 38.8%) only addressed one lifestyle behavior, with mental stimulation being the most frequently addressed. More than half (84/152, 55.2%) scored 2 points out of 9 on the Silberg scale, with a mean score of 2.4 (SD 1.0) points. Most of the 152 apps did not disclose essential information: 120 (78.9%) did not disclose expert consultation, 125 (82.2%) did not disclose evidence-based information, 146 (96.1%) did not disclose author credentials, and 134 (88.2%) did not disclose their information sources. In addition, 105 (69.2%) apps did not disclose adherence to data privacy and security practices.

CONCLUSIONS

There is an opportunity for mHealth apps to support individuals in engaging in behaviors linked to reducing dementia risk. While there is a market for these products, there is a lack of dementia-related apps focused on multiple lifestyle behaviors. Gaps in the rigor of app development regarding evidence base, credibility, and adherence to data privacy and security standards must be addressed. Following established and validated guidelines will be necessary for dementia-related apps to be effective and advance successfully.

Application of the participatory design in the testing of a baropodometric insole prototype for weight-bearing asymmetry after a stroke: A qualitative study

Introduction

Currently studies indicate the need to incorporate the user`s perspective in the testing of new assistive technologies. The objective of this paper is to test a baropodometric insole prototype for monitoring and treatment weight-bearing asymmetry, according to the Participatory Design.

Methods

We used a qualitative case study approach during the testing phase of the baropodometric insole prototype. The focus group approach addressed topics related to the experience and accessibility of the potential user in conjunction with professionals, researchers, and physiotherapy students. Facilitators, barriers, and requirements for the device were collected through audio recordings of the discussions during and after prototype testing.

Results

Key steps in the prototype testing process were divided into (1) Test of the prototype according to the Participatory Design, divided into Who, When, How, and Why the potential user was involved in the study; and (2) Facilitators, barriers and requirements to improve the prototype.

Conclusions

The baropodometric insole prototype can be seen as a promising device for monitoring and treating weight-bearing asymmetry.

Smartphone App Designed to Collect Health Information in Older Adults: Usability Study

BACKGROUND

Studies evaluating the usability of mobile-phone assessments in older adults are limited.

OBJECTIVE

This study aims to identify design-based barriers and facilitators to mobile app survey completion among 2 samples of older adults; those in the Framingham Heart Study and a more diverse sample from a hospital-based setting.

METHODS

We used mixed methods to identify challenging and beneficial features of the mobile app in participants from the electronic Framingham Heart Study (n=15; mean age of 72 years; 6/15, 40% women; 15/15, 100% non-Hispanic and White) and among participants recruited from a hospital-based setting (n=15; mean age of 71 years; 7/15, 47% women; 3/15, 20% Hispanic; and 8/15, 53% non-White). A variety of app-based measures with different response formats were tested, including self-reported surveys, pictorial assessments (to indicate body pain sites), and cognitive testing tasks (eg, Trail Making Test and Stroop). Participants completed each measure using a think-aloud protocol, while being audio- and video-recorded with a qualitative interview conducted at the end of the session. Recordings were coded for participant usability errors by 2 pairs of coders. Participants completed the Mobile App Rating Scale to assess the app (response range 1=inadequate to 5=excellent).

RESULTS

In electronic Framingham Heart Study participants, the average total Mobile App Rating Scale score was 7.6 (SD 1.1), with no significant differences in the hospital-based sample. In general, participants were pleased with the app and found it easy to use. A large minority had at least 1 navigational issue, most committed only once. Most older adults did not have difficulty completing the self-reported multiple-choice measures unless it included lengthy instructions but participants had usability issues with the Stroop and Trail Making Test.

CONCLUSIONS

Our methods and results help guide app development and app-based survey construction for older adults, while also giving consideration to sociodemographic differences.

Implementation of digital health technologies for older adults: a scoping review

The critical importance of technological innovation in home care for older adults is indisputable. Less well understood is the question of how to measure its performance and impact on the delivery of healthcare to older adults who are living with chronic illness and disability. Knowing how well digital technologies, such as smartphones, tablets, wearable devices, and Ambient Assisted Living Technologies (AAL) systems "work" should certainly include assessing their impact on older adults' health and ability to function in daily living but that will not guarantee that it will necessarily be adopted by the user or implemented by a healthcare facility or the healthcare system. Technology implementation is a process of planned and guided activities to launch, introduce and support technologies in a certain context to innovate or improve healthcare, which delivers the evidence for adoption and upscaling a technology in healthcare practices. Factors in addition to user acceptance and clinical effectiveness require investigation. Failure to appreciate these factors can result in increased likelihood of technology rejection or protracted procurement decision at the "adoption decision" stage or delayed or incomplete implementation or discontinuance (following initial adoption) during implementation. The aim of our research to analyze research studies on the effectiveness of digital health technologies for older adults to answer the question, "How well do these studies address factors that affect the implementation of technology?" We found common problems with the conceptualization, design, and methodology in studies of digital technology that have contributed to the slow pace of implementation in home care and long-term care. We recommend a framework for improving the quality of research in this critical area. Systematic Review Registration: https://archive.org/details/osf-registrations-f56rb-v1, identifier osf-registrations-f56rb-v1.

A Serious Game (MyDiabetic) to Support Children's Education in Type 1 Diabetes Mellitus: Iterative Participatory Co-Design and Feasibility Study

BACKGROUND

Serious games, which are gaming applications used for purposes beyond entertainment to educate users on, and address, specific issues, may present a timely approach to promote healthy diabetes management behaviors among children with type 1 diabetes mellitus (T1DM). The lasting benefits associated with these serious games encompass improved patient education; enhanced glycemic control; the reinforcement of bonds within the community of people with diabetes; the facilitation of meaningful dialogues with caregivers, especially within the familial setting; and a significant reduction in the economic burdens associated with subsequent complications.

OBJECTIVE

This paper primarily aims to provide a detailed overview of the iterative design process and the associated evaluation methods used in the development of the educational game. Furthermore, this study aims to enhance motivation for sustained and extended engagement with the game over time. The MyDiabetic game design aims to educate children on various aspects, including the connections among food, insulin, and physical activity. Furthermore, it seeks to impart knowledge related to the operation of a glucometer and an insulin pen, as well as more advanced technologies such as administering glucagon, measuring ketoacidosis, and continuous glucose monitoring.

METHODS

The co-design methodology was applied, involving interviews, design workshops, and prototype feedback sessions. A combination of several approaches, such as tailoring, observational learning, social and family support, decision-making practice, and reward systems, was used to support children's compliance. Moreover, incorporating the literature, guidelines, and current practices into the design ensured that the game was aligned with established health care pathways and included relevant information and best practices for diabetes management.

RESULTS

The game was tested on 32 children in 3 iterations. Positive responses were received from children who tested the game as well as their parents. The game was also presented to 5 schoolmates of children with T1DM who appreciated a better understanding of the disease and the opportunity to support their friends more efficiently in T1DM compensation. The involvement of children and clinicians in participatory co-design contributed to to the game's high acceptance. With regard to the game's impact on education, 1 week of testing revealed an enhancement in educational outcomes.

CONCLUSIONS

The game is especially suitable for children newly diagnosed with T1DM because it acquaints them in a fun way with new terminology; for example, they can try to measure glycemia levels in an interactive way. The game also caters to children who still need to develop reading skills by including an audio guide. The guide ensures that children of all literacy levels can benefit from the game's educational content and interactive experiences. The game is available for download on Google Play and the Apple App Store.

A fusion architecture to deliver multipurpose mobile health services

Mobile Health (mHealth) services typically make use of customized software architectures, leading to development-dependent fragmentation. Nevertheless, irrespective of their specific purpose, most mHealth services share common functionalities, where standard pieces could be reused or adapted to expedite service deployment and even extend the follow-up of appearing conditions under the same service. To harness compatibility and reuse, this article presents a data fusion architecture proposing a common design framework for mHealth services. An exhaustive mapping of mHealth functionalities identified in the literature serves as starting point. The architecture is then conceptualized making use of the Joint Directors of Laboratories (JDL) data fusion model. The aim of the architecture is to exploit the multi-source data acquisition capabilities supported by smartphones and Internet of Things devices, and artificial intelligence-enabled feature fusion. A series of interconnected fusion layers ensure streamlined data management; each layer is composed of microservices which may be implemented or omitted depending on the specific goals of the healthcare service. Moreover, the architecture considers essential features related to authentication mechanisms, data sharing protocols, practitioner-patient communication, context-based notifications and tailored visualization interfaces. The effectiveness of the architecture is underscored by its instantiation for four real cases, encompassing risk assessment for youth with mental health issues, remote monitoring for SARS-CoV-2 patients, liquid intake control for kidney disease patients, and peritoneal dialysis treatment support. This breadth of applications exemplifies how the architecture can effectively serve as a guidance framework to accelerate the design of mHealth services.

Participatory development of an mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED)

BACKGROUND

The escalating global prevalence of type 2 diabetes and prediabetes presents a major public health challenge. Physical activity plays a critical role in managing (pre)diabetes; however, adherence to physical activity recommendations remains low. The ENERGISED trial was designed to address these challenges by integrating mHealth tools into the routine practice of general practitioners, aiming for a significant, scalable impact in (pre)diabetes patient care through increased physical activity and reduced sedentary behaviour.

METHODS

The mHealth intervention for the ENERGISED trial was developed according to the mHealth development and evaluation framework, which includes the active participation of (pre)diabetes patients. This iterative process encompasses four sequential phases: (a) conceptualisation to identify key aspects of the intervention; (b) formative research including two focus groups with (pre)diabetes patients (n = 14) to tailor the intervention to the needs and preferences of the target population; (c) pre-testing using think-aloud patient interviews (n = 7) to optimise the intervention components; and (d) piloting (n = 10) to refine the intervention to its final form.

RESULTS

The final intervention comprises six types of text messages, each embodying different behaviour change techniques. Some of the messages, such as those providing interim reviews of the patients' weekly step goal or feedback on their weekly performance, are delivered at fixed times of the week. Others are triggered just in time by specific physical behaviour events as detected by the Fitbit activity tracker: for example, prompts to increase walking pace are triggered after 5 min of continuous walking; and prompts to interrupt sitting following 30 min of uninterrupted sitting. For patients without a smartphone or reliable internet connection, the intervention is adapted to ensure inclusivity. Patients receive on average three to six messages per week for 12 months. During the first six months, the text messaging is supplemented with monthly phone counselling to enable personalisation of the intervention, assistance with technical issues, and enhancement of adherence.

CONCLUSIONS

The participatory development of the ENERGISED mHealth intervention, incorporating just-in-time prompts, has the potential to significantly enhance the capacity of general practitioners for personalised behavioural counselling on physical activity in (pre)diabetes patients, with implications for broader applications in primary care.

Cognitive telerehabilitation: an expert consensus paper on current evidence and future perspective

The progressive improvement of the living conditions and medical care of the population in industrialized countries has led to improvement in healthcare interventions, including rehabilitation. From this perspective, Telerehabilitation (TR) plays an important role. TR consists of the application of telemedicine to rehabilitation to offer remote rehabilitation services to the population unable to reach healthcare. TR integrates therapy-recovery-assistance, with continuity of treatments, aimed at neurological and psychological recovery, involving the patient in a family environment, with an active role also of the caregivers. This leads to reduced healthcare costs and improves the continuity of specialist care, as well as showing efficacy for the treatment of cognitive disorders, and leading to advantages for patients and their families, such as avoiding travel, reducing associated costs, improving the frequency, continuity, and comfort of performing the rehabilitation in its own spaces, times and arrangements. The aim of this consensus paper is to investigate the current evidence on the use and effectiveness of TR in the cognitive field, trying to also suggest some recommendations and future perspectives. To the best of our knowledge, this is the first consensus paper among multiple expert researchers that comprehensively examines TR in different neurological diseases. Our results supported the efficacy and feasibility of TR with good adherence and no adverse events among patients. Our consensus summarizes the current evidence for the application of cognitive TR in neurological populations, highlighting the potential of this tool, but also the limitations that need to be explored further.

Older adults' perceptions of online physical exercise management

The study addresses the challenges of digitally transforming physical exercises for older adults (aged more than 55 years) to be performed in virtual environments (during the COVID-19 pandemic) as a long-term proactive strategic initiative in response to the global ageing society and technological development trend. A focus group with a sample of 24 older adults and three trainers were used as part of a 3-month physical exercise pilot conducted by the Jožef Stefan Institute to identify the skills and well-being gained and identify factors that influence success with online exercises for older adults on the individual and organisational levels. First, on the individual level, communication differences were identified when comparing face-to-face exercises with online exercises. Second, on the organisational level, the study identified several challenges arising from the digital transformation of exercises (i.e., onboarding, technical, structural, isolation and motivational). Finally, recommendations are proposed to transform older adults' exercises when performed in a virtual environment. The study results can also benefit health management practices and theory in the work environment to ensure that older workers can still utilise their strengths to perform successfully while remaining healthy. Online physical exercises tailored to older adults' needs and specifications could be provided as part of corporate wellness programmes in organisations.

Toward Sustaining Web-Based Senior Center Programming Accessibility With and for Older Adult Immigrants: Community-Based Participatory Research Cross-Sectional Study

BACKGROUND

During the COVID-19 pandemic, many community-based organizations serving Asian Americans pivoted to provide web-based care and social services. Asian American community leaders in the United States Pacific Northwest, including Asian Health & Service Center expressed that there are older immigrant adults who experienced backlash from discrimination, fear, and anxiety owing in part to anti-Asian hate and isolation, including from infection precautions. Pivoting supported staying safe from COVID-19 transmission and anti-Asian hate crimes.

OBJECTIVE

This study aims to examine the readiness of diverse groups of older Asian American immigrant adults (Chinese, Koreans, and Vietnamese) to use a web-based senior center, including technology access and telehealth use, and to identify the psychosocial health impacts that a web-based senior center could be positioned to meet.

METHODS

A community-based participatory research approach was used to conduct a cross-sectional survey study in an Asian-based health and service center in 2022. We selected surveys from the National Institutes of Health-supported PhenX Toolkit. Analyses were performed using R software.

RESULTS

There was an 88.2% (216/245) response rate. Overall, 39.8% (86/216) of participants were Chinese, 25% (54/216) were Korean, and 24.5% (53/216) were Vietnamese. There were significant group differences in mobile data plans (P=.0005). Most had an unlimited mobile data plan (38/86, 44% Chinese; 39/54, 72% Koreans; 25/53, 47% Vietnamese). Significant group differences existed regarding whether they started using a new electronic device to communicate with friends or family after the COVID-19 outbreak (P=.0005); most were Korean participants (31/54, 57%). For written text and audio or video apps, most Chinese participants used WeChat (65/85, 76%; 57/84, 68%, respectively), most Koreans used KakaoTalk (49/54, 91%; 49/54, 91%, respectively), and most Vietnamese used Facebook Messenger for written text (32/50, 64%) and Apple Face Time (33/50, 66%) or Facebook Messenger (31/50, 62%) for audio or video. Significant group differences existed regarding whether to try telehealth (P=.0005); most Vietnamese expressed that they would never consider it (41/53, 77%). Significant group differences existed regarding how well they were able to concentrate (χ22=44.7; P<.0001); Chinese participants reported a greater inability (median 5, IQR 4-6). With regard to difficulties in life experiences (χ22=51; P<.0001), the median was 6 (IQR 5-7) for the Vietnamese group. Significant group differences existed in having had a family/household member's salary, hours, and contracts reduced (P=.0005) and having had a family/household member or friend fallen physically ill (P=.0005)-most Vietnamese (15/53, 28%) and Korean participants (10/53, 19%).

CONCLUSIONS

To build an efficacious, web-based senior center with web-based care and social service options, more older adults need access to the internet and education about using technology-enabled communication devices. Addressing the unique psychosocial impacts of the COVID-19 pandemic on each group could improve health equity. The strength of the participating older adults was observed and honored.

Evidence of How Physicians and Their Patients Adopt mHealth Apps in Germany: Exploratory Qualitative Study

BACKGROUND

The enactment of the "Act to Improve Healthcare Provision through Digitalisation and Innovation " (Digital Healthcare Act; Digitale-Versorgung-Gesetz [DVG]) in Germany has introduced a paradigm shift in medical practice, allowing physicians to prescribe mobile health (mHealth) apps alongside traditional medications. This transformation imposes a dual responsibility on physicians to acquaint themselves with qualifying apps and align them with patient diagnoses, while requiring patients to adhere to the prescribed app use, similar to pharmaceutical adherence. This transition, particularly challenging for older generations who are less skilled with technology, underscores a significant evolution in Germany's medical landscape.

OBJECTIVE

This study aims to investigate physicians' responses to this novel treatment option, their strategies for adapting to this form of prescription, and the willingness of patients to adhere to prescribed mHealth apps.

METHODS

Using an exploratory qualitative study design, we conducted semistructured interviews with 28 physicians and 30 potential patients aged 50 years and older from August 2020 to June 2021.

RESULTS

The findings reveal several factors influencing the adoption of mHealth apps, prompting a nuanced understanding of adoption research. Notably, both physicians and patients demonstrated a lack of information regarding mHealth apps and their positive health impacts, contributing to a deficiency in trust. Physicians' self-perceived digital competence and their evaluation of patients' digital proficiency emerge as pivotal factors influencing the prescription of mHealth apps.

CONCLUSIONS

Our study provides comprehensive insights into the prescription process and the fundamental factors shaping the adoption of mHealth apps in Germany. The identified information gaps on both the physicians' and patients' sides contribute to a trust deficit and hindered digital competence. This research advances the understanding of adoption dynamics regarding digital health technologies and highlights crucial considerations for the successful integration of digital health apps into medical practice.

Older Adults' and Family Caregivers' Technological Arrangements on Risk of Institutionalization

Internet-enabled resources could facilitate older adults' ability to live in the community longer, but studies have often overlooked how family caregivers utilize the internet to assist older care recipients. We examined whether different family-level arrangements of internet use may affect the risk of institutionalization among older adults. Using the National Health and Aging Trends Study (2015-2020) and National Study on Caregiving (2015), we estimated multinominal logistic regression and inverse-probability weighted Cox proportional hazard models to investigate the determinants of technological arrangements in 2015 (i.e., no internet use, only caregiver use, only care recipient use, both caregiver and care recipient internet use) and how they may affect the risk of moving to an assisted living or nursing facility between 2015 and 2020. The most prevalent technological arrangement in 2015 was the one where neither the care recipient nor their caregiver reported using the internet. Relatively disadvantaged older care recipients (e.g., people of color, fewer years of education, less income, worse cognitive functioning) and caregivers (e.g., older, fewer years of education) were more likely to be in a non-internet use arrangement. Compared to older adults in other categories, older adults who were internet users and had a family caregiver who also used the internet in their caregiving tasks had a much lower risk of relocation during the study period. Findings suggest that digital interventions aimed at serving the older adult population should assess the gap in access and utilization at a family level and consider the role of older adults' social partners.

Shaping the future of chronic disease management: Insights into patient needs for AI-based homecare systems

BACKGROUND

The rising demand for healthcare resources, especially in chronic disease management, has elevated the importance of Artificial Intelligence (AI) in healthcare. While AI-based homecare systems are being developed, the perspectives of chronic patients, who are one of the primary beneficiaries and risk bearers of these technologies, remain largely under-researched. While recent research has highlighted the importance of AI-based homecare systems, the current understanding of patients' desired designs and features is still limited.

OBJECTIVE

This paper explores chronic patients' perspectives regarding AI-based homecare systems, an area currently underrepresented in research. We aim to identify the factors influencing their decision to use such systems, elucidate the potential roles of government and other concerned authorities, and provide feedback to AI developers to enhance adoption, system design, and usability and improve the overall healthcare experiences of chronic patients.

METHOD

A web-based open-ended questionnaire was designed to gather the perspectives of chronic patients about AI-based homecare systems. In total, responses from 181 participants were collected. Using Krippendorff's clustering technique, an inductive thematic analysis was performed to identify the main themes and their respective subthemes.

RESULT

Through rigorous coding and thematic analysis of the collected responses, we identified four major themes further segmented into thirteen subthemes. These four primary themes were: 1) "Personalized Design", emphasizing the need for patients to manage their health condition better through personalized and educational resources and user-friendly interfaces; 2) "Emotional & Social Support", underscoring the desire for AI systems to facilitate social connectivity and provide emotional support to improve the well-being of chronic patients at home; 3) "System Integration & Proactive Care", addressing the importance of seamless communication, proactive patient monitoring and integration with existing healthcare platforms; and 4) "Ethics & Regulation", prioritizing ethical guidelines, regulatory compliance, and affordability in the design.

CONCLUSION

This study has offered significant insights into the needs and expectations of chronic patients regarding AI-based home care systems. 'The findings highlight the importance of personalized and accessible care, emotional and social support, seamless system integration, proactive care, and ethical considerations in designing and implementing such systems. By aligning the design and operation of these systems with the lived experiences and expectations of patients, we can better ensure their acceptance and effectiveness.

Incorporating usability evaluation into iterative development of an online platform to support research participation in Parkinson's disease: a mixed methods protocol

INTRODUCTION

Many people with Parkinson's (PwP) are not given the opportunity or do not have adequate access to participate in clinical research. To address this, we have codeveloped with users an online platform that connects PwP to clinical studies in their local area. It enables site staff to communicate with potential participants and aims to increase the participation of the Parkinson's community in research. This protocol outlines the mixed methods study protocol for the usability testing of the platform.

METHODS AND ANALYSIS

We will seek user input to finalise the platform's design, which will then be deployed in a limited launch for beta testing. The beta version will be used as a recruitment tool for up to three studies with multiple UK sites. Usability data will be collected from the three intended user groups: PwP, care partners acting on their behalf and site study coordinators. Usability questionnaires and website analytics will be used to capture user experience quantitatively, and a purposive sample of users will be invited to provide further feedback via semistructured interviews. Quantitative data will be analysed using descriptive statistics, and a thematic analysis undertaken for interview data. Data from this study will inform future platform iterations.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Plymouth (3291; 3 May 2022). We will share our findings via a 'Latest News' section within the platform, presentations, conference meetings and national PwP networks.

A Brain Computer Interface Neuromodulatory Device for Stroke Rehabilitation: Iterative User-Centered Design Approach

BACKGROUND

Rehabilitation technologies for people with stroke are rapidly evolving. These technologies have the potential to support higher volumes of rehabilitation to improve outcomes for people with stroke. Despite growing evidence of their efficacy, there is a lack of uptake and sustained use in stroke rehabilitation and a call for user-centered design approaches during technology design and development. This study focuses on a novel rehabilitation technology called exciteBCI, a complex neuromodulatory wearable technology in the prototype stage that augments locomotor rehabilitation for people with stroke. The exciteBCI consists of a brain computer interface, a muscle electrical stimulator, and a mobile app.

OBJECTIVE

This study presents the evaluation phase of an iterative user-centered design approach supported by a qualitative descriptive methodology that sought to (1) explore users' perspectives and experiences of exciteBCI and how well it fits with rehabilitation, and (2) facilitate modifications to exciteBCI design features.

METHODS

The iterative usability evaluation of exciteBCI was conducted in 2 phases. Phase 1 consisted of 3 sprint cycles consisting of single usability sessions with people with stroke (n=4) and physiotherapists (n=4). During their interactions with exciteBCI, participants used a "think-aloud" approach, followed by a semistructured interview. At the end of each sprint cycle, device requirements were gathered and the device was modified in preparation for the next cycle. Phase 2 focused on a "near-live" approach in which 2 people with stroke and 1 physiotherapist participated in a 3-week program of rehabilitation augmented by exciteBCI (n=3). Participants completed a semistructured interview at the end of the program. Data were analyzed from both phases using conventional content analysis.

RESULTS

Overall, participants perceived and experienced exciteBCI positively, while providing guidance for iterative changes. Five interrelated themes were identified from the data: (1) "This is rehab" illustrated that participants viewed exciteBCI as having a good fit with rehabilitation practice; (2) "Getting the most out of rehab" highlighted that exciteBCI was perceived as a means to enhance rehabilitation through increased engagement and challenge; (3) "It is a tool not a therapist," revealed views that the technology could either enhance or disrupt the therapeutic relationship; and (4) "Weighing up the benefits versus the burden" and (5) "Don't make me look different" emphasized important design considerations related to device set-up, use, and social acceptability.

CONCLUSIONS

This study offers several important findings that can inform the design and implementation of rehabilitation technologies. These include (1) the design of rehabilitation technology should support the therapeutic relationship between the patient and therapist, (2) social acceptability is a design priority in rehabilitation technology but its importance varies depending on the use context, and (3) there is value in using design research methods that support understanding usability in the context of sustained use.

Technologies for Managing the Health of Older Adults with Multiple Chronic Conditions: A Systematic Literature Review

Multimorbidity is defined as the presence of two or more chronic medical conditions in a person, whether physical, mental or long-term infectious diseases. This is especially common in older populations, affecting their quality of life and emotionally impacting their caregivers and family. Technology can allow for monitoring, managing, and motivating older adults in their self-care, as well as supporting their caregivers. However, when several conditions are present at once, it may be necessary to manage several types of technologies, or for technology to manage the interaction between conditions. This work aims to understand and describe the technologies that are used to support the management of multimorbidity for older adults. We conducted a systematic review of ten years of scientific literature from four online databases. We reviewed a corpus of 681 research papers, finally including 25 in our review. The technologies used most frequently by older adults with multimorbidity are mobile applications and websites, and they are mostly focused on communication and connectivity. We then propose opportunities for future research on addressing the challenges in the management of several simultaneous health conditions, potentially creating a better approach than managing each condition as if it were independent.

Perceptions of registered nurses on facilitators and barriers of implementing the AI-IoT-based healthcare pilot project for older adults during the COVID-19 pandemic in South Korea

Objective

This study explored the perceptions of registered nurses on the facilitators and barriers to implementing an AI/IoT (Artificial Intelligence/Internet of Things)-based healthcare pilot project, designed to prevent frailty and improve health behaviors by providing Bluetooth-enabled smart devices (including blood pressure and blood glucose meters) for the older adults aged over 65 years and above in South Korea.

Methods

Using a qualitative descriptive methodology, interviews and qualitative surveys were conducted with 15 registered nurses from 11 public health centers. Data were analyzed using qualitative content analysis.

Results

The study found that the AI·IoT-based healthcare pilot project was well received by participants, leading to increased client satisfaction and improved health behaviors. Government support and funding were crucial facilitators of project implementation. However, technical challenges and disparities in digital literacy among older adults pose significant barriers.

Conclusion

The findings highlight the potential of AI·IoT technologies in improving the healthcare of older adults. Efforts to address technological challenges and enhance digital literacy among vulnerable populations are necessary for successfully implementing such interventions. Government support and ongoing training for healthcare professionals can help optimize the AI·IoT-based healthcare services for older adults.

Design of the STEPS trial: a phase II randomized controlled trial evaluating eHealth-supported motor-cognitive home training for Parkinson's disease

BACKGROUND

Electronic health (eHealth) technology offers the potential to support and motivate physical activity for symptom management in Parkinson's disease (PD). It is also recommended that motor exercise in PD be complemented with cognitive training aimed at attentional or executive functions. This paper describes the protocol for a double-blind randomized controlled trial to evaluate the effects of motor-cognitive training in the home environment, supported by eHealth.

METHODS/DESIGN

The Support for home Training using Ehealth in Parkinsons diseaSe (STEPS) is a double-blind single center randomized controlled trial. Two parallel groups will include in total 120 participants with mild to moderate PD who will receive either (i) the intervention (a progressive 10-week individualized motor-cognitive eHealth training with cognitive behavioral elements to increase physical activity levels) or (ii) an active control group (an individualized 10-week paper-based home exercise program). The active control group will not receive motor-cognitive exercises or cognitive behavioral approaches to increase physical activity level. The primary outcome is walking capacity assessed by the six-minute walk test (6MWT). Secondary outcomes will include gait performance during single and dual task conditions, gait speed, functional mobility and lower limb strength, balance, physical activity behavior and a range of patient reported outcome measures relevant in PD.

DISCUSSION

The STEPS trial will answer the question whether 10 weeks of eHealth supported motor-cognitive exercise in the home environment can improve walking capacity in PD when compared to a standard paper exercise program. Findings from this study will also strengthen the evidence concerning the efficacy of PD-specific eHealth interventions with a view meeting future health care demands by addressing issues of inaccessibility to specialized neurological rehabilitation in PD.

TRIAL REGISTRATION

ClinicalTrials.gov August 2022, NCT05510739.

Impact of new technologies on neurology in Spain. Review by the New Technologies Ad-Hoc Committee of the Spanish Society of Neurology

INTRODUCTION

New technologies are increasingly widespread in biomedicine. Using the consensus definition of new technologies established by the New Technologies Ad-Hoc Committee of the Spanish Society of Neurology (SEN), we evaluated the impact of these technologies on Spanish neurology, based on communications presented at Annual Meetings of the SEN.

MATERIAL AND METHODS

We defined the concept of new technology in neurology as a novel technology or novel application of an existing technology, characterised by a certain degree of coherence persisting over time, with the potential to have an impact on the present and/or future of neurology. We conducted a descriptive study of scientific communications presented at the SEN's annual meetings from 2012 to 2018, analysing the type of technology, the field of neurology, and the geographical provenance of the studies.

RESULTS

We identified 299 communications related with new technologies from a total of 8139 (3.7%), including 120 posters and 179 oral communications, ranging from 1.6% of all communications in 2012 to 6.8% in 2018. The technologies most commonly addressed were advanced neuroimaging (24.7%), biosensors (17.1%), electrophysiology and neurostimulation (14.7%), and telemedicine (13.7%). The neurological fields where new technologies were most widely employed were movement disorders (18.4%), cerebrovascular diseases (15.7%), and dementia (13.4%). Madrid was the region presenting the highest number of communications related to new technologies (32.8%), followed by Catalonia (26.8%) and Andalusia (9.0%).

CONCLUSIONS

The number of communications addressing new technologies follows an upward trend. The number of technologies used in neurology has increased in parallel with their availability. We found scientific communications in all neurological subspecialties, with a heterogeneous geographical distribution.

A self-management app to improve asthma control in adults with limited health literacy: a mixed-method feasibility study

BACKGROUND

Digital technology tailored for those with limited health literacy has the potential to reduce health inequalities. Although mobile apps can support self-management in chronic diseases, there is little evidence that this approach applies to people with limited health literacy. We aimed to determine the acceptability of a self-management app in adults living with asthma and have limited health literacy and the feasibility of delivering the intervention and assessing outcomes.

METHODS

We recruited eligible adults from the Klang Asthma Cohort registry in primary care for a 3-month mixed-method study plus a 2-month extended observation. We collected baseline data on socio-demography, health literacy and asthma control level. The outcomes of the intervention were assessed at 1- and 3-month: i) adoption (app download and usage), ii) adherence (app usage), iii) retention (app usage in the observation period), iv) health outcomes (e.g., severe asthma attacks) and v) process outcomes (e.g., ownership and use of action plans). At 1-month, participants were purposively sampled for in-depth interviews, which were audio-recorded, transcribed verbatim, and analysed deductively.

RESULTS

We recruited 48 participants; 35 participants (23 Female; median age = 43 years; median HLS score = 28) completed the 3 months study. Of these, 14 participants (10 Female; median age = 48 years; median HLS score = 28) provided interviews. Thirty-seven (77%) participants adopted the app (downloaded and used it in the first month of the study). The main factor reported as influencing adoption was the ease of using the app. A total of 950 app usage were captured during the 3-month feasibility study. App usage increased gradually, peaking at month 2 (355 total log-ins) accounting for 78% of users. In month 5, 51.4% of the participants used the app at least once. The main factors influencing continued use included adherence features (e.g., prompts and reminders), familiarity with app function and support from family members.

CONCLUSIONS

An asthma self-management app intervention was acceptable for adults with limited health literacy and it was feasible to collect the desired outcomes at different time points during the study. A future trial is warranted to estimate the clinical and cost-effectiveness of the intervention and to explore implementation strategies.

Design Guidelines of Mobile Apps for Older Adults: Systematic Review and Thematic Analysis

BACKGROUND

Mobile apps are fundamental tools in today's society for practical and social endeavors. However, these technologies are often not usable for older users. Given the increased use of mobile apps by this group of users and the impact that certain services may have on their quality of life, such as mobile health, personal finance, or online administrative procedures, a clear set of guidelines for mobile app designers is needed. Existing recommendations for older adults focus on investigations with certain groups of older adults or have not been extracted from experimental results.

OBJECTIVE

In this research work, we systematically reviewed the scientific literature that provided recommendations for the design of mobile apps based on usability testing with older adults and organized such recommendations into a meaningful set of design guidelines.

METHODS

We conducted a systematic literature review of journal and conference articles from 2010 to 2021. We included articles that carried out usability tests with populations aged >60 years and presented transferable guidelines on mobile software design, resulting in a final set of 40 articles. We then carried out a thematic analysis with 3 rounds of analysis to provide meaning to an otherwise diverse set of recommendations. At this stage, we discarded recommendations that were made by just 1 article, were based on a specific mobile app and were therefore nontransferrable, were based on other authors' literature (as opposed to recommendations based on the results of usability tests), or were not sufficiently argued. With the remaining recommendations, we identified commonalities, wrote a faithful statement for each guideline, used a common language for the entire set, and organized the guidelines into categories, thereby giving shape to an otherwise diverse set of recommendations.

RESULTS

Among the 27 resulting guidelines, the rules Simplify and Increase the size and distance between interactive controls were transversal and of the greatest significance. The rest of the guidelines were divided into 5 categories (Help & Training, Navigation, Visual Design, Cognitive Load, and Interaction) and consequent subcategories in Visual Design (Layout, Icons, and Appearance) and Interaction (Input and Output). The recommendations were structured, explained in detail, and illustrated with applied examples extracted from the selected studies, where appropriate. We discussed the design implications of applying these guidelines, contextualized with relevant studies. We also discussed the limitations of the approach followed, stressing the need for further experimentation to gain a better understanding of how older adults use mobile apps and how to better design such apps with these users in mind.

CONCLUSIONS

The compiled guidelines support the design of mobile apps that cater to the needs of older adults because they are based on the results of actual usability tests with users aged >60 years.

Effects of Web-Based and Mobile Self-Care Support in Addition to Standard Care in Patients After Radical Prostatectomy: Randomized Controlled Trial

BACKGROUND

Prostate cancer is a common form of cancer that is often treated with radical prostatectomy, which can leave patients with urinary incontinence and sexual dysfunction. Self-care (pelvic floor muscle exercises and physical activity) is recommended to reduce the side effects. As more and more men are living in the aftermath of treatment, effective rehabilitation support is warranted. Digital self-care support has the potential to improve patient outcomes, but it has rarely been evaluated longitudinally in randomized controlled trials. Therefore, we developed and evaluated the effects of digital self-care support (electronic Patient Activation in Treatment at Home [ePATH]) on prostate-specific symptoms.

OBJECTIVE

This study aimed to investigate the effects of web-based and mobile self-care support on urinary continence, sexual function, and self-care, compared with standard care, at 1, 3, 6, and 12 months after radical prostatectomy.

METHODS

A multicenter randomized controlled trial with 2 study arms was conducted, with the longitudinal effects of additional digital self-care support (ePATH) compared with those of standard care alone. ePATH was designed based on the self-determination theory to strengthen patients' activation in self-care through nurse-assisted individualized modules. Men planned for radical prostatectomy at 3 county hospitals in southern Sweden were included offline and randomly assigned to the intervention or control group. The effects of ePATH were evaluated for 1 year after surgery using self-assessed questionnaires. Linear mixed models and ordinal regression analyses were performed.

RESULTS

This study included 170 men (85 in each group) from January 2018 to December 2019. The participants in the intervention and control groups did not differ in their demographic characteristics. In the intervention group, 64% (53/83) of the participants used ePATH, but the use declined over time. The linear mixed model showed no substantial differences between the groups in urinary continence (β=-5.60; P=.09; 95% CI -12.15 to -0.96) or sexual function (β=-.12; P=.97; 95% CI -7.05 to -6.81). Participants in the intervention and control groups did not differ in physical activity (odds ratio 1.16, 95% CI 0.71-1.89; P=.57) or pelvic floor muscle exercises (odds ratio 1.51, 95% CI 0.86-2.66; P=.15).

CONCLUSIONS

ePATH did not affect postoperative side effects or self-care but reflected how this support may work in typical clinical conditions. To complement standard rehabilitation, digital self-care support must be adapted to the context and individual preferences for use and effect.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN18055968; https://www.isrctn.com/ISRCTN18055968.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11625.

Bridging the ICT Revolution and Communication Inequality: Lessons for Cancer Survivors

The rapid development of information and communication technologies (ICTs) offers new opportunities for providing health information to patients. In this study, we examined the contrasting effects that communication innovation through ICTs can bring in the care of patients with chronic diseases and the health promotion of medical consumers. We also discussed how disparities in information technology usage, based on socioeconomic status, affect the information gap and health inequalities among medical consumers. ICTs have democratized health information, but the information gap persists and can deepen health inequality. Communication inequality manifests in access to technology, information processing, attention to health information, information seeking, and health outcomes. Significant differences in health communication behaviors exist according to social class. Social disparities in technology access and usage contribute to the information gap, which ultimately leads to different health levels. Communication innovation through ICT has both positive and negative effects on managing chronic diseases. Positively, it democratizes information generation and consumption, enabling patients to interact with healthcare providers and peers for support and advice. Negatively, an abundance of medical information can cause cognitive overload. To maximize benefits and minimize adverse effects, efforts should focus on promoting ICTs in healthcare, enhancing patients' decision-making abilities, and addressing communication inequality. Healthcare institutions must provide consistent, high-quality information, and governments should support underserved populations' access to information, ensuring that ICTs contribute to improved health outcomes.

Outcomes of Emergency Trauma Patients After the Implementation of Web Application Operating Systems

PURPOSE

Trauma has significant impacts on the livelihoods and well-being of patients. Prompt emergency, medical, and nursing care is the key to reducing mortality rates. Digital platforms have become important for patient care. This research aimed to evaluate patient outcomes after implementing a novel web application operating system in trauma care.

METHODS

A descriptive comparative study was conducted on trauma patients. The patients were divided into two groups: those who used the developed application (n = 70) and those who did not (n = 70). The patients' characteristics, the time of the trauma team's arrival at the emergency department (ED) and the length of stay in the ED, and patients' outcomes were collected from electronic medical records and the application database. A statistical analysis was performed to evaluate this data. Sixty registered nurses who used the application completed the survey on the feasibility of the application.

RESULTS

The activated trauma intervals for the non-application-used group and the application-used group were 5.0 ± 1.1 and 3.1 ± 0.4 minutes, respectively (p = .010). The length of stay in the ED for the non-application-used group and the application-used group were 30.1 ± 5.1 and 18.3 ± 6.2 minutes, respectively. A high level of agreement confirms the feasibility of the application.

CONCLUSIONS

This application improves patient outcomes in terms of length of stay. This mobile application can improve the cooperation and communication and efficacy of the trauma care team.

Improving Predictability and Effectiveness in Preventive Digital Health Interventions: Scoping Review

BACKGROUND

Lifestyle-related diseases caused by inadequate diet and physical activity cause premature death, loss of healthy life years, and increased health care costs. Randomized controlled trial (RCT) studies indicate that preventive digital health interventions (P-DHIs) can be effective in preventing these health problems, but the results of these studies are mixed. Adoption studies have identified multiple factors related to individuals and the context in which they live that complicate the transfer of positive results from RCT studies to practical use. Implementation studies have revealed barriers to the large-scale implementation of mobile health (mHealth) solutions in general. Consequently, there is no clear path to delivering predictable outcomes from P-DHIs and achieving effectiveness when scaling up interventions to reduce health problems in society.

OBJECTIVE

This research aimed to expand our understanding of how to increase the outcome predictability of P-DHIs by focusing on physical activity and diet behaviors and amplify our understanding of how to improve effectiveness in large-scale implementations.

METHODS

The research objective was pursued through a multidisciplinary scoping review. This scoping review used the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) as a guide. A comprehensive search of Web of Science and PubMed limited to English-language journal articles published before January 2022 was conducted. Google Scholar was used for hand searches. Information systems theory was used to identify key constructs influencing outcomes of IT in general. Public health and mHealth literature were used to identify factors influencing the adoption of, outcomes from, and implementation of P-DHIs. Finally, the P-DHI investment model was developed based on information systems constructs and factors from the public health and mHealth literature.

RESULTS

In total, 203 articles met the eligibility criteria. The included studies used a variety of methodologies, including literature reviews, interviews, surveys, and RCT studies. The P-DHI investment model suggests which constructs and related factors should be emphasized to increase the predictability of P-DHI outcomes and improve the effectiveness of large-scale implementations.

CONCLUSIONS

The research suggests that outcome predictability could be improved by including descriptions of the constructs and factors in the P-DHI investment model when reporting from empirical studies. Doing so would increase our understanding of when and why P-DHIs succeed or fail. The effectiveness of large-scale implementations may be improved by using the P-DHI investment model to evaluate potential difficulties and possibilities in implementing P-DHIs to create better environments for their use before investing in them and when designing and implementing them. The cost-effectiveness of large-scale implementations is unknown; implementations are far more complicated than just downloading and using apps, and there is uncertainty accompanying implementations given the lack of coordinated control over the constructs and factors that influence the outcome.

Enablers and inhibitors to the adoption of mHealth apps by patients - A qualitative analysis of German doctors' perspectives

OBJECTIVE

Germany is the first country that approved validated mobile health apps (called DiGA) for prescription by doctors and psychotherapists. The aim of this study is to investigate doctors' perspectives towards these mobile health apps and their intentions to prescribe them. Additionally, we investigated the influence of different roles and expectations of outcomes.

METHODS

We used a qualitative study design to determine doctors' viewpoints on prescribing DiGAs. We conducted 28 semi-structured interviews and used the grounded theory method for analysis. We adopted a classical conceptualist approach to gain theoretical insights.

RESULTS

The results show that doctors' acceptance and support of DiGAs are critical in mobile health uptake and utilisation. Although mobile health is seen to be supportive of patient management and patient education doctors nevertheless need to adopt a motivating and persuasive role in the process.

CONCLUSIONS

Doctors consider DiGAs complementary to their role in patient management and are predominantly positive about DiGAs. A trusted relationship with patients must be developed to ensure the appropriate support of DiGAs.

PRACTICE IMPLICATIONS

Our study suggests that targeted education, user-centred DiGAs, consideration of social presence and user engagement, and co-development with doctors can improve longer-term DiGA use and effectiveness.

Development of an eHealth Tool for Capturing and Analyzing the Immune-related Adverse Events (irAEs) in Cancer Treatment

Introduction

Immunotherapy has revolutionized the treatment of many different types of cancer, but it is associated with a myriad of immune-related adverse events (irAEs). Patient-reported outcome (PRO) measures have been identified as valuable tools for continuously collecting patient-centered data and are frequently used in oncology trials. However, few studies still research an ePRO follow-up approach on patients treated with Immunotherapy, potentially reflecting a lack of support services for this population.

Methods

The team co-developed a digital platform (V-Care) using ePROs to create a new follow-up pathway for cancer patients receiving immunotherapy. To operationalize the first 3 phases of the CeHRes roadmap, we employed multiple methods that were integrated throughout the development process, rather than being performed in a linear fashion. The teams employed an agile approach in a dynamic and iterative manner, engaging key stakeholders throughout the process.

Results

The development of the application was categorized into 2 phases: "user interface" (UI) and "user experience" (UX) designs. In the first phase, the pages of the application were segmented into general categories, and feedback from all stakeholders was received and used to modify the application. In phase 2, mock-up pages were developed and sent to the Figma website. Moreover, the Android Package Kit (APK) of the application was installed and tested multiple times on a mobile phone to proactively detect and fix any errors. After resolving some technical issues and adjusting errors on the Android version to improve the user experience, the iOS version of the application was developed.

Discussion

By incorporating the latest technological developments, V-Care has enabled cancer patients to have access to more comprehensive and personalized care, allowing them to better manage their condition and be better informed about their health decisions. These advances have also enabled healthcare professionals to be better equipped with the knowledge and tools to provide more effective and efficient care. In addition, the advances in V-Care technology have allowed patients to connect with their healthcare providers more easily, providing a platform to facilitate communication and collaboration. Although usability testing is necessary to evaluate the efficacy and user experience of the app, it can be a significant investment of time and resources.

Conclusion

The V-Care platform can be used to investigate the reported symptoms experienced by cancer patients receiving Immune checkpoint inhibitors (ICIs) and to compare them with the results from clinical trials. Furthermore, the project will utilize ePRO tools to collect symptoms from patients and provide insight into whether the reported symptoms are linked to the treatment.

Clinical Relevance

V-Care provides a secure, easy-to-use interface for patient-clinician communication and data exchange. Its clinical system stores and manages patient data in a secure environment, while its clinical decision support system helps clinicians make decisions that are more informed, efficient, and cost-effective. This system has the potential to improve patient safety and quality of care, while also helping to reduce healthcare costs.

Effectiveness and implementation of mPATH™-CRC: a mobile health system for colorectal cancer screening

BACKGROUND

Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates.

METHODS

The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a "high touch" evidence-based implementation strategy with a "low touch" implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50-74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the "high touch" and "low touch" implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation).

DISCUSSION

This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.

Challenges and opportunities for increasing patient involvement in heart failure self-care programs and self-care in the post-hospital discharge period

BACKGROUND

People living with heart failure (HF) are particularly vulnerable after hospital discharge. An alliance between patient authors, clinicians, industry, and co-developers of HF programs can represent an effective way to address the unique concerns and obstacles people living with HF face during this period. The aim of this narrative review article is to discuss challenges and opportunities of this approach, with the goal of improving participation and clinical outcomes of people living with HF.

METHODS

This article was co-authored by people living with HF, heart transplant recipients, patient advocacy representatives, cardiologists with expertise in HF care, and industry representatives specializing in patient engagement and cardiovascular medicine, and reviews opportunities and challenges for people living with HF in the post-hospital discharge period to be more integrally involved in their care. A literature search was conducted, and the authors collaborated through two virtual roundtables and via email to develop the content for this review article.

RESULTS

Numerous transitional-care programs exist to ease the transition from the hospital to the home and to provide needed education and support for people living with HF, to avoid rehospitalizations and other adverse outcomes. However, many programs have limitations and do not integrally involve patients in the design and co-development of the intervention. There are thus opportunities for improvement. This can enable patients to better care for themselves with less of the worry and fear that typically accompany the transition from the hospital. We discuss the importance of including people living with HF in the development of such programs and offer suggestions for strategies that can help achieve these goals. An underlying theme of the literature reviewed is that education and engagement of people living with HF after hospitalization are critical. However, while clinical trial evidence on existing approaches to transitions in HF care indicates numerous benefits, such approaches also have limitations.

CONCLUSION

Numerous challenges continue to affect people living with HF in the post-hospital discharge period. Strategies that involve patients are needed, and should be encouraged, to optimally address these challenges.

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.

Learning Designers as Expert Evaluators of Usability: Understanding Their Potential Contribution to Improving the Universality of Interface Design for Health Resources

User-based evaluation by end users is an essential step in designing useful interfaces. Inspection methods can offer an alternate approach when end-user recruitment is problematic. A Learning Designers' usability scholarship could offer usability evaluation expertise adjunct to multidisciplinary teams in academic settings. The feasibility of Learning Designers as 'expert evaluators' is assessed within this study. Two groups, healthcare professionals and Learning Designers, applied a hybrid evaluation method to generate usability feedback from a palliative care toolkit prototype. Expert data were compared to end-user errors detected from usability testing. Interface errors were categorised, meta-aggregated and severity calculated. The analysis found that reviewers detected N = 333 errors, with N = 167 uniquely occurring within the interface. Learning Designers identified errors at greater frequencies (60.66% total interface errors, mean (M) = 28.86 per expert) than other evaluator groups (healthcare professionals 23.12%, M = 19.25 and end users 16.22%, M = 9.0). Patterns in severity and error types were also observed between reviewer groups. The findings suggest that Learning Designers are skilled in detecting interface errors, which benefits developers assessing usability when access to end users is limited. Whilst not offering rich narrative feedback generated by user-based evaluations, Learning Designers complement healthcare professionals' content-specific knowledge as a 'composite expert reviewer' with the ability to generate meaningful feedback to shape digital health interfaces.

Mundo de Pólus serious game for people with bipolar disorder

BACKGROUND

Serious games are play-based technologies designed to teach users a wide range of concepts and skills applicable in the non-virtual environment.

OBJECTIVES

This paper describes the process of developing a serious game for people with bipolar disorder to promote symptom recognition and the safe use of medications.

METHODS

This study was based on the User-Centered Design methodological model and the theoretical framework for Participatory Design. We conducted interviews with health professionals and discussion circles with people with bipolar disorder and their family members in order to identify the learning needs related to symptom recognition and safe medication use. A categorical analysis was completed of the participants' reports and the scientific literature and formed the basis for the design of Mundo de Pólus.

RESULTS

The game development process had three pillars (detailed in this manuscript): missions, simulation, and journal. The serious game focuses on the users' perceptions about their experience with the disorder, their interpersonal relationships, coping strategies, use of medications, and non-pharmacological treatments.

CONCLUSIONS

These scientific and technological outcomes are useful to promote literacy and safety in medication therapy for people with bipolar disorder.

How to Influence Behavioral Intention Toward Age-Friendly Home Modifications in Urban Older People Aged 70

Aging in place with a suitable living environment is essential for the health and well-being of older adults. However, the willingness of older people to modify their housing to meet their needs is not strong. Using the Analytic Network Process (ANP) method, the study first explores the weights of factors, such as perceived behavioral control, policies, and market conditions that influence older adults' behavioral intention. Then, a structural equation modeling (SEM) approach was used to dissect the psychological factors which account for the largest proportion. Using data from 560 people aged 70 or older from Beijing, results suggest that effectiveness perception, cost perception, and subjective norms can influence older people's behavioral intention directly or indirectly through emotional attitudes. Risk perception can moderate the level of behavioral intention triggered by cost perceptions. This study provides new evidence for the impact of factors and interaction mechanism on older adults' behavioral intentions toward age-friendly home modifications.

The potential of mHealth for older adults on dialysis and their care partners: What's been done and where do we go from here?

Self-care, or the dynamic, daily process of becoming actively involved in one's own care, is paramount to prevent and manage complications of end-stage kidney disease. However, many older dialysis patients face distinctive challenges to adequate engagement in self-care. One promising strategy for facilitating self-care among older dialysis patients and their care partners is the utilization of mobile health (mhealth). mHealth encompasses mobile and wireless communication devices used to improve healthcare delivery, patient and care partner outcomes, and patient care. In other disease populations, mHealth has been linked to maintenance of or improvements in self-management, medication compliance, patient education, and patient-provider communication, all of which can slow disease progression. Although mHealth is considered feasible, acceptable, and clinically useful, this technology has predominately targeted younger patients. Thus, there is a need to develop mHealth for older dialysis patients and their care partners. In this article, we describe current mHealth usage in older dialysis patients, including promising findings, challenges, and research gaps. Given the lack of research on mHealth among care partners of older dialysis patients, we highlight lessons learned from other disease populations to inform the future design and implementation of mHealth for these key stakeholders. We also propose that leveraging care partners represents an opportunity to meaningfully tailor mHealth applications and, by extension, improve care partner physical and mental health and decrease caregiver burden. We conclude with a summary of future directions to help older dialysis patients and their care partners receive recognition as target end-users amid the constant evolution of mHealth.

The development of an electronic geriatric assessment tool: Comprehensive health assessment for my plan (CHAMP)

INTRODUCTION

Geriatric assessment (GA) provides information on key health domains of older adults and is recommended to help inform cancer treatment decisions and cancer care. However, GA is not feasible in many health institutions due to lack of geriatric staff and/or resources. To increase accessibility to GA and improve treatment decision making for older adults with cancer (≥65 years), we developed a self-reported, electronic geriatric assessment tool: Comprehensive Assessment for My Plan (CHAMP).

MATERIALS AND METHODS

Older adults with cancer were invited to join user-centered design sessions to develop the layout and content of the tool. Subsequently, they participated in usability testing to test the usability of the tool (ease of use, acceptability, etc.). Design sessions were also conducted with oncology clinicians (oncologists and nurses) to develop the tool's clinician interface. GA assessment questions and GA recommendations were guided by a systematic review and Delphi expert panel.

RESULTS

A total of seventeen older adults participated in the study. Participants were mainly males (82.4%) and 75% were aged 75 years and older. Nine oncology clinicians participated in design sessions. Older adults and clinicians agreed that the tool was user-friendly. Domains in the final CHAMP tool (with questions and recommendations) included functional status, falls risk, cognitive impairment, nutrition, medication review, social supports, depression, substance use disorder, and miscellaneous items.

DISCUSSION

CHAMP was designed for use by older adults and oncologists and may enhance access to GA for older adults with cancer. The next phase of the CHAMP study will involve field validation in oncology clinics.

Needs of patients with multi-morbidity and heart failure for the development of a mHealth to improve their self-management: A qualitative analysis

Objective

To provide practical information regarding needs, preferences of content and format of an app to assist the self-management in patients with multi-morbidity and heart failure (HF).

Methods

The three-phase study was conducted in Spain. Six integrative reviews, a qualitative methodology based on Van Manen's hermeneutic phenomenology through semi-structured interviews and user stories were used. Data collection continued until data saturation was reached. All data were transcribed verbatim and analysed using a framework approach. Thematic analysis technique following the methods of Braun and Clarke was used for emerging themes.

Results

Integrative reviews conducted included practical recommendations to include in the content and format of the App and helped create the interview guide. Interviews revealed 15 subthemes that captured the meaning of narratives offering contextual insights into the development of the App. The main effective mechanisms of multicomponent interventions for patients with HF must contain (a) components that increase the patient's understanding of HF, (b) self-care, (c) self-efficacy and participation of the family/informal caregiver, (4) psychosocial well-being and (5) professional support and use of technology. User stories revealed that patients prioritized improvements in direct contact with health services in case of emergency (90%), nutritional information (70%), type of exercises in order to improve their physical condition (75%) and information about food and drug interaction (60%). The importance of motivation messages (60%) was highlighted by transversal way.

Conclusions

The three-phase process integrating theoretical basis, evidence from integrative reviews and research findings from target users has been considered a guide for future app development.

Use of mobile applications and health technologies among dementia caregivers with chronic conditions: A cross-sectional study

Objective

Almost 80% of people, who are caring for someone with dementia, have one or more chronic conditions and require self-management support. New technologies offer promising solutions; however, little is known about what technologies caregivers use for their health or in general. This study aimed to describe the prevalence of mobile application (app) and health-related technology use among caregivers who have chronic conditions and care for someone with dementia.

Methods

A cross-sectional study was conducted with 122 caregivers recruited online and from communities in the Baltimore-metropolitan area. Data were collected with online surveys and computer-assisted telephone interviews. Descriptive and inferential statistics were used to analyze survey data.

Results

Study participants were primarily female (95 of 122, 77.9%), middle-aged (average 53 years, standard deviation (SD) 17), well educated (average 16 years, SD 3.3), an adult child of the person with dementia (53 of 122, 43.4%), and had 4 chronic conditions on average (SD 2.6). Over 90% of caregivers used mobile apps (116 of 122), spending a range of 9 to 82 min on each app. Most caregivers reported using social media apps (96 of 116, 82.8%), weather apps (96 of 116, 82.8%), and/or music or entertainment apps (89 of 116, 76.7%). Among caregivers using each app type, more than half of caregivers used social media (66 of 96, 69%), games (49 of 74, 66%), weather (62 of 96, 65%), and/or music or entertainment apps (51 of 89, 57%) daily. Caregivers also used several technologies to support their own health-the most common being websites, mobile devices, and health-related mobile apps.

Conclusion

This study supports the feasibility of using technologies to promote health behavior change and support self-management among caregivers.

Digital resilience monitoring of informal caregivers of persons with dementia for early detection of overburden: Development and pilot testing

OBJECTIVES

Informal caregiving is becoming increasingly important in dementia care, but causes a considerable burden on caregivers which impacts their wellbeing. We aimed to develop and pilot test a digital monitoring tool (REsilience Monitor for INformal caregivers in Dementia [REMIND]) for wellbeing and resilience of informal caregivers to provide timely support and thereby prevent their overburden and eventually crises admissions of persons with dementia.

METHODS

A human-centered design method based on co-creation with informal caregivers and professionals was used to design REMIND. During co-creation meetings and in-between sprint sessions, a point of focus was formulated, and a prototype was created. Case manager-caregiver duos pilot-tested REMIND for 3 months. Semi-structured interviews were conducted to determine usability and acceptability. Thematic analysis was applied to the transcripts.

RESULTS

Informal caregivers and professionals with varying backgrounds participated in three co-creation meetings. Defined point of focus was to develop a tool that is able to provide insight into the experienced burden of informal caregivers. The REMIND prototype consisted of weekly questions about wellbeing and resilience for informal caregivers and a dashboard with answers for case managers. Eight case managers and 13 informal caregivers considered REMIND easy-to-use. Informal caregivers mentioned that REMIND stimulated self-reflection. Case managers appreciated the tool's ability to gain insight in the actual wellbeing of informal caregivers.

CONCLUSIONS

The REMIND tool developed in co-creation with end-users potentially increases insight in actual wellbeing of informal caregivers for both caregivers and case managers. A long-term (controlled) follow-up study is needed to evaluate REMIND's impact on caregiver burden and crisis admissions.

Assessment of the effectiveness of parent-targeted interventions for the use of child restraint systems: a systematic review and meta-analysis

BACKGROUND

It is essential to implement parent-targeted interventions to increase the use of child restraint systems (CRS) and thus reduce the injuries and deaths of children due to motor vehicle collisions. To optimize future intervention designs, this meta-analysis sought to quantify the effects of parent-targeted interventions and explore potential intervention moderators.

METHODS

Studies met inclusion criteria if they included a parents-targeted intervention that focused on increasing CRS use for children, published from the inception of the databases to January 2022, were systematically retrieved from the PubMed, Embase, Cochrane library, Web of Science, Sinomed, Wanfang, and CNKI databases. Next, 2 researchers independently screened the retrieved articles, evaluated their quality according to the Cochrane Tool, and extracted the data. Finally, Stata12.0 was used for the meta-analysis. Heterogeneity was examined with I², stratified analyses, and meta-regression.

RESULTS

Of the 1,690 articles retrieved, 9 studies, comprising 22,329 parents of children aged 0-12 years, were ultimately included in the analysis. The results of the meta-analysis showed that the CRS use rate of the intervention group was 1.62 times higher than that of the control group [95% confidence interval (CI): 1.25-2.11, Z=3.616, P<0.001], indicating the positive effect of parent-targeted interventions on promoting the use of CRS. The subgroup analysis found that interventions guided by behavioral theories increased the use of CRS (odds ratio: 1.44, 95% CI: 1.27-1.63, n=5). The difference in the use of CRS between the groups in the studies that were not guided by theories was not statistically significant, indicating that interventions guided by behavioral theories may be the source of the heterogeneity. Risk of bias was low in most studies.

CONCLUSIONS

It is necessary to conduct interventions with parents to increase the use of CRS. The effects on CRS use appear to differ depending on whether the interventions are guided by behavioral theories. In-depth research needs to be conducted to explore the characteristics of the interventions, especially those guided by different behavioral theories, to reduce child vehicle injuries.

Mobile App Prototype in Older Adults for Postfracture Acute Pain Management: User-Centered Design Approach

BACKGROUND

Postfracture acute pain is often inadequately managed in older adults. Mobile health (mHealth) technologies can offer opportunities for self-management of pain; however, insufficient apps exist for acute pain management after a fracture, and none are designed for an older adult population.

OBJECTIVE

This study aims to design, develop, and evaluate an mHealth app prototype using a human-centered design approach to support older adults in the self-management of postfracture acute pain.

METHODS

This study used a multidisciplinary and user-centered design approach. Overall, 7 stakeholders (ie, 1 clinician-researcher specialized in internal medicine, 2 user experience designers, 1 computer science researcher, 1 clinical research assistant researcher, and 2 pharmacists) from the project team, together with 355 external stakeholders, were involved throughout our user-centered development process that included surveys, requirement elicitation, participatory design workshops, mobile app design and development, mobile app content development, and usability testing. We completed this study in 3 phases. We analyzed data from prior surveys administered to 305 members of the Canadian Osteoporosis Patient Network and 34 health care professionals to identify requirements for designing a low-fidelity prototype. Next, we facilitated 4 participatory design workshops with 6 participants for feedback on content, presentation, and interaction with our proposed low-fidelity prototype. After analyzing the collected data using thematic analysis, we designed a medium-fidelity prototype. Finally, to evaluate our medium-fidelity prototype, we conducted usability tests with 10 participants. The results informed the design of our high-fidelity prototype. Throughout all the phases of this development study, we incorporated inputs from health professionals to ensure the accuracy and validity of the medical content in our prototypes.

RESULTS

We identified 3 categories of functionalities necessary to include in the design of our initial low-fidelity prototype: the need for support resources, diary entries, and access to educational materials. We then conducted a thematic analysis of the data collected in the design workshops, which revealed 4 themes: feedback on the user interface design and usability, requests for additional functionalities, feedback on medical guides and educational materials, and suggestions for additional medical content. On the basis of these results, we designed a medium-fidelity prototype. All the participants in the usability evaluation tests found the medium-fidelity prototype useful and easy to use. On the basis of the feedback and difficulties experienced by participants, we adjusted our design in preparation for the high-fidelity prototype.

CONCLUSIONS

We designed, developed, and evaluated an mHealth app to support older adults in the self-management of pain after a fracture. The participants found our proposed prototype useful for managing acute pain and easy to interact with and navigate. Assessment of the clinical outcomes and long-term effects of our proposed mHealth app will be evaluated in the future.

Longitudinal study of the flash glucose monitoring system in type 1 diabetics: An mHealth ally in times of COVID-19

AIMS AND OBJECTIVES

The aim of this study was to assess the effect of the FreeStyle Libre device implantation in adult type 1 diabetics in a Health Area of Castilla La Mancha (Spain) during the COVID-19 pandemic.

BACKGROUND

FreeStyle Libre is a so-called mHealth device that supports health care. During COVID-1 confinement, diabetic patients could have improved their glycaemic monitoring thanks to these devices, although health care in these patients may have been limited due to confinement.

METHODS

A 12-month longitudinal study in which a total of 206 type I diabetics participated, belonging to a single health area. Sociodemographic and analytical data and the Self Care Inventory Revised questionnaire (SCI-R) were collected. STROBE checklist was followed.

RESULTS

The analysis showed differences related to the use of the sensor. After the study period, patients obtained better levels of basal glucose, glycosylated haemoglobin, creatinine, cholesterol, triglycerides and LDL. In addition, a significant increase in the total score of the SCI-R questionnaire was observed after the use of the monitor (MD -7.77; 95% CI -10.43, -8.29). The same occurred with different SCI-R items such as diet (MD -2.995; 95% CI -3.24, -2.57), glucose determination (MD -3.21; 95% CI -3.52, -2.91), medication administration (MD -2.58; 95% CI -2.53, -1.96) and hypoglycaemic episodes (MD -1.07; 95% CI -1.21, -0.93). In the analysis by groups, worse values of glycosylated haemoglobin and adherence to treatment (p < .05) were observed in overweight/obese subjects versus those with normal weight after one year of study.

CONCLUSION

The use of flash monitoring is related to better adherence to most of the recommended habits in diabetes. Nevertheless, there seems to be no relationship with an improvement in physical exercise and preventive aspects of diabetes. A good nursing intervention to support physical exercise and the use of mHealth devices could improve the control of diabetic patients.

RELEVANCE TO CLINICAL PRACTICE

The use of this mHealth device has shown positive results and reduced complications. Despite less contact with healthcare facilities due to the pandemic, type 1 diabetic patients have improved their blood results and adherence after using the device for one year. Nursing staff should focus on promoting physical activity and routine disease care in type 1 diabetics.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

Background

Multimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.

Materials and methods

We randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.

Results

Among the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p &lt; 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.

Conclusion

Multimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.

How Useful Are Digital Health Terms for Outcomes Research? An ISPOR Special Interest Group Report

OBJECTIVES

This study aimed to review definitions of digital health and understand their relevance for health outcomes research. Four umbrella terms (digital health, electronic health, mobile health, and telehealth/telemedicine) were summarized in this article.

METHODS

PubMed/MEDLINE, Embase, Cochrane Library, and EconLit were searched from January 2015 to May 2020 for systematic reviews containing key Medical Subject Headings terms for digital health (n = 38) and synonyms of "definition." Independent pairs of reviewers performed each stage of the review, with reconciliation by a third reviewer if required. A single reviewer consolidated each definition for consistency. We performed text analysis via word clouds and computed document frequency-and inverse corpus frequency scores.

RESULTS

The search retrieved 2610 records with 545 articles (20.9%) taken forward for full-text review. Of these, 39.3% (214 of 545) were eligible for data extraction, of which 134 full-text articles were retained for this analysis containing 142 unique definitions of umbrella terms (digital health [n = 4], electronic health [n = 36], mobile health [n = 50], and telehealth/telemedicine [n = 52]). Seminal definitions exist but have increasingly been adapted over time and new definitions were created. Nevertheless, the most characteristic words extracted from the definitions via the text analyses still showed considerable overlap between the 4 umbrella terms.

CONCLUSIONS

To focus evidence summaries for outcomes research purposes, umbrella terms should be accompanied by Medical Subject Headings terms reflecting population, intervention, comparator, outcome, timing, and setting. Ultimately a functional classification system is needed to create standardized terminology for digital health interventions denoting the domains of patient-level effects and outcomes.

Implementing a Telehealth Support Tool for Community-Dwelling Older Adults During the COVID-19 Pandemic: A Qualitative Investigation of Provider Experiences

During the COVID-19 pandemic, policymakers had to quickly offer telehealth services to address older adults' needs. This study aimed to understand the experiences of providers who implemented a telephone-based telehealth tool named Socio-Geriatric Evaluation (ESOGER), which assessed health and social isolation risks in community-dwelling older adults in Quebec (Canada). This qualitative study used 20 semi-structured online/phone interviews with health and social service providers coming from publicly-funded healthcare facilities and community organizations. We included adopters and non-adopters of the telehealth tool. Interviews were audio-recorded and transcribed verbatim. We used reflexive thematic analysis to interpret the data. Three dimensions of providers' practice influenced the tool's implementation: service organization, working conditions, and interactions with older adults. Participants reported that the tool fostered continuity of care, provided guidance for their pandemic-related new tasks, and helped identify and support socially isolated older adults. Challenges to implementation included limited appropriateness of the telehealth tool for diverse services, feasibility barriers to adopting a new tool amid the health crisis, and acceptability challenges with some older adults. Despite relevance of the telehealth tool for providers, organizational, professional, and interactional barriers could hinder implementation success. Participatory approaches to telehealth may be promising avenues for future policies in this field.

Operational challenges in the pre-intervention phase of a mental health trial in rural India: reflections from SMART Mental Health

BACKGROUND

Availability of mental health services in low- and middle-income countries is largely concentrated in tertiary care with limited resources and scarcity of trained professionals at the primary care level. SMART Mental Health is a strategy that combines a community anti-stigma campaign with a primary health care workforce strengthening initiative, using electronic decision support with the goal of better identifying and supporting people with common mental disorders in India.

METHODS

We describe the challenges faced and lessons learnt during the pre-intervention phase of SMART Mental Health cluster Randomised Controlled Trial. Pre-intervention phase includes preliminary activities for setting-up the trial and research activities prior to delivery of the intervention. Field notes from project site visit, project team meetings and detailed follow-up discussions with members of the project team were used to document operational challenges and strategies adopted to overcome them. The socio-ecological model was used as the analytical framework to organise the findings.

RESULTS

Key challenges included delays in government approvals, addressing community health worker needs, and building trust in the community. These were addressed through continuous communication, leveraging support of relevant stakeholders, and addressing concerns of community health workers and community. Issues related to use of digital platform for data collection were addressed by a dedicated technical support team. The COVID-19 pandemic and political unrest led to significant and unexpected challenges requiring important adaptations to successfully implement the project.

CONCLUSION

Setting up of this trial has posed challenges at a combination of community, health system and broader socio-political levels. Successful mitigating strategies to overcome these challenges must be innovative, timely and flexibly delivered according to local context. Systematic ongoing documentation of field-level challenges and subsequent adaptations can help optimise implementation processes and support high quality trials.

TRIAL REGISTRATION

The trial is registered with Clinical Trials Registry India (CTRI/2018/08/015355). Registered on 16th August 2018. http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=23254&EncHid=&userName=CTRI/2018/08/015355.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool’s effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Implementation of interprofessional digital communication tools in primary care for frail older adults: An interview study

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use.

Effectiveness and Acceptability of e- and m-Health Interventions to Promote Physical Activity and Prevent Falls in Nursing Homes—A Systematic Review

Age-related decreases in physical activity (PA) and a decline in physical functioning lead to increased fall risk. As falls are a major cause of accidental deaths and hospitalization in older adults, PA promotion and fall prevention are important measures, especially in nursing homes (NH). With advances in information and communication technology, e- and m-health solutions have been developed to positively influence various health-related factors. To date, only little research exists on the implementation of these technologies to promote health in NH. Therefore, the objective of this systematic review was to provide an overview of the effectiveness, acceptability, and feasibility of e- and m-health interventions aimed at promoting PA and preventing falls in NH. Additionally, the effectiveness of such interventions regarding the secondary outcomes physical function, cognitive function, neuropsychiatric symptoms, and psychosocial status was examined. A systematic literature search was performed in five databases and studies published until 15 November 2021, were considered for inclusion. All studies that examined the effectiveness and/or the acceptability and feasibility of e- or m-health interventions in promoting PA and preventing falls in NH, without restriction on language or date of publication, were included in the final synthesis. Of the 1,358 records retrieved, 28 studies were included in this systematic review. Twenty-four studies contained digital exergaming as an intervention or as a part of the intervention, the four additional studies on e-health interventions only examined a small number of outcomes. No m-health intervention study was identified. Data synthesis indicates that exergaming may be effective in reducing the number of falls and fall risk in NH residents. Several significant improvements were also reported regarding secondary outcomes albeit not consistent across studies. No conclusion can be drawn about the effects of exergaming and other e-health interventions on PA, as data is scarce. E-health interventions were mostly reported as feasible and well accepted by NH residents. However, these findings may not be applicable to NH residents with advanced physical and/or cognitive impairments, since they were excluded in many studies. Therefore, more research examining other digital solutions besides exergaming to promote PA in this specific population is critical.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/, identifier CRD42021289488