Health Literacy and Health Information Technology Adoption: The Potential for a New Digital Divide

Geolocation, ethics, and HIV research

The HIV epidemic continues to disproportionally affect marginalized populations. Digital tools, including global positioning system and ecologic momentary assessment, have been studied as methods for improving data collection and interventions among HIV-affected communities. Although people living with HIV and populations at high risk have found it acceptable to use digital technologies for HIV research, concerns over privacy and trust have also been expressed. This paper explores and describes the use of geolocation technology data (e.g., location-based social media) in HIV research as well as the ethical and implementation considerations that warrant examination prior to use. Transparent and clear language in consent forms might improve participant trust in the project and investigators' ability to keep participant data secure and private. With respect to institutional review boards, a committee member who is knowledgeable about digital technologies and consumer protections may offer guidance in assessing adequate protections in study protocols. As technology used in research continues to evolve, investigators and the research community must continue to examine the ethical challenges that emerge to address participant concerns.

User perspectives and preferences regarding a mobile health cough application: A qualitative study during the coronavirus disease pandemic in Denmark

Introduction

Health care systems worldwide are currently facing major challenges because of the coronavirus disease pandemic. When individuals experience coronavirus disease symptoms, they often have to decide whether to seek health care services and render themselves vulnerable to infection or stay home and monitor their condition. Coronavirus disease management strategies should aim to reduce transmission, promote disease control, and facilitate self-monitoring within the population. In this regard, mobile health technologies serve as supportive tools, and acquiring knowledge about user perspectives will facilitate the development and integration of coronavirus disease-related applications. Accordingly, this study aimed to examine user perspectives on applications that monitor coronavirus disease-related physical signs and identify discrepancies between user expectations and developer design perspectives within the Danish context.

Materials and methods

A qualitative research design was adopted. Semi-structured telephone interviews were conducted to examine user expectations during the first wave of the coronavirus disease pandemic in April 2020. The theoretical framework, which was inspired by the concept of health literacy, was developed using a six-step thematic analytic approach.

Results

The analysis yielded two major themes that captured user experiences: (1) coronavirus disease-related applications may serve as digital tools that foster safety when physical signs are monitored and (2) the acceptability of coronavirus disease-related applications depends on the adoption of a personalised and user-friendly design.

Characteristics of Acute Childhood Illness Apps for Parents: Environmental Scan

Background

Providing parents with resources that aid in the identification and management of acute childhood illnesses helps those parents feel better equipped to assess their children’s health and significantly changes parental health-seeking behaviors. Some of these resources are limited by accessibility and scalability. Remote locations and staffing limitations create challenges for parents aiming to access their child’s health information. Mobile health apps offer a scalable, accessible solution for improving health literacy by enabling access to health information through mobile devices. 

Objective

The aim of our study is to create an inventory of acute childhood illness apps that are available to North American parents and caregivers, assess their quality, and identify the areas in which future apps can be improved.

Methods

We conducted an environmental scan to identify and summarize app information for parents and digital health researchers. The Google and Apple app marketplaces were used as search platforms. We built a list of search terms and searched the platforms for apps targeted at parents and related to acute pediatric illnesses in the United States and Canada. We assessed apps meeting the inclusion criteria using the Mobile App Rating Scale (MARS), a validated tool for assessing the quality of health apps. The MARS examines apps on 5 subscales: engagement, functionality, aesthetics, information quality, and subjective quality. Data were analyzed by MARS subscale averages and individual item scores.

Results

Overall, 650 unique apps were screened, and 53 (8.2%) were included. On a scale of 1-5, apps had an average engagement score of 2.82/5 (SD 0.86), functionality score of 3.98/5 (SD 0.72), aesthetics score of 3.09/5 (SD 0.87), information quality score of 2.73/5 (SD 1.32), and subjective quality score of 2.20/5 (SD 0.79). On the same scale of 1-5, app scores ranged from 2.2/5 to 4.5/5 (mean 3.2, SD 0.6). The top 3 MARS-scored apps were Baby and Child First Aid (4.5/5), Ada (4.5/5), and HANDi Paediatric (4.2/5). Taken together, the top 3 apps covered topics of emergency pediatric first aid, identification of (and appropriate response to) common childhood illnesses, a means of checking symptoms, and a means of responding to emergency situations. There was a lack of Canadian-based app content available to parents in both marketplaces; this space was filled with content originating primarily in the United Kingdom and the United States. In addition, published evidence of the impact of the included apps was poor: of 53 apps, only 5 (9%) had an evidence base showing that the app had been trialed for usability or efficacy.

Conclusions

There is a need for evidence-based acute childhood illness apps of Canadian origin. This environmental scan offers a comprehensive picture of the health app landscape by examining trends in acute childhood illness apps that are readily available to parents and by identifying gaps in app design.

Digital Health Literacy in Bipolar Disorder: International Web-Based Survey

BACKGROUND

Web-based resources can support people with bipolar disorder (BD) to improve their knowledge and self-management. However, publicly available resources are heterogeneous in terms of their quality and ease of use. Characterizing digital health literacy (the skillset that enable people to navigate and make use of health information in a web-based context) in BD will support the development of educational resources.

OBJECTIVE

The aim of this study was to develop understanding of digital health literacy and its predictors in people with BD.

METHODS

A web-based survey was used to explore self-reported digital health literacy (as measured by the e-Health Literacy Scale [eHEALS]) in people with BD. Multiple regression analysis was used to evaluate potential predictors, including demographic/clinical characteristics and technology use.

RESULTS

A total of 919 respondents (77.9% female; mean age 36.9 years) completed the survey. Older age (β=0.09; P=.01), postgraduate education (β=0.11; P=.01), and current use of self-management apps related to BD (β=0.13; P<.001) were associated with higher eHEALS ratings.

CONCLUSIONS

Levels of self-reported digital health literacy were comparable or higher than other studies in the general population and specific physical/mental health conditions. However, individuals with BD who are younger, have completed less education, or are less familiar with mental health apps may require extra support to safely and productively navigate web-based health resources. Relevant educational initiatives are discussed. Future studies should evaluate skill development interventions for less digitally literate groups.

Can digital health technologies exacerbate the health gap? A clustering analysis of mothers' opinions toward digitizing the maternal and child health handbook

Background

The use of mobile health has increased worldwide, but along with its increased utilization comes the risk of the digital divide, inequity in access to information and communications technologies, exerting greater influence on health inequity caused by socioeconomic determinants of health. There is a growing need to investigate whether the digitization of existing health interventions has a risk of worsening the health gap.

Methods

We investigated the attitudes of mothers and pregnant women toward digitization of the Maternal and Child Health Handbook (MCHH), a popular personal health record (PHR) used by almost every pregnant woman or mother in Japan, using a cross-sectional survey. We determined sociodemographic factors associated with favorable opinions toward digitization using a multivariate regression model. We then grouped the participants using partitioning around medoids clustering, a machine-learning approach, to interpret their varying attitudes toward digitization in light of their sociodemographic characteristics as well as their affinity toward the paper MCHH.

Findings

Higher income and educational level, older age, and less reliance on the MCHH were significantly associated with favorable opinion toward digitization. Clustering analysis identified four latent clusters. The cluster with the highest socioeconomic status (SES) was the most favorable toward digitization, while two clusters with the lowest SES, one of which relied heavily on the paper MCHH, were less favorable of digitization compared to the high SES cluster. The final cluster was comprised of mothers with the experience of raising multiple children and did not rely heavily on the MCHH.

Interpretation

Our study identified a socioeconomic divide in opinions toward digitization of an existing health intervention. A hasty digitization may result in an unbalanced uptake of the digitized health intervention among different social classes.

•

No study has evaluated the possible consequences of digitizing health interventions.

•

Mothers with lower SES tended to have less favorable opinions toward digitization.

•

Digitization of existing health intervention may exacerbate the health gap.

Integrating health literacy into a theory-based drug-use prevention program: a quasi-experimental study among junior high students in Taiwan

BACKGROUND

In Taiwan, illegal drug use is a critical health problem during adolescence. Schools playa vital role in preventing students' illegal drug use. Accordingly, we developed and evaluated a school-based, drug-use prevention program integrating the theory of planned behavior (TPB) and health literacy for junior high school students.

AIM

This study aimed to use a theory-based program to prevent students from illegal drug use in Taiwanese junior high school students.

METHODS

We recruited 648 junior high school students aged around 13-14 years (grades 7 to 8 students) from 14 selected schools: N = 323 in the experimental group, N = 325 in the comparison group. The experimental group received 10 45-min sessions of a theory-based drug-use prevention program. The comparison group received traditional didactic teaching and drug refusal skill training. We used a generalized estimating equation (GEE) to analyze data.

RESULTS

Results of paired t-tests indicated that drug-use health literacy and TPB-related variables improved in the experimental group. The GEE analyses indicated that participants in the experimental group also demonstrated significantly improved health literacy (p < 0.001) compared to the comparison group, especially for functional (p < 0.001) and critical health literacy (p = 0.017). The experimental group also showed significant post-intervention improvement in terms of subjective norm scores (p = 0.024).

CONCLUSION

Study results demonstrated the effectiveness of a drug-use prevention program on health literacy and subjective norm through integrating the Theory of Planned Behavior and health literacy. The study supports that the future implementation of similar programs for junior high school students can integrate health literacy and subjective norms as two critical program components.

Using Gaze Tracking as a Research Tool in the Deaf Health Literacy and Access to Health Information Project: Protocol for a Multisite Mixed Methods Study and Preliminary Results

BACKGROUND

Previous studies have identified the internet as a major source of health information. Reliable and accessible sources of web-based health information are critical for cultivating patient-centered care. However, the accessibility and use of web-based health information remains largely unknown for deaf individuals. We used gaze-tracking technology to understand the navigation and use of web-based health information by deaf adults who communicate with sign language and by hearing adults.

OBJECTIVE

This paper discusses our protocol for implementing gaze-tracking technology in a study that included both deaf and hearing participants. We report the preliminary results and lessons learned from the implementation of the protocol.

METHODS

We conducted gaze-tracking sessions with 450 deaf signers and 450 hearing participants as a part of a larger, multisite mixed methods research study. Then, we conducted qualitative elicitation interviews with a subsample of 21 deaf and 13 hearing participants, who engaged in a search task and reviewed their gaze recordings. To our knowledge, no study has implemented a similar research protocol to better understand the experiences of deaf adults. As such, we also examined research staff notes and observations from team meetings regarding the conduct of gaze-tracking data to delineate lessons learned and best practices for research protocols in this area.

RESULTS

Findings from the implementation of this study protocol highlight the use of gaze technology with deaf participants. We developed additional protocol steps to minimize gaze disruption from either lipreading or communicating in sign language. For example, research assistants were often unable to maintain eye contact with participants while signing because of the need to simultaneously point at the computer monitor to provide instructions related to gaze study components, such as the calibration process. In addition to developing ways to effectively provide instructions in American Sign Language, a practice exercise was included in the gaze tracker session to familiarize participants with the computer and technology. The use of the playback feature permitted a deeper dialogue between researchers and participants, which we found vital for understanding the experiences of deaf participants.

CONCLUSIONS

On the basis of our experience using the study protocol through a large research project, incorporating gaze-tracking technology offers beneficial avenues for better understanding how individuals interact with health information. Gaze tracking can determine the type and placement of visual content that attracts attention from the viewers of diverse backgrounds, including deaf individuals. The lessons learned through this study will help future researchers in determining ideal study designs, such as suitable protocols and participant characteristics (eg, deaf signers), while including gaze trackers in their projects. This approach explored how different ways of presenting health information can affect or enable visual learners to engage and use health information effectively.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/26708.

Re-Prioritizing Digital Health and Health Literacy in Healthy People 2030 to Affect Health Equity

The U.S. Healthy People 2030 health objective-setting process has taken place in an inequitable social structure with significant implications for health literacy, health equity, and population health. The draft 2030 objectives have greatly reduced the number of digital health and health literacy objectives, meaning our national agenda is poised to capture only a fraction of what will evolve in digital and health literacy between 2020 and 2030. This paper synthesizes two decades of Healthy People data on health literacy and digital health objectives, highlights the digital health and health literacy trends and disparities that persist and proposes remedies to ensure that health literacy and digital health issues receive the attention they deserve in the next decade. These remedies can inform policies, research, and interventions that touch health communication and digital health issues.

The Challenge of Sustainable Access to Telemonitoring Tools for People with Diabetes in Europe: Lessons from COVID-19 and Beyond

Telemedicine in diabetes care has been evolving over several years, particularly since the advent of cloud-connected technologies for diabetes management, such as glucose monitoring devices, including continuous glucose monitoring (CGM) systems, that facilitate sharing of glucose data between people with diabetes and their healthcare professionals in near-real time. Extreme social distancing and shielding in place for vulnerable patients during the COVID-19 pandemic has created both the challenge and the opportunity to provide care at a distance on a large scale. Available evidence suggests that glucose control has in fact improved during this period for people with diabetes who are able to use CGM devices for remote glucose monitoring. The development of telemedicine as part of the standard of care in diabetes faces significant challenges in the European context, particularly in terms of providing consistent and effective care at a distance to large populations of patients while using robust systems that can be supported by large regional and national healthcare services. These challenges include a fragmented approach to healthcare technology assessment and reimbursement, lack of eHealth education and literacy, particularly amongst healthcare professionals, lack of data integration, as well as concerns about electronic health records, patient consent and privacy. Here we review the benefits of and challenges to wider application of telemedicine and telemonitoring in the post-pandemic future, with the aim to ensure that the value of these eHealth services is provided to patients, healthcare providers and health systems.

Does health literacy impact technological comfort in cancer patients?

Introduction

As healthcare systems are adapting due to COVID-19, there has been an increased need for telehealth in the outpatient setting. Not all patients have been comfortable with this transition. We sought to determine the relationship between health literacy and technological comfort in our cancer patients.

Methods

We conducted a survey of patients that presented to the oncology clinics at a single-center over a 2-month period. Patients were given a voluntary, anonymous, survey during their visit containing questions regarding demographics, health literacy and technological comfort.

Results

344 surveys were returned (response-rate 64.3%). The median patient age was 61 years, 70% of responders were female and the most common race was White (67.3%). Increasing patient age, male gender, Black and Native-American race, decreased health literacy and lack of home broadband were associated with lower technological comfort score.

Conclusion

In our cohort, patients with lower health literacy scores, older and male patients, or who have poor internet access showed a lower level of technological comfort. At risk patients can be identified and provided additional support in their use of telehealth services.

Who is more likely to adopt and comply with the electronic patient-reported outcome measure (ePROM) mobile application? A real-world study with cancer patients undergoing active treatment

PURPOSE

This study aims to identify factors associated with the adoption and compliance of electronic patient-reported outcome measure (ePROM) use among cancer patients in a real-world setting.

METHODS

This prospective cohort study was conducted at the Samsung Medical Center in Seoul, Korea, from September 2018 to January 2019. Cancer patients aged 18 years or older who owned smartphones and who were receiving chemotherapy or radiation therapy were eligible for this study. Patients were asked to use the app to report their symptoms every 7 days for a total of 21 days (3 weeks). Logistic regression was performed to identify the factors associated with the adoption and compliance.

RESULTS

Among 580 patients, 417 (71.9%) adopted the ePROM app and 159 (27.4%) out of 417 had good compliance. Patients who had greater expectations regarding the ease of use (adjusted odds ratio [aOR] 2.67, 95% CI: 1.28-5.57) and usefulness (aOR 1.69, 95% CI: 1.05-2.72) of the ePROM app were more likely to adopt the app than those who did not. Patients who had greater satisfaction with usefulness (aOR 1.89, 95% CI 1.10-3.25) were more likely to comply with using the app, but satisfaction with ease of use was not related to the compliance.

CONCLUSION

While expectation regarding the ease of use and usefulness of the ePROM app was associated with the adoption of the app, satisfaction with ease of use was not related to compliance with the ePROM app. Satisfaction with usefulness was associated with the compliance of ePROM app use.

Disparities in Telehealth Utilization Within Pediatric Gastroenterology: One Academic Center's Experience

OBJECTIVES

While the use of telemedicine has accelerated significantly with the recent pandemic, it has also magnified disparities in access to telemedicine. This study aims to look at telemedicine utilization patterns within a large pediatric gastroenterology practice.

METHODS

A retrospective study of ambulatory care visits within Yale-New Haven Hospital's pediatric gastroenterology practice during the peak expansion of the telemedicine program was conducted. Zip code-level socioeconomic data were obtained using the Distressed Communities Index. A multivariate logistic regression to evaluate disparities between the use of video versus telephone visits was computed, and unadjusted and adjusted odds ratios with 95% confidence intervals (CIs) were obtained.

RESULTS

A total of 1273 clinic visits were included in analysis. The majority of the patients listed English as their preferred language, had private insurance, and identified as non-Hispanic White. When adjusting for co-variates, having public insurance/Medicaid was associated with decreased odds of having video over telephone visits (adjusted odds ratio [aOR] 0.60; 95% CI 0.44-0.80). Those whose primary language was not English continued to have a statistically significant decreased odds of using video visits (Spanish aOR 0.24; 95% CI 0.13-0.44; other aOR 0.29; 95% CI 0.12-0.72). Within the adjusted multivariate logistic regression, race/ethnicity and SES were, however, no longer found to have a statistically significant decreased odds of video visits.

CONCLUSIONS

The accelerated implementation of telemedicine within pediatric gastroenterology has given rise to disparities in its use. Further studies are needed to understand these disparities and develop interventions to lessen this gap in usage.

Voicing Individual Concerns for Engagement in Hemodialysis (VOICE-HD): A Mixed Method, Randomized Pilot Trial of Digital Health in Dialysis Care Delivery

BACKGROUND

People receiving in-center hemodialysis (HD) have prioritized the need for more individualized health information and better communication with nephrologists. The most common setting for patient-nephrologist interactions is during the HD treatment, which is a time pressured setting that lacks privacy.

OBJECTIVE

To facilitate effective communication in the hemodialysis (HD) unit, we evaluated the usability of a web application (web app) from both the patient and physician perspective. The main aim of the web app was to support patients in prioritizing their dialysis concerns outside of the clinical HD encounter.

DESIGN

Mixed method, parallel arm, multi-site, pilot randomized controlled trial.

SETTING

Two outpatient Canadian HD centers.

PARTICIPANTS

Adult patients receiving in-center HD and their attending nephrologists.

METHODS

Patients were randomized to either a web application or an active control (paper form) for logging concerns to be addressed at weekly encounters with the nephrologist over 8 weeks. Topics included: HD treatment, symptoms, modality, and medications. The primary outcome was usability, defined as effectiveness (engagement with the tool, frequency of submitted concerns, whether the concern was satisfactorily addressed) and satisfaction with the tool using a priori thresholds and explored in interviews with patients and nephrologists.

RESULTS

77 patients (30 women, median age 61, interquartile range [53,67], median 2 years [1,4] on dialysis) and 19 nephrologists (4 women, median age 46 [36,65]) were enrolled. Patient use of a digital device at baseline was low (20%). Engagement with the tool was 70% (web app) and 100% (paper) with a lower proportion of patients in the web app group submitting at least one concern over 8 weeks compared to the paper form group: 56.7% vs 87.9%. Weekly concerns were satisfactorily addressed in both groups and ≥70% of patients would continue to use the tools. For patients, both tools promoted preparation and participation in the encounter; however, only the web app facilitated greater privacy in relaying concerns. For most nephrologists, the tools were disruptive to their workflow and were perceived as unnecessary given existing processes and familiarity with patients. For future versions of the app, patients suggested more features to facilitate self-management and nephrologists suggested integration with health databases and multidisciplinary teams.

LIMITATIONS

Tertiary setting may limit generalizability.

CONCLUSIONS

Both tools promoted fundamental components of self-management; however, patients in the paper form group submitted concerns more often and this tool was easier to remember to use. Although modifications would likely enhance web app usability, successful future adoption is limited by physician acceptance.Trial registration ClinicalTrials.gov NCT03605875.

Age as an Independent Predictor of Adult Spinal Cord Stimulation Pain Outcomes

INTRODUCTION

Spinal cord stimulation (SCS) is an efficacious chronic pain treatment most commonly used in middle-aged patients. Results from previous studies that investigated SCS' effects in older patient populations have been equivocal. We examine whether SCS outcomes correlate with age.

METHODS

We retrospectively examined prospectively collected outcomes from 189 patients who underwent SCS at Albany Medical Center between 2012 and 2020. The patients completed the Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) preoperatively and 1 year postoperatively. The mean percent change in each outcome was determined and compared via a regression analysis to determine relationships between patient age and each respective outcome metrics. Demographics were compared between patients aged under 65 versus those aged 65 and older via χ2 tests.

RESULTS

All subjects demonstrated the expected improvement on NRS, BDI, PCS, and MPQ from baseline to 1-year follow-up, with several demonstrating statistically significant changes: NRS-worst pain (18.66%, p < 0.001), NRS-least pain (26.9%, p < 0.001), NRS-average pain (26.9%, p < 0.01), NRS-current pain (26.4%, p < 0.001), ODI (19.6%, p < 0.001), PCS (29.8%, p < 0.001), and MPQ (29.4%, p < 0.001). There was no significant difference between patients aged under 65 versus those aged 65 and older based on lead type (p = 0.454). Six patients (3.1%) had lead migration, one of whom was 65 or older. Regression analysis revealed improvements in MPQ-sensory and MPQ-affective scores as age increased (p < 0.001, R2 = 0.09; p = 0.046, R2 = 0.05, respectively). Age did not correlate with NRS, ODI, BDI, or PCS. Diagnosis, spinal level of SCS, and lead type were not found to influence any respective outcome measure based on covariate analysis.

CONCLUSION

This study represents the largest study where age was correlated to specific pain, depression, and disability outcomes following SCS. We provide evidence that SCS outcomes are equivalent, or better, in older patients following SCS. Based on these findings, SCS is a viable option for treatment of chronic pain in elderly patient populations.

Descriptive Review of Online Information Resources for People With Stroke: Protocol for a Scoping Review

BACKGROUND

People with stroke and their caregivers experience numerous information needs; internet-based resources may offer cost-effective ways to improve access to information about this condition and its management, including the availability of resources and support. The quality of online health information is, therefore, an important consideration for both developers and consumers of these online resources.

OBJECTIVE

This study aims to map and evaluate the content, readability, understandability, design, and quality characteristics of freely available online information resources (ie, websites) that empower people with stroke and their caregivers with information and self-help strategies poststroke.

METHODS

This descriptive review will follow the five systematic and rigorous methodological steps that are recommended for scoping reviews, which include the following: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. Data will then be synthesized and analyzed thematically.

RESULTS

As of February 2021, the scoping review is in the data extraction stage. Data will be synthesized, and the first results are expected to be submitted for publication in an open-access peer-reviewed journal in August 2021. In addition, we will develop an accessible summary of the results for stakeholder meetings. Ethical approval is not required for this review, as it will only include publicly available information.

CONCLUSIONS

This study is novel and will evaluate the typology, content, and design-related criteria, including accessibility, aesthetics, navigability, interactivity, privacy, and data protection, of online information resources for stroke. The review will be limited to online resources published in English.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23174.

Patient Portals: Useful for Whom and for What? A Cross-Sectional Analysis of National Survey Data

BACKGROUND

Patients who use patient portals may be more engaged and empowered in their care; however, differences in who accesses patient portals remain. The characteristics of who uses patient portals more frequently and who perceives them as useful may also differ, as well as which functions people use.

OBJECTIVE

We assessed the characteristics of patient portal users to examine who uses them more frequently and who perceives them as useful. In addition, we wanted to see if those who use them more frequently or perceive them to be more useful use different functions or more functions of patient portals.

METHODS

Pooled cross-sectional data from 2017 to 2018 Health Information National Trends Survey (HINTS) were used. Ordinal regression models were developed to assess frequency of use and perceived usefulness by demographics, and multivariable logistic regression models were used to examine the association between the use of 10 patient portal functions and frequency of use and perceived usefulness of patient portals.

RESULTS

The odds of using patient portals more frequently were higher among those with Bachelor's degrees, incomes between $35,000 and $75,000, and those with two or more chronic conditions. Respondents with three or more chronic conditions had higher odds of rating patient portals as useful. Those who used their patient portal 10 or more times in the past year had higher odds of using all functions except for viewing test results compared with those who used their patient portal one to two times per year. Those who rated patient portals as "very useful" had higher odds of using seven of the functions compared with those who rated them "not very"/"not at all useful."

CONCLUSION

It is important to continue to assess usefulness, frequency of use, and overall patient portal function use to identify opportunities to increase patient engagement with patient portals.

eHealth literacy during the COVID-19 pandemic: seeking, sharing, suspicion amongst older and younger UK populations

The containment of infectious diseases is most successful when at-risk populations have a high level of relevant health literacy (HL). To achieve this both literacy needs and patterns of knowledge sharing must be understood within the context of the disease being studied. It is also important to understand these processes from both offline (HL) and online (eHL) perspectives and amongst demographics with access to different types of information and social capital, and who have different levels of vulnerability. This paper discusses the insights gained over a series of 30 interviews with the UK residents aged either 19 − 30 years of age or older than 70 years—focussing on how they seek, understand, evaluate and convey information about COVID-19 during the current pandemic. Using thematic analysis, we identified themes around motivations to seek information, the information journey, digital choice and engagement, dilemmas and challenges of managing and appraising information, and sharing information. There was little difference in the eHL between the two age groups who both had high levels of education and were sophisticated digital citizens. The COVID-19 pandemic highlights three dominant processes in managing complex and uncertain information: some individuals may suffer from information fatigue but there was no evidence of any impact on their behaviours; others seek and share information across many networks; and there were strikingly high levels of distrust leading to complex processes of meaning-making demanding critical health literacy skills.

Association of Smartphone Ownership and Internet Use With Markers of Health Literacy and Access: Cross-sectional Survey Study of Perspectives From Project PLACE (Population Level Approaches to Cancer Elimination)

Background

Telehealth is an increasingly important component of health care delivery in response to the COVID-19 pandemic. However, well-documented disparities persist in the use of digital technologies.

Objective

This study aims to describe smartphone and internet use within a diverse sample, to assess the association of smartphone and internet use with markers of health literacy and health access, and to identify the mediating factors in these relationships.

Methods

Surveys were distributed to a targeted sample designed to oversample historically underserved communities from April 2017 to December 2017. Multivariate logistic regression was used to estimate the association of internet and smartphone use with outcomes describing health care access and markers of health literacy for the total cohort and after stratifying by personal history of cancer. Health care access was captured using multiple variables, including the ability to obtain medical care when needed. Markers of health literacy included self-reported confidence in obtaining health information.

Results

Of the 2149 participants, 1319 (61.38%) were women, 655 (30.48%) were non-Hispanic White, and 666 (30.99%) were non-Hispanic Black. The median age was 51 years (IQR 38-65). Most respondents reported using the internet (1921/2149, 89.39%) and owning a smartphone (1800/2149, 83.76%). Compared with the respondents with smartphone or internet access, those without smartphone or internet access were more likely to report that a doctor was their most recent source of health information (344/1800, 19.11% vs 116/349, 33.2% for smartphone and 380/1921, 19.78% vs 80/228, 35.1% for internet, respectively; both P<.001). Internet use was associated with having looked for information on health topics from any source (odds ratio [OR] 3.81, 95% CI 2.53-5.75) and confidence in obtaining health information when needed (OR 1.83, 95% CI 1.00-3.34) compared with noninternet users. Smartphone owners had lower odds of being unable to obtain needed medical care (OR 0.62, 95% CI 0.40-0.95) than nonsmartphone owners. Among participants with a prior history of cancer, smartphone ownership was significantly associated with higher odds of confidence in ability to obtain needed health information (OR 5.63, 95% CI 1.05-30.23) and lower odds of inability to obtain needed medical care (OR 0.17, 95% CI 0.06-0.47), although these associations were not significant among participants without a prior history of cancer.

Conclusions

We describe widespread use of digital technologies in a community-based cohort, although disparities persist. In this cohort, smartphone ownership was significantly associated with ability to obtain needed medical care, suggesting that the use of smartphone technology may play a role in increasing health care access. Similarly, major illnesses such as cancer have the potential to amplify health engagement. Finally, special emphasis must be placed on reaching patient populations with limited digital access, so these patients are not further disadvantaged in the new age of telehealth.

Novel Validated Index for the Measurement of Disinformation Susceptibility at the County Level

In the past decade, disinformation has become an increasingly dangerous enemy of public health, scientific advancement, and social stability. To address and counter this trend, it is essential to first identify communities most at risk for disinformation. The Jin-Hafiz Disinformation Index (JHDI) is developed and validated as a tool to counter disinformation and address deficits of good information on a county level in the United States. Once vulnerable communities are identified with the JHDI, targeted interventions with community partnerships can be conducted to address knowledge concerns.

Associations Between Rural or Urban Status, Health Outcomes and Behaviors, and COVID-19 Perceptions Among Meditation App Users: Longitudinal Survey Study

BACKGROUND

Rural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users.

OBJECTIVE

We aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time.

METHODS

This study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity.

RESULTS

Participants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor's degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre-COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence.

CONCLUSIONS

We did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases

Health information technology (HIT) can enhance optimal health care access and utilization among individuals living with chronic diseases. This study aimed to provide population-level information on racial/ethnic disparities in HIT use and associated trends among those living with chronic diseases. The study sample consisted of adult respondents (≥18 years) of the 2011-2018 National Health Interview Survey living with at least 1 chronic condition. Binomial regression was used to analyze the association between race/ethnicity, year, and 4 measures of HIT use for patient-provider interaction. Regression parameter estimates were used to predict the trends in probability of the outcome variables across race/ethnicity. About 73% of the study sample were non-Hispanic Whites, 15% were non-Hispanic Blacks, and 13% were Hispanics. Compared to non-Hispanic Whites, there were decreased adjusted odds of any HIT use among non-Hispanic Blacks (OR = 0.72; 95% CI = 0.67, 0.76) and Hispanics (OR = 0.78; 95% CI = 0.72, 0.84). The likelihood of any HIT use increased with increasing year (OR: 1.16; 95% CI = 1.15, 1.18). Trends in racial/ethnic disparities were wider for email communication with provider and online prescription refill compared to online scheduling of appointment. The COVID-19 pandemic has led to accelerated adoption or expansion of HIT for patient care. Limited HIT use among non-Hispanic Blacks and Hispanics could worsen the disproportionate chronic disease burden, suboptimal clinical outcomes, and preventable health care costs experienced by this subpopulation. In conclusion, there is a need for intentional and strategic population-level interventions to increase HIT adoption and use among non-Hispanic Blacks and Hispanics living with chronic diseases.

Generation Gaps in Digital Health Literacy and Their Impact on Health Information Seeking Behavior and Health Empowerment in Hungary

Background: Today the internet is a major source of health information, and younger generations have more confidence in their digital information seeking skills and awareness of online resources than older generations. Older generations, however, are more in demand of health services. The aim of our study was to explore these generational differences as related to self-perceived eHealth literacy and health care system utilization.

Methods: A cross-sectional survey study with 522 subjects was done in Hungary. Every subject belonged to one of four generations (Baby boomers, X, Y, and Z). The Web-based survey was designed and tested in English-speaking countries and translated into Hungarian for the present study. Variables include Internet health information seeking, eHealth literacy (measured by eHeals score), the self-perceived gain in empowerment by that information, and the number of health care appointments. One-way ANOVA was used for comparing the scores of the generations, and correlational and linear regression analysis was employed within the generations for further data analysis.

Results: We found significant differences among the generations in eHealth literacy as well as in the self-perceived gain in empowerment: while Boomers were the generation with the lowest eHeals scores, they showed the highest empowerment. Internet health information seeking behavior showed no differences. While subjects who use the Internet more frequently to search for health information have worse self-rated health status, the ones with higher eHeals scores report better subjective health status. We also identified the associations of the above variables within the older generations (Boomers and X) with the frequency of using health-care services: within the generation of Boomers the number of health care appointments was only associated with Internet health information seeking, while in Generation X with eHeals.

Conclusions: Baby boomers seek Internet health information as often as the younger generations, which provides a solid motivation for developing their eHealth literacy skills. We find it crucial to plan the Hungarian health promotion programmes utilizing this high frequency of Internet health information seeking, since the eHealth literacy skills of older generations have an effect on their subjective health status, and they are the most capable of applying information in making decisions.

Understanding Customers' Continuance Intention

The purpose of this study is to understand the difference between Internet users' continuing use behavior in the context of digital inequality. Data were collected through a survey of Internet users in the Ivory Coast. The structural equation modeling technique was used to test the research hypothesis. This study showed empirically that concern over information and communication technologies (ICT) access as an explanation for digital inequality should be toned down. This research suggests emphasizing alternative factors to explain Internet sustained use intention by underprivileged individuals, including normative beliefs. The results will help internet service providers, governments, and international aid agencies to better understand users' behaviors or reactions to ICT available to them. This understanding provides a foundational platform upon which viable and effective information technology-enabled solutions and policies can be conceptualized and implemented. This study is one of the few that integrate three salient beliefs to differentiate ICT use continuance intention in the context of digital inequality.

A Technology Acceptance Model for Deploying Masks to Combat the COVID-19 Pandemic in Taiwan (My Health Bank): Web-Based Cross-sectional Survey Study

BACKGROUND

The successful completion of medical practices often relies on information collection and analysis. Government agencies and medical institutions have encouraged people to use medical information technology (MIT) to manage their conditions and promote personal health. In 2014, Taiwan established the first electronic personal health record (PHR) platform, My Health Bank (MHB), which allows people to access and manage their PHRs at any time. In the face of the COVID-19 pandemic in 2020, Taiwan has used MIT to effectively prevent the spread of COVID-19 and undertaken various prevention measures before the onset of the outbreak. Using MHB to purchase masks in an efficient and orderly way and thoroughly implementing personal protection efforts is highly important to contain disease spread.

OBJECTIVE

This study aims to understand people's intention to use the electronic PHR platform MHB and to investigate the factors affecting their intention to use this platform.

METHODS

From March 31 to April 9, 2014, in a promotion via email and Facebook, participants were asked to fill out a structured questionnaire after watching an introductory video about MHB on YouTube. The questionnaire included seven dimensions: perceived usefulness, perceived ease of use, health literacy, privacy and security, computer self-efficacy, attitude toward use, and behavioral intention to use. Each question was measured on a 5-point Likert scale ranging from "strongly disagree" (1 point) to "strongly agree" (5 points). Descriptive statistics and structural equation analysis were performed using SPSS 21 and AMOS 21 software.

RESULTS

A total of 350 valid questionnaire responses were collected (female: 219/350, 62.6%; age: 21-30 years: 238/350, 68.0%; university-level education: 228/350, 65.1%; occupation as student: 195/350, 56.6%; average monthly income

CONCLUSIONS

From the perspective of the populace, this study explored the factors affecting the use of MHB and constructed an interpretation model with a strong goodness of fit. The results of our analysis are consistent with the technology acceptance model. Through the diverse value-added services of MHB, Taiwan's experience in pandemic prevention with smart technology can facilitate future responses to unknown, emerging infectious diseases.

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Key Words

• COVID-19
• electronic health record
• electronic medical record
• intention
• literacy
• model
• my health bank
• personal health record
• privacy
• protection
• security
• structural equation model
• survey
• technology acceptance model
• usage

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MESH Headings

• Adult
• COVID-19/epidemiology
• COVID-19/prevention & control
• COVID-19/transmission
• Cross-Sectional Studies
• Disease Transmission, Infectious/prevention & control
• Female
• Humans
• Internet
• Male
• Masks
• Pandemics
• SARS-CoV-2
• Surveys and Questionnaires
• Taiwan/epidemiology
• Technology
• Young Adult

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Affiliation(s)

Wen-Hsun Tsai Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan Medical Administration Office, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
Yi-Syuan Wu Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
Chia-Shiang Cheng Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
Ming-Hao Kuo Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
Yu-Tien Chang School of Public Health, National Defense Medical Center, Taipei, Taiwan
Fu-Kang Hu Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan Medical Informatics Office, Tri-Service General Hospital, Taipei, Taiwan
Chien-An Sun Big Data Research Center, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
Chi-Wen Chang School of Nursing, College of Medicine, Chang-Gung University, Taoyuan, Taiwan Division of Pediatric Endocrinology & Genetics, Department of Pediatrics, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
Ta-Chien Chan Research Center for Humanities and Social Sciences, Academia Sinica, Taipei, Taiwan
Chao-Wen Chen Trauma and Critical Care Service Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Chia-Cheng Lee Medical Informatics Office, Tri-Service General Hospital, Taipei, Taiwan Division of Colorectal Surgery, Department of Surgery, Tri-Service General Hospital, Taipei, Taiwan
Chi-Ming Chu Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan School of Public Health, National Defense Medical Center, Taipei, Taiwan Big Data Research Center, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan Department of Public Health, China Medical University, Taichung, Taiwan Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Healthcare Administration and Medical Informatics, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

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Collaborators Collapse

Identifying the role of inpatient portals to support health literacy: Perspectives from patients and care team members

OBJECTIVE

Health literacy is a fundamental contributor to an individual's ability to self-manage their health and appropriately use health care services. Tools that positively impact health literacy therefore have potential to improve health outcomes. Inpatient portals are a tool that provides patients an opportunity to cultivate health literacy skills during hospitalization. Our study investigated how inpatient portal use could impact attributes of health literacy.

METHODS

We conducted semi-structured interviews with 132 patients and 440 care team members to learn about patients' inpatient portal use. Interview transcripts were analyzed deductively and inductively to categorize data and understand emergent themes around health literacy.

RESULTS

Patients and care team members identified inpatient portal functions that they perceived to positively impact health literacy. These functions included providing patients access to health information, care plans, and educational materials, as well as enabling patient communication with their care team.

CONCLUSION

Recognizing the potential of inpatient portals to improve health literacy is critical to ensure they are implemented in ways that leverage this benefit for patients.

PRACTICE IMPLICATIONS

Health care organizations should implement inpatient portals that include features that support health literacy and encourage patients to use these portals in ways that improve their health literacy skills.

The Geriatric Acute and Post-Acute Fall Prevention Intervention (GAPcare) II to Assess the Use of the Apple Watch in Older Emergency Department Patients With Falls: Protocol for a Mixed Methods Study

Background

Falls are a common problem among older adults that lead to injury, emergency department (ED) visits, and institutionalization. The Apple Watch can detect falls and alert caregivers and clinicians that help is needed; the device could also be used to objectively collect data on gait, fitness, and falls as part of clinical trials. However, little is known about the ease of use of this technology among older adult ED patients, a population at high risk of recurrent falls.

Objective

The goal of this study—the Geriatric Acute and Post-Acute Fall Prevention Intervention (GAPcare) II—is to examine the feasibility, acceptability, and usability of the Apple Watch Series 4 paired with the iPhone and our research app Rhode Island FitTest (RIFitTest) among older adult ED patients seeking care for falls.

Methods

We will conduct field-testing with older adult ED patients (n=25) who sustained a fall and their caregivers (n=5) to determine whether they can use the Apple Watch, iPhone, and app either (1) continuously or (2) periodically, with or without telephone assistance from the research staff, to assess gait, fitness, and/or falls over time. During the initial encounter, participants will receive training in the Apple Watch, iPhone, and our research app. They will receive an illustrated training manual and a number to call if they have questions about the research protocol or device usage. Participants will complete surveys and cognitive and motor assessments on the app during the study period. At the conclusion of the study, we will solicit participant feedback through semistructured interviews. Qualitative data will be summarized using framework matrix analyses. Sensor and survey response data will be analyzed using descriptive statistics.

Results

Recruitment began in December 2019 and was on pause from April 2020 until September 2020 due to the COVID-19 pandemic. Study recruitment will continue until 30 participants are enrolled. This study has been approved by the Rhode Island Hospital Institutional Review Board (approval 1400781-16).

Conclusions

GAPcare II will provide insights into the feasibility, acceptability, and usability of the Apple Watch, iPhone, and the RIFitTest app in the population most likely to benefit from the technology: older adults at high risk of recurrent falls. In the future, wearables could be used as part of fall prevention interventions to prevent injury before it occurs.

Trial Registration

ClinicalTrials.gov NCT04304495; https://clinicaltrials.gov/ct2/show/NCT04304495

International Registered Report Identifier (IRRID)

DERR1-10.2196/24455

Patient characteristics associated with objective measures of digital health tool use in the United States: A literature review

OBJECTIVE

The study sought to determine which patient characteristics are associated with the use of patient-facing digital health tools in the United States.

MATERIALS AND METHODS

We conducted a literature review of studies of patient-facing digital health tools that objectively evaluated use (eg, system/platform data representing frequency of use) by patient characteristics (eg, age, race or ethnicity, income, digital literacy). We included any type of patient-facing digital health tool except patient portals. We reran results using the subset of studies identified as having robust methodology to detect differences in patient characteristics.

RESULTS

We included 29 studies; 13 had robust methodology. Most studies examined smartphone apps and text messaging programs for chronic disease management and evaluated only 1-3 patient characteristics, primarily age and gender. Overall, the majority of studies found no association between patient characteristics and use. Among the subset with robust methodology, white race and poor health status appeared to be associated with higher use.

DISCUSSION

Given the substantial investment in digital health tools, it is surprising how little is known about the types of patients who use them. Strategies that engage diverse populations in digital health tool use appear to be needed.

CONCLUSION

Few studies evaluate objective measures of digital health tool use by patient characteristics, and those that do include a narrow range of characteristics. Evidence suggests that resources and need drive use.

Trends and Characteristics of the US Adult Population's Behavioral Patterns in Web-Based Prescription Filling: National Survey Study

Background

Filling a prescription on the web has become an alternative to in-person pharmacies for individuals to access their medications. However, the adoption of web-based filling has been gradual, and the use patterns remain to be unclear.

Objective

This study aims to estimate the trend and prevalence of web-based prescription-filling behavior and identify associated factors among adults in the United States.

Methods

We used data from the US National Health Interview Survey (NHIS) from 2009 to 2018. Adult respondents (aged ≥18 years and over) self-reported their behavior of web-based prescription filling, which was defined as having filled a prescription using the internet in the past 12 months during the survey year. We reported trends using weighted percentages adjusted by the NHIS complex sampling design. We used descriptive statistics and multivariable logistic regression models to examine trends and identify factors associated with web-based prescription-filling behavior.

Results

The estimated number of adults reporting web-based prescription-filling behavior significantly increased from 13,319,877 (13,319,877/225,217,942, 5.91%) in 2009 to 28,308,262 (28,308,262/246,611,125, 11.48%) in 2018 (P<.001). Those who were more likely to report filling a prescription on the web were aged between 35 and 74 years, female, White, and frequent users of the computer or internet; these adults also reported higher education, higher income, insurance coverage, and poorer health status.

Conclusions

Web-based prescription-filling behavior among US adults has increased significantly from 2009 to 2018. Health care providers should be aware of the upward trend in the use of web-based pharmacies and ensure the clinical safety of web-based prescriptions.

Examining an Integrative Cognitive Model of Predicting Health App Use: Longitudinal Observational Study

BACKGROUND

Specifying the determinants of using health apps has been an important research topic for health scholars as health apps have proliferated during the past decade. Socioeconomic status (SES) has been revealed as a significant determinant of using health apps, but the cognitive mechanisms underlying the relationship between SES and health app use are unknown.

OBJECTIVE

This study aims to examine the cognitive mechanisms underlying the relationships between SES and use of health apps, applying the integrative model of behavioral prediction (IM). The model hypothesizes the indirect influences of SES on intentions to use health apps, which in turn predict actual use of health apps. The relationships between SES and intentions to use health apps were assumed to be mediated by proximal variables (attitudes, perceived behavioral control [PBC], injunctive norms, and descriptive norms).

METHODS

We conducted path analyses using data from a two-wave opt-in panel survey of Korean adults who knew about health apps. The number of respondents was 605 at baseline and 440 at follow-up. We compared our model with two alternative theoretical models based on modified IM to further clarify the roles of determinants of health app use.

RESULTS

Attitudes (β=.220, P<.001), PBC (β=.461, P<.001), and injunctive norms (β=.186, P<.001) were positively associated with intentions to use health apps, which, in turn, were positively related to actual use of health apps (β=.106, P=.03). Income was positively associated with intentions to use health apps, and this relationship was mediated by attitudes (B=0.012, 95% CI 0.001-0.023) and PBC (B=0.026, 95% CI 0.004-0.048). Education was positively associated with descriptive norms (β=.078, P=.03), but descriptive norms were not significantly related to intentions to use health apps. We also found that PBC interacted with attitudes (B=0.043, SE 0.022, P=.046) and jointly influenced intentions to use health apps, whereas the results did not support direct influences of education, income, and PBC on health app use.

CONCLUSIONS

We found that PBC over using health apps may be the most important factor in predicting health app use. This suggests the necessity of designing and promoting health apps in a user-friendly way. Our findings also imply that socioeconomic inequalities in using health apps may be reduced by increasing positive attitudes toward, and boosting PBC over, health app use among individuals with low income.

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

BACKGROUND

Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas.

OBJECTIVES

The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers.

METHODS

We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges.

RESULTS

Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1-38) years and had used an electronic medical record for 7.0 (1-20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team).

CONCLUSION

Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.

Perioperative mobile application for mothers undergoing Cesarean delivery: a prospective cohort study on patient engagement

Purpose

Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care.

Method

We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1–5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care.

Results

Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31–36] yr. Each participant visited the application a median of 15 [9–31] times over 30 days and completed a median of 3 [2–4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2–7] out of eight education topics, with the most viewed patient education topics being “Controlling Pain” and “The First Few Days”. Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2–10).

Conclusion

Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs.

Trial registration

www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.

Supplementary Information

The online version of this article (10.1007/s12630-020-01907-x) contains supplementary material, which is available to authorized users.

Internal carotid artery aneurysm presenting as diplopia via telemedicine during COVID-19

A patient presented with acute onset of double vision during the start of the COVID-19 pandemic when elective medical care was restricted. Initially declining an in-person evaluation, she was examined using a telehealth video visit, incorporating multiple technological modalities to ascertain ophthalmic examination elements. Her findings prompted emergent neuroimaging, revealing a giant internal carotid artery aneurysm, which was successfully embolized to prevent debilitating and possibly fatal intracranial haemorrhage. This case report illustrates the successful use of telemedicine and remote patient data acquisition to make a life-saving diagnosis.

Trends and Predictors of Use of Digital Health Technology in the United States

BACKGROUND

Digital health technology is becoming central to health care. A better understanding of the trends and predictors of its use could reflect how people engage with the health care system and manage their health care needs.

METHODS

Using data from the National Health Interview Survey for years 2011 to 2018, we assessed the use of digital health technology among individuals aged ≥18 years in the United States across 2 domains: 1) search for health information online and 2) interaction with health care providers (eg, fill a prescription, schedule a medical appointment, or communicate with health care providers).

RESULTS

Our study included 253,829 individuals; representing nearly 237 million adults in the United States annually; mean age 49.6 years (SD 18.4); 51.8% women; and 65.9% non-Hispanic white individuals. Overall, 49.2% of individuals reported searching for health information online and 18.5% reported at least 1 technology-based interaction with the health care system. Between 2011 and 2018, the proportion who searched for health information online increased from 46.5% to 55.3% (P < .001), whereas the proportion who used technology to interact with the health care system increased from 12.5% to 27.4% (P < .001). Although technology-based interaction with the health care system increased across most subgroups, there were significant disparities in the extent of increase across clinical and sociodemographic subgroups.

CONCLUSIONS

The use of digital health technologies increased between 2011 and 2018, however, the uptake of these technologies has been unequal across subgroups. Future innovations and strategies should focus on expanding the reach of digital heath technology across all subgroups of society to ensure that its expansion does not exacerbate the existing health inequalities.

Development of health literacy among postgraduate students: From information literacy perspective

OBJECTIVES

Involving the patients in health-related decisions requires high health literacy. Health literacy is related to the concept of information literacy through its emphasis on information skills. Hence, the aim of this study was to investigate the relationship between information literacy and health literacy.

STUDY DESIGN

We carried out an original research.

MATERIALS AND METHODS

This is an applied research that is carried out in a survey method. The statistical population of this study is MSc and PhD students at School of Health Management and Information Science in Iran University of Medical Sciences who were selected by stratified random sampling. A standard health literacy questionnaire including access dimensions, reading skills, comprehension, evaluation, decision-making, and application of health information was used to assess the health literacy status of the students. To measure information literacy, the questionnaire includes identifying information needs, locating information, organizing information, and evaluating information were used. The data were analyzed by tests of one-sample t-test, Pearson correlation, and simple linear regression with spss software version 18 produced by IBM located at New York.

RESULTS

The results showed that the level of information literacy among students was higher than the average level. The average of information literacy rate in the sample is 49.09. In this regard, the most frequent information is gained from the internet, interacting with friends, and asking practitioners and health workers. In addition, there is a positive and significant relationship between all dimensions of information literacy with health literacy and information literacy affects 35.4% of health literacy changes.

CONCLUSIONS

It can be said that information literacy is a predictor of health literacy. Furthermore, the pattern of people's health information has moved to new information environments and to improve health having sufficient information seeking and information literacy skills are essential.

Health Literacy Interventions to Improve Health Outcomes in Low- and Middle-Income Countries

BACKGROUND

Health care systems in many low- and middle-income countries (LMICs) face considerable challenges in providing high-quality, affordable, and universally accessible care. Feasible solutions to these issues require health literacy (HL) interventions for people who live in LMICs. Low HL is a significant problem in many LMICs because of the low levels of general literacy and poorly resourced and functioning health systems. A comprehensive understanding of HL interventions is essential to determine whether these interventions meet the health information needs of people who live in LMICs and to develop other effective HL interventions specifically for people who live in LMICs, improve health outcomes, and reduce inequalities.

METHODS

A medical research librarian developed and implemented search strategies to identify relevant evidence. Included studies needed to contain HL in LMICs component to understand or evaluate HL interventions that target people who live in LMICs. Two reviewers selected studies, conducted quality assessments, and extracted data by using standard forms. Discussion or third-party adjudication resolved disagreements. The collected data include the design of the study, type of HL intervention, target audience, theoretical influences, approaches to evaluating the intervention delivered, intervention received, intervention fidelity, intervention reach, data analysis, and study outcomes.

KEY RESULTS

The reviewers systematically analyzed the data from 23 published research studies, including 20 quantitative, 1 qualitative, and 2 mixed-method studies, on HL interventions to improve the health outcomes in LMICs. The various HL interventions for different groups of the population depend on the health outcomes of the study. The reviewers identified four themes: traditional HL interventions, art-based HL interventions, interactive learning strategies, and technology-based HL interventions. The researchers of a few studies also used multicomponent interventions to improve the HL of the population.

DISCUSSION

Despite global improvements in health indicators over time, such as decreased mortality and morbidity, significant challenges remain regarding the quality of the delivery of health care in many LMICs. All of the HL interventions were effective and significantly improved the knowledge and awareness of the population. However, based on the literature review, the reviewers found significant evidence that only a limited number of HL interventions are delivered through innovative and technological learning strategies. In addition, the sustainability and scalability of these interventions is not clear. Therefore, future research on sustainability measures for effective HL interventions in LMICs is still needed. [HLRP: Health Literacy Research and Practice. 2020;4(4):e250-e266.].

Patient Experience Monitor (PEM): The Development of New Short-Form Picker Experience Questionnaires for Hospital Patients with a Wide Range of Literacy Levels

PURPOSE

Several patient-reported experience measures (PREMs) were developed through the years. These questionnaires are frequently found to be inappropriate for people with lower literacy levels. This paper describes the development of patient experience questionnaires for hospital patients with a wide range of literacy levels, while enabling the potential for quality improvement.

METHODS

Mixed methods were used to adapt Picker Institute patient experience questionnaires: selection of items and adaptation towards language level B1 (the language level of which patients can express their own opinion and describe experiences, events and expectations) by expert panels, usability tests with patients, analysis of psychometric properties and member checking. A theory-driven approach was followed for definitive enrolment of items, meaning that the items eligible for exclusion had been carefully reviewed by the expert team and representatives of a patient council before definitive exclusion.

RESULTS

A pilot study was performed in an University Medical Centre in the Netherlands among in- and outpatients after discharge. Two provisional questionnaires of 22 items, designed by an expert panel, were reduced towards a final selection of 14-15 items. This led to two short-form questionnaires, called Patient Experience Monitor (PEM) Adult Inpatient and PEM Adult Outpatient. To illustrate, the results of the PEM Adult Outpatient questionnaire are presented.

CONCLUSION

PEMs are short and valid questionnaires specifically developed to measure patient experiences of hospital patients with a wide range of literacy levels. Acceptance of the questionnaires for both lower and higher educated patients are confirmed by usability tests. The respondents of the pilot study represent both groups. The developed questionnaires should be seen as a dynamic entity and part of a continuous effort to evaluate and improve patient experiences. Future studies are needed to examine the usability of these new questionnaires for quality improvement.

Factors affecting the acceptance of integrated electronic personal health records in Saudi Arabia: The impact of e-health literacy

Background:

National implementation of electronic personal health record (ePHR) systems is of vital importance to governments worldwide because this type of technology promises to promote and enhance healthcare. Although there is widespread agreement as to the advantages of ePHRs, the level of awareness and acceptance of this technology among healthcare consumers has been low.

Objective:

The aim of this study was to identify the factors that can influence the acceptance and use of an integrated ePHR system in Saudi Arabia.

Method:

The unified theory of acceptance and use of technology model was extended in this study to include e-health literacy (e-HL) and tested using structural equation modelling. Data were collected via a questionnaire survey, resulting in 794 valid responses.

Results:

The proposed model explained 56% of the variance in behavioural intention (BI) to use the integrated ePHR system. Findings also highlighted the significance of performance expectancy, effort expectancy, social influence (SI) and e-HL as determinants of Saudi healthcare consumers’ intentions to accept and use the integrated ePHR system. Additionally, assessment of the research model moderators revealed that only gender had a moderating influence on the relationship between SI and BI. Finally, findings showed a low level of awareness among Saudi citizens about the national implementation of an integrated ePHR system, suggesting the need to promote a greater and more widespread awareness of the system and to demonstrate its usefulness.

Conclusion:

Findings from this study can assist governments, policymakers and developers of health information technologies and systems by identifying important factors that may influence the diffusion and use of integrated ePHRs.

Photovoice-Towards Engaging and Empowering People with Intellectual Disabilities in Innovation

E-health and welfare technology offer new ways to support health and social care delivery. While initiatives are made to engage disadvantaged user groups in innovation, people with intellectual disabilities tend to be excluded from design activities. This is a concern as this group can benefit from the use of assistive technology. However, it can be time-consuming and challenging to involve end-users in the design of technology. This calls for processes that are creative, empowering and that facilitate user involvement. In this study, we report and reflect on the process of using photovoice to understand user needs and to empower participants with intellectual disability in an innovation process. Nine persons with intellectual disability participated in photovoice to identify user needs connected to the design of assistive technology. The findings in our study suggest that the use of photovoice can contribute to the sharing of contextual and individual needs and an empowerment process that includes coping, self-determination and ownership. Photovoice can be a tool to reduce or remove some of the challenges that are faced when identifying user needs and is a way to strengthen the individual’s capacity to cope with the demands of participating in an innovation process.

Health Literacy of Adolescents

PURPOSE

The purpose of this study is to describe influencing factors of adolescent health literacy.

METHODS

This study is a descriptive, correlational, cross-sectional study. Based on an a priori power analysis and utilizing convenience sampling, 105 adolescents completed the Newest Vital Sign (NVS) health literacy instrument via the Qualtrics online platform. Health literacy was correlated with potential influencing factors to determine relationships between variables.

RESULTS

The mean NVS score was 3.78 (SD = 1.96), indicating possible limited health literacy in this population. There was a moderate, positive correlation between adolescent health literacy and race (r = 0.34, p = .00), with non-white adolescents scoring lower than white adolescents. There was a moderate, positive correlation between adolescent health literacy and income (r = 0.24, p < .05). There were no statistically significant correlations between adolescent health literacy and age or grade level. Regression analysis showed that the overall model accounts for a significant amount of the variance in health literacy scores (F (2, 95) =7.99, p = .001; R² = 0.144; R²_adjusted = 0.126). Race was the only variable that significantly contributed to the model (β = 1.26; SE(β) = 0.40; Standardized β = 0.30, p < .01).

CONCLUSIONS

This study adds to the paucity of adolescent health literacy literature. Furthermore, this study indicates that race and income may play significant roles in adolescent health literacy. Future research is needed to further investigate influencing factors of adolescent health literacy.

PRACTICE IMPLICATIONS

This article provides unique information for nurses to consider alongside other individualized assessments as they continue to design health promotion and patient education practices for adolescents.

The difference in knowledge and attitudes of using mobile health applications between actual user and non-user among adults aged 50 and older

Background

Despite the great benefits of mobile health applications (mHAs) in managing non-communicable diseases (NCDs) internationally, studies have documented general challenges to broad adoption of mHAs among older age groups. By focusing on broad adoption, these studies have been limited in their evaluation of adults aged 50 and older who have high risk of NCDs and can benefit the most from the functionalities provided by mHAs.

Objective

This study aims to evaluate the knowledge, self-confidence, perceived benefits, and barriers of using mHAs depending on experience with mHAs among adults aged 50 and older. Furthermore, we aim to identify the factors associated with the actual use of mHAs.

Methods

We conducted a cross-sectional survey at a single tertiary hospital in Seoul, Korea, between May 1 and May 31, 2018. Of the 625 participants who were contacted, 323 participants were granted full inclusion to the study. We compared demographics, knowledge, self-confidence, and perceived benefits and barriers by experience with using mHAs, then performed logistic regression to identify the factors associated with mHA use.

Results

Among the participants, 64.1% (N = 207) had experience using mHAs. Those in the experienced group were more likely to have more than college education (55.1% vs. 27.5%, P < 0.001) and to report a higher monthly income (≥ $7,000, 22.7% vs. 18.1%, P = 0.05) than their less-experienced counterparts. Although the experienced group was more likely to have higher self-confidence in using mHAs, about half of the study participants, including people with experience using mHAs, did not have appropriate knowledge of mobile technology. With adjusted logistic model, higher educated (adjusted PR (aPR) = 1.53, 95% CI, 1.26–1.80), higher perceived benefits of mHAs (aPR = 1.43, 95% CI, 1.04–1.83), and higher self-confidence using mHAs (aPR = 1.41, 95% CI, 1.12–1.70) were significant factors associated with mHA use.

Conclusions

The use of mHAs among adults aged 50 and older is becoming more common globally; nevertheless, there are still people unable to use mHAs properly because of lack of experience and knowledge. Strategies are needed to encourage the reliable usage of mHAs among those who may need it the most by improving self-confidence and better articulating benefits.

Electronic wearable device and physical activity among US adults: An analysis of 2019 HINTS data

BACKGROUND

Promoting physical activity is one of the most critical components in strategies to improve both individual and population health. Previous studies on electronic wearable devices (EWDs) have shown modest improvements in physical activity, including daily steps and energy expenditures. Large population-based evidence on EWDs and physical activity is needed to better understand the patterns of EWD use and physical activity.

METHODS

This cross-sectional study used data from the Health Information National Trends Survey 2019. We calculated weighted frequencies and prevalence of EWD utilization. Wald Chi-square test was used to compare individual characteristics by EWD use, and multivariable logistic regression model was fitted to examine the associations between EWD use and physical activity level while adjusting for sociodemographic/health-related characteristics.

RESULTS

The final sample included 4219 respondents representing 212,976,500 US adults aged 18 years or older. The overall utilization of EWDs in this group was 28.2 % (95 % CI, 26.0-30.5%). Respondents who used EWDs were more likely to have 150 min/week or over physical activities compared to those who did not use EWDs in the past 12 months (OR, 1.53, 95 % CI, 1.16-2.02). When restricting the analaysis to those with chronic conditions only, EWD use was still associated with higher level of physical activity (OR, 1.74, 95 % CI, 1.02-2.98).

CONCLUSIONS

About three in ten Americans reported using EWDs in the past year. EWD use seems to be associated with achieving a higher level of physical activity. Further studies are needed to examine the effect of EWD use on other clinical measures and subsequent health outcomes.

The Role of Telehealth During the COVID-19 Pandemic Across the Interdisciplinary Cancer Team: Implications for Practice

Objective

This literature review aims to explore the role of telehealth during the COVID-19 pandemic across the interdisciplinary cancer care team.

Data Sources

Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, and gray literature were searched using Google Scholar up until September 2020.

Conclusion

Although the safe and effective delivery of cancer care via telehealth requires education and training for health care professionals and patients, telehealth has provided a timely solution to the barriers caused by the COVID-19 pandemic on the delivery of interdisciplinary cancer services. Globally, evidence has shown that telehealth in cancer care can leverage an innovative response during the COVID-19 pandemic but may provide a long-lasting solution to enable patients to be treated appropriately in their home environment. Telehealth reduces the travel burden on patients for consultation, affords a timely solution to discuss distressing side effects, initiate interventions, and enable possible treatment additions and/or changes.

Implications for Nursing Practice

Global public health disasters pose significant and unique challenges to the provision of necessary services for people affected by cancer. Oncology nurses can provide a central contribution in the delivery of telehealth through transformational leadership across all domains and settings in cancer care. Oncology nurses provide the “hub of cancer care” safely embedded in the interdisciplinary team. Telehealth provides a solution to the current global health crisis but could also benefit the future provision of services and broad reach clinical trials.

Artificial Intelligence Chatbot Behavior Change Model for Designing Artificial Intelligence Chatbots to Promote Physical Activity and a Healthy Diet: Viewpoint

BACKGROUND

Chatbots empowered by artificial intelligence (AI) can increasingly engage in natural conversations and build relationships with users. Applying AI chatbots to lifestyle modification programs is one of the promising areas to develop cost-effective and feasible behavior interventions to promote physical activity and a healthy diet.

OBJECTIVE

The purposes of this perspective paper are to present a brief literature review of chatbot use in promoting physical activity and a healthy diet, describe the AI chatbot behavior change model our research team developed based on extensive interdisciplinary research, and discuss ethical principles and considerations.

METHODS

We conducted a preliminary search of studies reporting chatbots for improving physical activity and/or diet in four databases in July 2020. We summarized the characteristics of the chatbot studies and reviewed recent developments in human-AI communication research and innovations in natural language processing. Based on the identified gaps and opportunities, as well as our own clinical and research experience and findings, we propose an AI chatbot behavior change model.

RESULTS

Our review found a lack of understanding around theoretical guidance and practical recommendations on designing AI chatbots for lifestyle modification programs. The proposed AI chatbot behavior change model consists of the following four components to provide such guidance: (1) designing chatbot characteristics and understanding user background; (2) building relational capacity; (3) building persuasive conversational capacity; and (4) evaluating mechanisms and outcomes. The rationale and evidence supporting the design and evaluation choices for this model are presented in this paper.

CONCLUSIONS

As AI chatbots become increasingly integrated into various digital communications, our proposed theoretical framework is the first step to conceptualize the scope of utilization in health behavior change domains and to synthesize all possible dimensions of chatbot features to inform intervention design and evaluation. There is a need for more interdisciplinary work to continue developing AI techniques to improve a chatbot's relational and persuasive capacities to change physical activity and diet behaviors with strong ethical principles.

Potential Benefits and Risks Resulting From the Introduction of Health Apps and Wearables Into the German Statutory Health Care System: Scoping Review

BACKGROUND

Germany is the first country worldwide that has introduced a digital care act as an incentive system to enhance the use of digital health devices, namely health apps and wearables, among its population. The act allows physicians to prescribe statutory financed and previously certified health apps and wearables to patients. This initiative has the potential to improve treatment quality through better disease management and monitoring.

OBJECTIVE

The aim of this paper was to outline the key concepts related to the potential risks and benefits discussed in the current literature about health apps and wearables. Furthermore, this study aimed to answer the research question: Which risks and benefits may result from the implementation of the digital care act in Germany?

METHODS

We conducted the scoping study by searching the databases PubMed, Google Scholar, and JMIR using the keywords health apps and wearables. We discussed 55 of 136 identified articles published in the English language from 2015 to March 2019 in this paper using a qualitative thematic analysis approach.

RESULTS

We identified four key themes within the articles: Effectivity of health apps and wearables to improve health; users of health apps and wearables; the potential of bring-your-own, self-tracked data; and concerns and data privacy risks. Within these themes, we identified three main stages of benefits for the German health care system: Usage of health apps and wearables; continuing to use health apps and wearables; and sharing bring-your-own; self-tracked data with different agents in the health care sector.

CONCLUSIONS

The digital care act could lead to an improvement in treatment quality through better patient monitoring, disease management, personalized therapy, and better health education. However, physicians should play an active role in recommending and supervising health app use to reach digital-illiterate or health-illiterate people. Age must not be an exclusion criterion. Yet, concerns about data privacy and security are very strong in Germany. Transparency about data processing should be provided at all times for continuing success of the digital care act in Germany.

Effect of Prior Health Knowledge on the Usability of Two Home Medical Devices: Usability Study

Background

Studies on the usability of health care devices are becoming more common, although usability standards are not necessarily specified and followed. Yet, there is little knowledge about the impact of the context of use on the usability outcome. It is specified in the usability standard (ISO 9241-11, 2018) of a device that it may be affected by its context of use and especially by the characteristics of its users. Among these, prior health knowledge (ie, knowledge about human body functioning) is crucial. However, no study has shown that prior health knowledge influences the usability of medical devices. 

Objective

Our study aimed to fill this gap by analyzing the relationship between the usability of two home medical devices (soon to be used in the context of ambulatory surgery) and prior health knowledge through an experimental approach.

Methods

For assessing the usability of two home medical devices (blood pressure monitor and pulse oximeter), user tests were conducted among 149 students. A mixed-methods approach (subjective vs objective) using a variety of standard instruments was adopted (direct observation, video analysis, and questionnaires). Participants completed a questionnaire to show the extent of their previous health knowledge and then operated both devices randomly. Efficiency (ie, handling time) and effectiveness (ie, number of handling errors) measures were collected by video analysis. Satisfaction measures were collected by a questionnaire (system usability scale [SUS]). The qualitative observational data were coded using inductive analysis by two independent researchers specialized in cognitive psychology and cognitive ergonomics. Correlational analyses and clusters were performed to test how usability relates to sociodemographic characteristics and prior health knowledge.

Results

The results indicated a lack of usability for both devices. Regarding the blood pressure monitor (137 participants), users made approximately 0.77 errors (SD 1.49), and the mean SUS score was 72.4 (SD 21.07), which is considered “satisfactory.” The pulse oximeter (147 participants) appeared easier to use, but participants made more errors (mean 0.99, SD 0.92), and the mean SUS score was 71.52 (SD 17.29), which is considered “satisfactory.” The results showed a low negative and significant correlation only between the effectiveness of the two devices and previous knowledge (blood pressure monitor: r=−0.191, P=.03; pulse oximeter: r=−0.263, P=.001). More subtly, we experimentally identified the existence of a threshold level (χ²_2,146=10.9, P=.004) for health knowledge to correctly use the pulse oximeter, but this was missing for the blood pressure monitor.

Conclusions

This study has the following two contributions: (1) a theoretical interest highlighting the importance of user characteristics including prior health knowledge on usability outcomes and (2) an applied interest to provide recommendations to designers and medical staff.