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

Prostate Cancer Survival Estimates by the General Public Using Unrestricted Internet Searches and Online Nomograms

BACKGROUND

Patient understanding of cancer-associated risk influences treatment preferences and is vital for making informed treatment decisions. Although patients traditionally relied on physician visits for cancer information, most adults now use the Internet as a primary source of health information.

OBJECTIVE

To evaluate whether US adults can accurately estimate survival for hypothetical prostate cancer patients using unrestricted Internet searching and an online nomogram.

DESIGN, SETTING, AND PARTICIPANTS

Adults were recruited at the Minnesota State Fair. Participants were shown a pathology report for a prostatectomy cancer specimen and asked to estimate the patient's 15-yr survival using an unrestricted Internet search. Participants were then asked to re-estimate using a freely available, validated prostate cancer nomogram.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Participants' answers were compared to a "reference" estimate and a "ballpark" estimate of ±10 percentage points of the "reference" value.

RESULTS AND LIMITATIONS

A total of 129 participants met the inclusion criteria and generated complete responses. Only 12% (95% confidence interval [CI] 7.8-19.2%) were within the "ballpark" estimate when using unrestricted Internet searching for overall survival estimates. 23% (95% CI 16.8-31.3%) correctly used the nomogram and 51% (95% CI 42.6-59.6%) estimated within the "ballpark" when using the nomogram.

CONCLUSIONS

Use of an unrestricted Internet search often yields inaccurate estimations of life expectancy, while estimations significantly improve with nomogram use. Physicians should educate and guide patients towards credible online health resources, facilitate their effective use, and engage in discussion with patients regarding the utility of this information.

PATIENT SUMMARY

The general public finds it difficult to estimate prostate cancer survival using unrestricted Internet searches. Most patients would benefit from Internet guidance from their clinicians to better understand prostate cancer pathology reports.

Identification of Patient Perceptions That Can Affect the Uptake of Interventions Using Biometric Monitoring Devices: Systematic Review of Randomized Controlled Trials

Background

Biometric monitoring devices (BMDs) are wearable or environmental trackers and devices with embedded sensors that can remotely collect high-frequency objective data on patients’ physiological, biological, behavioral, and environmental contexts (for example, fitness trackers with accelerometer). The real-world effectiveness of interventions using biometric monitoring devices depends on patients’ perceptions of these interventions.

Objective

We aimed to systematically review whether and how recent randomized controlled trials (RCTs) evaluating interventions using BMDs assessed patients’ perceptions toward the intervention.

Methods

We systematically searched PubMed (MEDLINE) from January 1, 2017, to December 31, 2018, for RCTs evaluating interventions using BMDs. Two independent investigators extracted the following information: (1) whether the RCT collected information on patient perceptions toward the intervention using BMDs and (2) if so, what precisely was collected, based on items from questionnaires used and/or themes and subthemes identified from qualitative assessments. The two investigators then synthesized their findings in a schema of patient perceptions of interventions using BMDs.

Results

A total of 58 RCTs including 10,071 participants were included in the review (the median number of randomized participants was 60, IQR 37-133). BMDs used in interventions were accelerometers/pedometers (n=35, 60%), electrochemical biosensors (eg, continuous glucose monitoring; n=18, 31%), or ecological momentary assessment devices (eg, carbon monoxide monitors for smoking cessation; n=5, 9%). Overall, 26 (45%) trials collected information on patient perceptions toward the intervention using BMDs and allowed the identification of 76 unique aspects of patient perceptions that could affect the uptake of these interventions (eg, relevance of the information provided, alarm burden, privacy and data handling, impact on health outcomes, independence, interference with daily life). Patient perceptions were unevenly collected in trials. For example, only 5% (n=3) of trials assessed how patients felt about privacy and data handling aspects of the intervention using BMDs.

Conclusions

Our review showed that less than half of RCTs evaluating interventions using BMDs assessed patients’ perceptions toward interventions using BMDs. Trials that did assess perceptions often only assessed a fraction of them. This limits the extrapolation of the results of these RCTs to the real world. We thus provide a comprehensive schema of aspects of patient perceptions that may affect the uptake of interventions using BMDs and which should be considered in future trials.

Trial Registration

PROSPERO CRD42018115522; https://tinyurl.com/y5h8fjgx

Effectiveness of ICT-based intimate partner violence interventions: a systematic review

BACKGROUND

Intimate Partner Violence is a "global pandemic". Meanwhile, information and communication technologies (ICT), such as the internet, mobile phones, and smartphones, are spreading worldwide, including in low- and middle-income countries. We reviewed the available evidence on the use of ICT-based interventions to address intimate partner violence (IPV), evaluating the effectiveness, acceptability, and suitability of ICT for addressing different aspects of the problem (e.g., awareness, screening, prevention, treatment, mental health).

METHODS

We conducted a systematic review, following PRISMA guidelines, using the following databases: PubMed, PsycINFO, and Web of Science. Key search terms included women, violence, domestic violence, intimate partner violence, information, communication technology, ICT, technology, email, mobile, phone, digital, ehealth, web, computer, online, and computerized. Only articles written in English were included.

RESULTS

Twenty-five studies addressing screening and disclosure, IPV prevention, ICT suitability, support and women's mental health were identified. The evidence reviewed suggests that ICT-based interventions were effective mainly in screening, disclosure, and prevention. However, there is a lack of homogeneity among the studies' outcome measurements and the sample sizes, the control groups used (if any), the type of interventions, and the study recruitment space. Questions addressing safety, equity, and the unintended consequences of the use of ICT in IPV programming are virtually non-existent.

CONCLUSIONS

There is a clear need to develop women-centered ICT design when programming for IPV. Our study showed only one study that formally addressed software usability. The need for more research to address safety, equity, and the unintended consequences of the use of ICT in IPV programming is paramount. Studies addressing long term effects are also needed.

Problem-solving in technology-rich environments and cancer screening in later life

Routine cancer screening is widely recognized as an effective preventive strategy to reduce cancer mortality - the second leading cause of death in the US. However, cancer screening requires a complex array of tasks such as seeking up-to-date guidelines, making appointments, planning hospital visits, and communicating with health care professionals. Importantly, modern health care largely relies on technology to disseminate the latest information and administer the system. Yet, little is known about the technology-related skills that are relevant to regular cancer screening. This study examined the association between problem-solving skills in the technology-rich environment and cancer screening in later life. Using 2012/2014 Program for International Assessment of Adult Competencies data, binary logistic regressions with survey weights were used to estimate the association between problem-solving skills in the technology-rich environment and four cancer screening behaviors among the corresponding target populations aged between 45 and 74 years old (n = 1374 for cervical screening; n = 1373 for breast screening; n = 1166 for prostate screening; n = 2563 for colon screening). Results showed that greater problem-solving skills in the technology-rich environment scores (0-500 points) were significantly and positively associated with prostate cancer screening (odds ratio = 1.005, P < 0.05) among men, but not with colon (men and women) or cervical or breast (women) cancer screenings. Improvement in problem-solving skills in the technology-rich environment may promote specific cancer screening behaviors. Our findings inform future policy discussions and interventions that seek to improve cancer screening among a vulnerable section of older populations.

Recruiting Student Health Coaches to Improve Digital Blood Pressure Management: Randomized Controlled Pilot Study

BACKGROUND

Hypertension is a significant problem in the United States, affecting 1 in 3 adults aged above 18 years and is associated with a higher risk for cardiovascular disease and stroke. The prevalence of hypertension has increased in medically underserved areas (MUAs). Mobile health technologies, such as digital self-monitoring devices, have been shown to improve the management of chronic health conditions. However, patients from MUAs have reduced access to these devices because of limited resources and low health literacy. Health coaches and peer training programs are a potentially cost-effective solution for the shortage of physicians available to manage hypertension in MUAs. Activating young people as student health coaches (SHCs) is a promising strategy to improve community health.

OBJECTIVE

This pilot study aims to assess (1) the feasibility of training high school students as health technology coaches in MUAs and (2) whether the addition of SHCs to digital home monitoring improves the frequency of self-monitoring and overall blood pressure (BP) control.

METHODS

In total, 15 high school students completed 3-day health coach training. Patients who had a documented diagnosis of hypertension were randomly assigned to 1 of the 3 intervention arms. The QardioArm alone (Q) group was provided a QardioArm cuff only for convenience. The SHC alone (S) group was instructed to meet with a health coach for 30 min once a week for 5 weeks to create action plans for reducing BP. The student+QardioArm (S+Q) group received both interventions.

RESULTS

Participants (n=27) were randomly assigned to 3 groups in a ratio of 9:9:9. All 15 students completed training, of which 40% (6/15) of students completed all the 5 meetings with their assigned patient. Barriers to feasibility included transportation and patient response drop-off at the end of the study. Overall, 92% (11/12) of the students rated their experience as very good or higher and 69% (9/13) reported that this experience made them more likely to go into the medical field. There was a statistically significant difference in the frequency of cuff use (S+Q vs Q groups: 37 vs 17; P<.001). Participants in the S+Q group reported better BP control after the intervention compared with the other groups. The average BP at the end of the intervention was 145/84 (SD 9/18) mm Hg, 150/85 (SD 18/12) mm Hg, and 128/69 (SD 20/14) mm Hg in the Q, S, and S+Q groups, respectively.

CONCLUSIONS

This pilot study demonstrates the feasibility of pairing technology with young student coaches, although challenges existed. The S+Q group used their cuff more than the Q group. Patients were more engaged in the S+Q group, reporting higher satisfaction with their SHC and better control of their BP.

A Digital Health Intervention for Weight Management for Latino Families Living in Rural Communities: Perspectives and Lessons Learned During Development

Rural residents face numerous challenges in accessing quality health care for management of chronic diseases (eg, obesity, diabetes), including scarcity of health care services and insufficient public transport. Digital health interventions, which include modalities such as internet, smartphones, and monitoring sensors, may help increase rural residents’ access to health care. While digital health interventions have become an increasingly popular intervention strategy to address obesity, research examining the use of technological tools for obesity management among rural Latino populations is limited. In this paper, we share our experience developing a culturally tailored, interactive health intervention using digital technologies for a family-oriented, weight management program in a rural, primarily Latino community. We describe the formative research that guided the development of the intervention, discuss the process of developing the intervention technologies including issues of privacy and data security, examine the results of a pilot study, and share lessons learned. Our experience can help others design user-centered digital health interventions to engage underserved populations in the uptake of healthy lifestyle and disease management skills.

Influence of Personality on mHealth Use in Patients with Diabetes: Prospective Pilot Study

Background

Mobile technology for health (mHealth) interventions are increasingly being used to help improve self-management among patients with diabetes; however, these interventions have not been adopted by a large number of patients and often have high dropout rates. Patient personality characteristics may play a critical role in app adoption and active utilization, but few studies have focused on addressing this question.

Objective

This study aims to address a gap in understanding of the relationship between personality traits and mHealth treatment for patients with diabetes. We tested the role of the five-factor model of personality traits (openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism) in mHealth adoption preference and active utilization.

Methods

We developed an mHealth app (DiaSocial) aimed to encourage diabetes self-management. We recruited 98 patients with diabetes—each patient freely chose whether to receive the standard care or the mHealth app intervention. Patient demographic information and patient personality characteristics were assessed at baseline. App usage data were collected to measure user utilization of the app. Patient health outcomes were assessed with lab measures of glycated hemoglobin (HbA_1c level). Logistic regression models and linear regression were employed to explore factors predicting the relationship between mHealth use (adoption and active utilization) and changes in health outcome.

Results

Of 98 study participants, 46 (47%) downloaded and used the app. Relatively younger patients with diabetes were 9% more likely to try and use the app (P=.02, odds ratio [OR] 0.91, 95% CI 0.85-0.98) than older patients with diabetes were. Extraversion was negatively associated with adoption of the mHealth app (P=.04, OR 0.71, 95% CI 0.51-0.98), and openness to experience was positively associated with adoption of the app (P=.03, OR 1.73, 95% CI 1.07-2.80). Gender (P=.43, OR 0.66, 95% CI 0.23-1.88), education (senior: P=.99, OR 1.00, 95% CI 0.32-3.11; higher: P=.21, OR 2.51, 95% CI 0.59-10.66), and baseline HbA_1c level (P=.36, OR 0.79, 95% CI 0.47-1.31) were not associated with app adoption. Among those who adopted the app, a low education level (senior versus primary P=.003; higher versus primary P=.03) and a high level of openness to experience (P=.048, OR 2.01, 95% CI 1.01-4.00) were associated with active app utilization. Active users showed a significantly greater decrease in HbA_1c level than other users (ΔHbA_1c=−0.64, P=.05).

Conclusions

This is one of the first studies to investigate how different personality traits influence the adoption and active utilization of an mHealth app among patients with diabetes. The research findings suggest that personality is a factor that should be considered when trying to identify patients who would benefit the most from apps for diabetes management.

A new age intervention to support medication adherence

Adherence to pharmacological treatments is a complex behaviour which is influenced by a number of factors throughout a person's medication use journey. No single intervention has yet been shown to effectively address non-adherence long term. Technology, which can support a multifaceted intervention targeted to the needs of a person, may present a feasible solution to optimise adherence. Technological interventions such as mobile applications (apps) have shown early promise, increasing medication adherence rates and providing health care practitioners with an opportunity to monitor and measure adherence. Some of their features include providing informational messages, saving prescription details and sending refill reminders. Their inability to address patient specific factors across the three phases of adherence (initiation, implementation and discontinuation) limit their usefulness in clinical practice. We propose recommendations to guide the design of digital interventions that can support adherence. Interventions should be individualised to address patient specific factors that affect adherence to medications; the features should support individuals across all three phases of adherence. Interventions must integrate within existing prescriber and dispensing software and interconnect all members of an individual's healthcare team. Finally, to ensure optimal outcomes for the individual, all digital interventions should inform the person about why adherence is necessary.

A Systematic Review of Randomized Controlled Trials of Telehealth and Digital Technology Use by Community Pharmacists to Improve Public Health

Community pharmacists (CPs) continue to have an important role in improving public health, however, advances in telehealth and digital technology mean that the methods by which they support their customers and patients are changing. The primary aim of this study was to identify which telehealth and digital technology tools are used by CPs for public health purposes and determine if these have a positive impact on public health outcomes. A systematic review was carried out using databases including PubMed and ScienceDirect, covering a time period from April 2005 until April 2020. The search criteria were the following: randomized controlled trials, published in English, investigating the delivery of public health services by community pharmacists using a telehealth or digital tool. Thirteen studies were included out of 719 initially identified. Nine studies detailed the use of telephone prompts or calls, one study detailed the use of a mobile health application, two studies detailed the use of a remote monitoring device, and one study detailed the use of photo-aging software. Public health topics that were addressed included vaccination uptake (n = 2), smoking cessation (n = 1), hypertension management (n = 2), and medication adherence and counseling (n = 8). More studies are needed to demonstrate whether or not the use of novel technology by CPs can improve public health.

Relationship between electronic health literacy, quality of life, and self-efficacy in Tehran, Iran: A community-based study

BACKGROUND

The concept of electronic health literacy has become a main focus of health-care professionals along with the increasing use of the Internet. In Iran, the Internet not yet has much impact on providing health services, and the physicians' and patients' community are now more willing to use the traditional method for diagnosing disease and prescribing medicines. This study aimed to determine the correlation between electronic health literacy, quality of life (QoL), and self-efficacy among Tehran citizens.

MATERIALS AND METHODS

The present study is a descriptive, cross-sectional study with a correlation approach that was conducted on 400 clients of community health centers of Shahid Beheshti University of Medical Sciences in 2019. Samples were selected by stratified random sampling method. Data were collected using E-Health Literacy Questionnaire (α = 0.88), 12-item Short-Form Health Survey (α = 0.73), and General Self-Efficacy Scale (α = 0.87). Analytic statistics were using by descriptive statistics (mean and standard deviation) and inferential statistics (Pearson correlation coefficient and regression analysis) at the significant level (P < 0.05).

RESULTS

Correlation between electronic health literacy and QoL was 0.14 and with self-efficacy was 0.10, which was positive and statistically significant (P < 0.05). In addition, the correlation between QoL and self-efficacy was 0.33, which was positive, statistically significant, and moderate (P < 0.05).

CONCLUSION

According to the findings of this study, it is possible to improve the QoL through the promotion of electronic health literacy and self-efficacy. The results of this study can be used as a basis for health service providers and policymakers in designing and implementing health-related interventions.

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums

Background

The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support.

Objective

The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively.

Methods

A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery.

Results

A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals.

Conclusions

Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.

The Application of Drones in Healthcare and Health-Related Services in North America: A Scoping Review

Using drone aircraft to deliver healthcare and other health-related services is a relatively new application of this technology in North America. For health service providers, drones represent a feasible means to increase their efficiency and ability to provide services to individuals, especially those in difficult to reach locations. This paper presents the results of a scoping review of the research literature to determine how drones are used for healthcare and health-related services in North America, and how such applications account for human operating and machine design factors. Data were collected from PubMed, CINAHL, Scopus, Web of Science, and IEEE Xplore using a block search protocol that combined 13 synonyms for “drone” and eight broad terms capturing healthcare and health-related services. Four-thousand-six-hundred-and-sixty-five documents were retrieved, and following a title, abstract, and full-text screening procedure completed by all authors, 29 documents were retained for analysis through an inductive coding process. Overall, findings indicate that drones may represent a financially feasible means to promote healthcare and health-related service accessibility for those in difficult-to-reach areas; however, further work is required to fully understand the costs to healthcare organizations and the communities they serve.

Differences Between Races in Health Information Seeking and Trust Over Time: Evidence From a Cross-Sectional, Pooled Analyses of HINTS Data

PURPOSE

Assessed racial disparities in health information-seeking behavior and trust of information sources from 2007 to 2017.

DESIGN

Pooled cross-sectional survey data.

SETTING

Health Information National Trends Survey (HINTS).

PARTICIPATION

Data included 6 iterations of HINTS (pooled: N = 19 496; 2007: n = 3593; 2011: n = 3959; 2013: n = 3185; Food and Drug Administration [FDA] 2015: n = 3738; 2017: n = 3285; and FDA 2017: n = 1736).

MEASURES

Outcome variables were health information seeking, high confidence, and high trust of health information from several sources. Independent variable was race group, controlling for other sociodemographic and socioeconomic variables.

ANALYSIS

Weighted descriptive and multivariate logistic regression for the pooled sample assessed associations by race. Fully interacted models with race-survey year interactions compared differences in outcomes between years.

RESULTS

Black respondents, relative to white, had greater odds of having high confidence in their ability to attain health information, trust of health information from newspapers and magazines, radio, internet, television, government, charitable organizations, and religious organizations. Hispanic respondents, relative to white, had lower odds of seeking health information and trusting health information from doctors. They had higher odds of trusting health information from the radio, the internet, television, charitable organizations, and religious organizations.

CONCLUSION

Disparities between races in trust of information sources remained across time. Understanding optimal information media, their reach, and credibility among racial groups could enable more targeted approaches to developing interventions. Our analytical approach minimized limitations present in the HINTS.

Adherence to Dysphagia Treatment Recommendations: A Conceptual Model

Purpose Conceptual models of complex health problems are useful when designing targeted clinical interventions and focused research studies. Understanding and studying patient adherence often involves interplay among many factors that influence whether a patient successfully follows recommendations or completes a therapy program. Functional frameworks serve to arrange these factors visually, increasing interpretability and allowing for empirical testing of relationships among concepts. The purpose of this article is to integrate relevant factors from the literature into a comprehensive framework that describes adherence to dysphagia treatment. Method Using peer-reviewed, published guidelines regarding conceptual model construction, the authors created a list of potential factors that influence patient adherence to dysphagia-related treatment recommendations. During model construction, following extensive review of the literature and existing theories that have been applied in other areas of health care, factors were identified and grouped into conceptually similar domains (clusters). Clusters were arranged into larger categories that emerged during model optimization. Ultimately, two models were created: one that illustrates the interrelated factors of patient adherence and another that illustrates a subset of modifiable risk factors that a clinical speech-language pathologist may influence when developing a dysphagia treatment plan. Results Three general categories from 14 factors emerged based on relationships between factors and aspects of patient care: health factors, individual patient factors, and contextual factors. A second model consisting of modifiable risk factors included access, treatment type, patient perceptions, self-efficacy, health literacy, support factors, and provider bias. Conclusions This conceptual model allows clinicians and researchers to identify and explore the mechanisms driving adherence. Continual refinements of this model should be made as future studies uncover how the interconnectedness of factors affects adherence in dysphagia management. The models we have presented here are ready for clinical application and should also serve researchers as they generate hypotheses and design targeted research questions.

Digital Health Strategies to Fight COVID-19 Worldwide: Challenges, Recommendations, and a Call for Papers

The coronavirus disease (COVID-19) pandemic has created an urgent need for coordinated mechanisms to respond to the outbreak across health sectors, and digital health solutions have been identified as promising approaches to address this challenge. This editorial discusses the current situation regarding digital health solutions to fight COVID-19 as well as the challenges and ethical hurdles to broad and long-term implementation of these solutions. To decrease the risk of infection, telemedicine has been used as a successful health care model in both emergency and primary care. Official communication plans should promote facile and diverse channels to inform people about the pandemic and to avoid rumors and reduce threats to public health. Social media platforms such as Twitter and Google Trends analyses are highly beneficial to model pandemic trends as well as to monitor the evolution of patients' symptoms or public reaction to the pandemic over time. However, acceptability of digital solutions may face challenges due to potential conflicts with users' cultural, moral, and religious backgrounds. Digital tools can provide collective public health benefits; however, they may be intrusive and can erode individual freedoms or leave vulnerable populations behind. The COVID-19 pandemic has demonstrated the strong potential of various digital health solutions that have been tested during the crisis. More concerted measures should be implemented to ensure that future digital health initiatives will have a greater impact on the epidemic and meet the most strategic needs to ease the life of people who are at the forefront of the crisis.

The Use of Internet-Based Health and Care Services by Elderly People in Europe and the Importance of the Country Context: Multilevel Study

Background

Digital health care is becoming increasingly important, but it has the risk of further increasing the digital divide, as not all individuals have the opportunity, skills, and knowledge to fully benefit from potential advantages. In particular, elderly people have less experience with the internet, and hence, they are in danger of being excluded. Knowledge on the influences of the adoption of internet-based health and care services by elderly people will help to develop and promote strategies for decreasing the digital divide.

Objective

This study examined if and how elderly people are using digital services to access health and social care. Moreover, it examined what personal characteristics are associated with using these services and if there are country differences.

Methods

Data for this study were obtained from the Special Eurobarometer 460 (SB 460), which collected data on Europeans’ handling of and attitudes toward digital technologies, robots, and artificial intelligence, including data on the use of internet-based health and social care services, among 27,901 EU citizens aged 15 years or older. Multilevel logistic regression models were adopted to analyze the association of using the internet for health and social care services with several individual and country-level variables.

Results

At the individual level, young age, high education, high social class, and living in an urban area were positively associated with a high probability of using internet-based health and social services. At the country level, the proportion of elderly people who participated in any training activity within the last month was positively associated with the proportion of elderly people using these services.

Conclusions

The probability of using internet-based health and social services and their accompanying advantages strongly depend on the socioeconomic background. Training and educational programs might be helpful to mitigate these differences.

Using Electronic Health Record Portals to Improve Patient Engagement: Research Priorities and Best Practices

Ninety percent of health care systems now offer patient portals to access electronic health records (EHRs) in the United States, but only 15% to 30% of patients use these platforms. Using PubMed, the authors identified 53 studies published from September 2013 to June 2019 that informed best practices and priorities for future research on patient engagement with EHR data through patient portals, These studies mostly involved outpatient settings and fell into 3 major categories: interventions to increase use of patient portals, usability testing of portal interfaces, and documentation of patient and clinician barriers to portal use. Interventions that used one-on-one patient training were associated with the highest portal use. Patients with limited health or digital literacy faced challenges to portal use. Clinicians reported a lack of workflows to support patient use of portals in routine practice. These studies suggest that achieving higher rates of patient engagement through EHR portals will require paying more attention to the needs of diverse patients and systematically measuring usability as well as scope of content. Future work should incorporate implementation science approaches and directly address the key role of clinicians and staff in promoting portal use.

Impact of Age on Patients' Communication and Technology Preferences in the Era of Meaningful Use: Mixed Methods Study

BACKGROUND

Identifying effective means of communication between patients and their health care providers has a positive impact on patients' satisfaction, adherence, and health-related outcomes.

OBJECTIVE

This study aimed to identify the impact of patients' age on their communication and technology preferences when managing their health. We hypothesize that a patient's age affects their communication and technology preferences when interacting with clinicians and managing their health.

METHODS

A mixed methods study was conducted to identify the preferences of patients with cardiovascular diseases. Results were analyzed based on the patients' age. Grounded theory was used to analyze the qualitative data. Patients were recruited based on age, gender, ethnicity, and zip code.

RESULTS

A total of 104 patients were recruited: 34 young adults (19-39 years), 33 middle aged (40-64), and 37 senior citizens (>65). Young adults (mean 8.29, SD 1.66) reported higher computer self-efficacy than middle-aged participants (mean 5.56, SD 3.43; P<.05) and senior citizens (mean 47.55, SD 31.23; P<.05). Qualitative analysis identified the following three themes: (1) patient engagement (young adults favored mobile technologies and text messaging, middle-aged patients preferred phone calls, and senior citizens preferred direct interactions with the health care provider); (2) patient safety (young adults preferred electronic after-visit summaries [AVS] and medication reconciliation over the internet; middle-aged patients preferred paper-based or emailed AVS and medication reconciliation in person; senior citizens preferred paper-based summaries and in-person medication reconciliation); (3) technology (young adults preferred smartphones and middle-aged patients and senior citizens preferred tablets or PCs). Middle-aged patients were more concerned about computer security than any other group. A unique finding among senior citizens was the desire for caregivers to have access to their personal health record (PHR).

CONCLUSIONS

Patients of different ages have different communication and technology preferences and different preferences with respect to how they would like information presented to them and how they wish to interact with their provider. The PHR is one approach to improving patient engagement, but nontechnological options need to be sustained to support all patients.

Influences on the Uptake of and Engagement With Health and Well-Being Smartphone Apps: Systematic Review

BACKGROUND

The public health impact of health and well-being digital interventions is dependent upon sufficient real-world uptake and engagement. Uptake is currently largely dependent on popularity indicators (eg, ranking and user ratings on app stores), which may not correspond with effectiveness, and rapid disengagement is common. Therefore, there is an urgent need to identify factors that influence uptake and engagement with health and well-being apps to inform new approaches that promote the effective use of such tools.

OBJECTIVE

This review aimed to understand what is known about influences on the uptake of and engagement with health and well-being smartphone apps among adults.

METHODS

We conducted a systematic review of quantitative, qualitative, and mixed methods studies. Studies conducted on adults were included if they focused on health and well-being smartphone apps reporting on uptake and engagement behavior. Studies identified through a systematic search in Medical Literature Analysis and Retrieval System Online, or MEDLARS Online (MEDLINE), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Scopus, Cochrane library databases, DataBase systems and Logic Programming (DBLP), and Association for Computing Machinery (ACM) Digital library were screened, with a proportion screened independently by 2 authors. Data synthesis and interpretation were undertaken using a deductive iterative process. External validity checking was undertaken by an independent researcher. A narrative synthesis of the findings was structured around the components of the capability, opportunity, motivation, behavior change model and the theoretical domains framework (TDF).

RESULTS

Of the 7640 identified studies, 41 were included in the review. Factors related to uptake (U), engagement (E), or both (B) were identified. Under capability, the main factors identified were app literacy skills (B), app awareness (U), available user guidance (B), health information (E), statistical information on progress (E), well-designed reminders (E), features to reduce cognitive load (E), and self-monitoring features (E). Availability at low cost (U), positive tone, and personalization (E) were identified as physical opportunity factors, whereas recommendations for health and well-being apps (U), embedded health professional support (E), and social networking (E) possibilities were social opportunity factors. Finally, the motivation factors included positive feedback (E), available rewards (E), goal setting (E), and the perceived utility of the app (E).

CONCLUSIONS

Across a wide range of populations and behaviors, 26 factors relating to capability, opportunity, and motivation appear to influence the uptake of and engagement with health and well-being smartphone apps. Our recommendations may help app developers, health app portal developers, and policy makers in the optimization of health and well-being apps.

Public Engagement and Government Responsiveness in the Communications About COVID-19 During the Early Epidemic Stage in China: Infodemiology Study on Social Media Data

BACKGROUND

Effective risk communication about the outbreak of a newly emerging infectious disease in the early stage is critical for managing public anxiety and promoting behavioral compliance. China has experienced the unprecedented epidemic of the coronavirus disease (COVID-19) in an era when social media has fundamentally transformed information production and consumption patterns.

OBJECTIVE

This study examined public engagement and government responsiveness in the communications about COVID-19 during the early epidemic stage based on an analysis of data from Sina Weibo, a major social media platform in China.

METHODS

Weibo data relevant to COVID-19 from December 1, 2019, to January 31, 2020, were retrieved. Engagement data (likes, comments, shares, and followers) of posts from government agency accounts were extracted to evaluate public engagement with government posts online. Content analyses were conducted for a random subset of 644 posts from personal accounts of individuals, and 273 posts from 10 relatively more active government agency accounts and the National Health Commission of China to identify major thematic contents in online discussions. Latent class analysis further explored main content patterns, and chi-square for trend examined how proportions of main content patterns changed by time within the study time frame.

RESULTS

The public response to COVID-19 seemed to follow the spread of the disease and government actions but was earlier for Weibo than the government. Online users generally had low engagement with posts relevant to COVID-19 from government agency accounts. The common content patterns identified in personal and government posts included sharing epidemic situations; general knowledge of the new disease; and policies, guidelines, and official actions. However, personal posts were more likely to show empathy to affected people (χ²₁=13.3, P<.001), attribute blame to other individuals or government (χ²₁=28.9, P<.001), and express worry about the epidemic (χ²₁=32.1, P<.001), while government posts were more likely to share instrumental support (χ²₁=32.5, P<.001) and praise people or organizations (χ²₁=8.7, P=.003). As the epidemic evolved, sharing situation updates (for trend, χ²₁=19.7, P<.001) and policies, guidelines, and official actions (for trend, χ²₁=15.3, P<.001) became less frequent in personal posts but remained stable or increased significantly in government posts. Moreover, as the epidemic evolved, showing empathy and attributing blame (for trend, χ²₁=25.3, P<.001) became more frequent in personal posts, corresponding to a slight increase in sharing instrumental support, praising, and empathizing in government posts (for trend, χ²₁=9.0, P=.003).

CONCLUSIONS

The government should closely monitor social media data to improve the timing of communications about an epidemic. As the epidemic evolves, merely sharing situation updates and policies may be insufficient to capture public interest in the messages. The government may adopt a more empathic communication style as more people are affected by the disease to address public concerns.

Low-Cost Consumer-Based Trackers to Measure Physical Activity and Sleep Duration Among Adults in Free-Living Conditions: Validation Study

Background

Wearable trackers for monitoring physical activity (PA) and total sleep time (TST) are increasingly popular. These devices are used not only by consumers to monitor their behavior but also by researchers to track the behavior of large samples and by health professionals to implement interventions aimed at health promotion and to remotely monitor patients. However, high costs and accuracy concerns may be barriers to widespread adoption.

Objective

This study aimed to investigate the concurrent validity of 6 low-cost activity trackers for measuring steps, moderate-to-vigorous physical activity (MVPA), and TST: Geonaut On Coach, iWown i5 Plus, MyKronoz ZeFit4, Nokia GO, VeryFit 2.0, and Xiaomi MiBand 2.

Methods

A free-living protocol was used in which 20 adults engaged in their usual daily activities and sleep. For 3 days and 3 nights, they simultaneously wore a low-cost tracker and a high-cost tracker (Fitbit Charge HR) on the nondominant wrist. Participants wore an ActiGraph GT3X+ accelerometer on the hip at daytime and a BodyMedia SenseWear device on the nondominant upper arm at nighttime. Validity was assessed by comparing each tracker with the ActiGraph GT3X+ and BodyMedia SenseWear using mean absolute percentage error scores, correlations, and Bland-Altman plots in IBM SPSS 24.0.

Results

Large variations were shown between trackers. Low-cost trackers showed moderate-to-strong correlations (Spearman r=0.53-0.91) and low-to-good agreement (intraclass correlation coefficient [ICC]=0.51-0.90) for measuring steps. Weak-to-moderate correlations (Spearman r=0.24-0.56) and low agreement (ICC=0.18-0.56) were shown for measuring MVPA. For measuring TST, the low-cost trackers showed weak-to-strong correlations (Spearman r=0.04-0.73) and low agreement (ICC=0.05-0.52). The Bland-Altman plot revealed a variation between overcounting and undercounting for measuring steps, MVPA, and TST, depending on the used low-cost tracker. None of the trackers, including Fitbit (a high-cost tracker), showed high validity to measure MVPA.

Conclusions

This study was the first to examine the concurrent validity of low-cost trackers. Validity was strongest for the measurement of steps; there was evidence of validity for measurement of sleep in some trackers, and validity for measurement of MVPA time was weak throughout all devices. Validity ranged between devices, with Xiaomi having the highest validity for measurement of steps and VeryFit performing relatively strong across both sleep and steps domains. Low-cost trackers hold promise for monitoring and measurement of movement and sleep behaviors, both for consumers and researchers.

Determinants of eHealth Literacy among Adults in China

eHealth can empower patients to make informed health decisions. However, inaccurate and misleading health information is not uncommon on the Internet, which requires users' competencies to both utilize eHealth technologies and evaluate eHealth credibilities. Therefore, this study investigates the determinants of both self-efficacy in utilizing eHealth and frequency of eHealth information evaluation. An Internet-based survey of 923 Chinese adults who are residing in China aged from 21 to 55 years old was conducted. Path analysis was adopted to examine sociodemographic variables, Internet literacy, and health information evaluation as determinants of eHealth literacy variables. Findings demonstrated that Internet literacy positively predicted only self-efficacy in utilizing eHealth. In contrast, health information orientation positively predicted both self-efficacy in utilizing eHealth and frequency of eHealth information evaluation. In addition, Internet literacy and health information orientation mediated the predicted effects of sociodemographic factors on the two eHealth variables. The findings imply that Internet literacy is no longer the primary determinant of eHealth competencies for adults who are tech-savvy users. Instead, interests in health information play a crucial role in improving eHealth competencies.

Health information technology use among older adults in the United States, 2009-2018

Objectives: The purpose of this study was to assess (1) the trends of and (2) the factors associated with health information technology (HIT) use among older adults in the U.S.Methods: A decade (2009-2018) of data from the U.S. National Health Interview Survey (NHIS) was used. The trends of HIT use among older adults (aged 65 over) were reported and compared to younger adults (aged 18-64) using weighted percentages adjusted by NHIS complex sampling design. HIT use, which was assessed with five questions asking whether respondents used the internet to (1) look up health information, (2) use chat groups to learn about health topics, (3) fill a prescription, (4) schedule medical appointments, and (5) communicate with health care providers by email. Andersen's Behavioral Model of Health Services Use was used to select and categorize the covariates. Multivariable logistic regression models were conducted to identify the predictors of HIT use.Results: The prevalence of HIT use significantly increased from 9.3 million (24.8% of the 37.3 million older adults) in 2009 to 22.3 million (43.9% of the 50.9 million older adults) in 2018 (p < .01). Among U.S. older adults, young-older, white females, higher education, higher income, insurance coverage, and good health status were more likely to report HIT use.Conclusions: This study found an increasing trend of HIT use among older adults in the U.S. from 2009 to 2018. Healthcare providers should be conscious of older adults' increased HIT use patterns and guide them to proper health management.

Establishing a digital health platform in an academic medical center supporting rural communities

The University of Arkansas for Medical Sciences (UAMS), like many rural states, faces clinical and research obstacles to which digital innovation is seen as a promising solution. To implement digital technology, a mobile health interest group was established to lay the foundation for an enterprise-wide digital health innovation platform. To create a foundation, an interprofessional team was established, and a series of formal networking events was conducted. Three online digital health training models were developed, and a full-day regional conference was held featuring nationally recognized speakers and panel discussions with clinicians, researchers, and patient advocates involved in digital health programs at UAMS. Finally, an institution-wide survey exploring the interest in and knowledge of digital health technologies was distributed. The networking events averaged 35-45 attendees. About 100 individuals attended the regional conference with positive feedback from participants. To evaluate mHealth knowledge at the institution, a survey was completed by 257 UAMS clinicians, researchers, and staff. It revealed that there are opportunities to increase training, communication, and collaboration for digital health implementation. The inclusion of the mobile health working group in the newly formed Institute for Digital Health and Innovation provides a nexus for healthcare providers and researches to facilitate translational research.

Health promotion with physiolytics: What is driving people to subscribe in a data-driven health plan

Data-driven health promotion programs and health plans try to harness the new possibilities of ubiquitous and pervasive physiolytics devices. In this paper we seek to explore what drives people to subscribe to such a data-driven health plan. Our study reveals that the decision to subscribe to a data-driven health plan is strongly influenced by the beliefs of seeing physiolytics as enabler for positive health behavior change and of perceiving health insurances as trustworthy organizations that are capable of securely and righteously manage the data collected by physiolytics.

Exploring the Effect of Health App Use on Fruit and Vegetable Consumption

People may use multiple health apps at the same time or in close sequence, and the effect of health apps may vary across different socioeconomic groups. However, in the context of healthy eating, studies have focused on the effect of using a single health app. This study aims to test the relationship of using multiple health apps with fruit and vegetable consumption, assessing moderation by education level. Employing longitudinal survey data from South Korean adults, we conducted regression analyses to test the lagged association between use of health apps and intake of fruits and vegetables, and whether education moderates the relationship. The results supported the positive lagged relationship of health app use with fruit and vegetable consumption, significant after controlling for confounders and baseline fruit and vegetable consumption. The association was smaller among respondents with higher education. Our findings suggest the positive effect of using multiple health apps on fruit and vegetable consumption, implying the importance of finding the best combination of health apps to maximize their effectiveness in promoting healthy eating. Also, the negative interaction of health app use and education support using mobile communication technology to improve the public health of low socioeconomic status individuals.

Engagement with a Web-Based Health Promotion Intervention among Vocational School Students: A Secondary User and Usage Analysis

Engagement with web-based interventions is both generally low and typically declining. Visits and revisits remain a challenge. Based on log data of a web-based cluster randomized controlled trial conducted in vocational schools, the present secondary analysis aimed to identify influencing factors on initially logging in to a health promotion platform among young adults and to examine the engagement over the course of an eight-week intervention. Data of 336 students (62.2% female, age span 18–25) from two intervention arms (web-based intervention and web-based intervention with an additional initial face-to-face contact) was included. Binary logistic regression and log-data visualization were performed. An additional initial face-to-face contact (odds ratio (OR) = 2.971, p = 0.005), female sex (OR = 2.237, p = 0.046) and the health-related skill “dealing with health information” (OR = 2.179, p = 0.030) significantly increased the likelihood of initially logging in. Other variables showed no influence. 16.6% of all potential users logged in at least once, of which 57.4% revisited the platform. Most logins were tracked at the beginning of the intervention and repeated engagement was low. To increase the engagement with web-based interventions, health-related skills should be fostered. In addition, a strategy could be to interlink comparable interventions in vocational schools more regularly with everyday teaching through multi-component interventions.

Future Trends of the Primary Healthcare System in Iran: A Qualitative Study

Background

Primary healthcare system in Iran has played an extensive role in promoting people health in the past decades. However, regarding universal developments in the different global aspects effective on health, the performance of this system has been influenced significantly. The aim of the present research is to identify the future trends of the primary health care in Iran.

Methods

The participants of this qualitative case study were experts in primary healthcare, which were selected and interviewed through purposive sampling method. The interview process was saturated after 25 interviews, so we stopped the process at this point. Framework analysis based on STEEP model used to analysis the interviews.

Results

The most important social/value, technological, economic, environmental, and political future trends of primary healthcare in Iran included demographic transition, epidemiological transition, social and cultural changes, emergence of modern and advanced technologies, internet and cyberspace, budgeting limitations, resource management, changing paradigm from volume to value in providing health services, environmental pollutions, natural disasters, health governance, intellectual paradigm of senior officials, regional security, international development, and other internal factors of the health system.

Conclusions

The identified factors can be turned into opportunities for Iran primary healthcare system if health planners and policymakers have a deep and accurate look at these influential factors and manage them properly.

Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions

BACKGROUND

Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD.

METHODS

Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data.

RESULTS

Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD.

CONCLUSION

These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.

Beyond validation: getting health apps into clinical practice

Fueled by advances in technology, increased access to smartphones, and capital investment, the number of available health "apps" has exploded in recent years. Patients use their smartphones for many things, but not as much as they might for health, especially for managing their chronic conditions. Moreover, while significant work is ongoing to develop, validate, and evaluate these apps, it is less clear how to effectively disseminate apps into routine clinical practice. We propose a framework for prescribing apps and outline the key issues that need to be addressed to enable app dissemination in clinical care. This includes: education and awareness, creating digital formularies, workflow and EHR integration, payment models, and patient/provider support. As work in digital health continues to expand, integrating health apps into clinical care delivery will be critical if digital health is to achieve its potential.

[Digital divide-social inequalities in the utilisation of digital healthcare]

Today, health inequalities are one of the most important issues in public health worldwide. The digitalisation of healthcare is frequently attributed with the potential to reduce health inequalities. At the same time, effective internet usage is a prerequisite of the successful utilisation of digital health interventions. This might be a new obstacle for those who lack the necessary material resources or individual skills.Evidence on how exactly digital health interventions affect health inequalities is scarce. The aim of this study was to present a narrative review of the available literature. The majority of studies showed an association between the usage of digital health interventions and sociodemographic factors. The utilisation was generally higher among younger people and those with higher education and higher income. Only few studies showed no association. Other studies reported higher utilisation among those with higher levels of health literacy while health literacy showed a social gradient to the disadvantage of those in lower socioeconomic position. With a low overall level of evidence, there is currently no indication that digital health interventions are reducing health inequalities.The studies analysed in this review indicate that existing inequalities persist in the digital realm. Further evidence is needed to create a better understanding of the importance of sociodemographic factors for digital health interventions.

Parents' Use of Technologies for Health Management: A Health Literacy Perspective

OBJECTIVE

Parent use of technology to manage child health issues has the potential to improve access and health outcomes. Few studies have examined how parent health literacy affects usage of Internet and cell phone technologies for health management.

METHODS

Cross-sectional analysis of data collected as part of a randomized controlled experiment in 3 urban pediatric clinics. English- and Spanish-speaking parents (n = 858) of children ≤8 years answered questions regarding use of and preferences related to Internet and cell phone technologies. Parent health literacy was measured using the Newest Vital Sign.

RESULTS

The majority of parents were high Internet (70.2%) and cell phone (85.1%) users (multiple times a day). A total of 75.1% had limited health literacy (32.1% low, 43.0% marginal). Parents with higher health literacy levels had greater Internet and cell phone use (adequate vs low: adjusted odds ratio [AOR], 1.7 [confidence interval, 1.2-2.5]) and were more likely to use them for health management (AOR, 1.5 [confidence interval, 1.2-1.8]); those with higher health literacy levels were more likely to use the Internet for provider communication (adequate vs marginal vs low: 25.0% vs 18.0% vs 12.0%, P = .001) and health-related cell phone apps (40.6% vs 29.7% vs 16.4%, P < .001). Overall preference for using technology for provider communication was high (∼70%) and did not differ by health literacy, although Internet and cell phone apps were preferred by higher literacy parents; no differences were seen for texting.

CONCLUSIONS

Health literacy-associated disparities in parent use of Internet and cell phone technologies exist, but parents' desire for use of these technologies for provider communication was overall high and did not differ by health literacy.

A Mobile Patient-Reported Outcome Measure App With Talking Touchscreen: Usability Assessment

Background

In the past years, a mobile health (mHealth) app called the Dutch Talking Touch Screen Questionnaire (DTTSQ) was developed in The Netherlands. The aim of development was to enable Dutch physical therapy patients to autonomously complete a health-related questionnaire regardless of their level of literacy and digital skills.

Objective

The aim of this study was to evaluate the usability (defined as the effectiveness, efficiency, and satisfaction) of the prototype of the DTTSQ for Dutch physical therapy patients with diverse levels of experience in using mobile technology.

Methods

The qualitative Three-Step Test-Interview method, including both think-aloud and retrospective probing techniques, was used to gain insight into the usability of the DTTSQ. A total of 24 physical therapy patients were included. The interview data were analyzed using a thematic content analysis approach aimed at analyzing the accuracy and completeness with which participants completed the questionnaire (effectiveness), the time it took the participants to complete the questionnaire (efficiency), and the extent to which the participants were satisfied with the ease of use of the questionnaire (satisfaction). The problems encountered by the participants in this study were given a severity rating that was used to provide a rough estimate of the need for additional usability efforts.

Results

All participants within this study were very satisfied with the ease of use of the DTTSQ. Overall, 9 participants stated that the usability of the app exceeded their expectations. The group of 4 average-/high-experienced participants encountered only 1 problem in total, whereas the 11 little-experienced participants encountered an average of 2 problems per person and the 9 inexperienced participants an average of 3 problems per person. A total of 13 different kind of problems were found during this study. Of these problems, 4 need to be addressed before the DTTSQ will be released because they have the potential to negatively influence future usage of the tool. The other 9 problems were less likely to influence future usage of the tool substantially.

Conclusions

The usability of the DTTSQ needs to be improved before it can be released. No problems were found with satisfaction or efficiency during the usability test. The effectiveness needs to be improved by (1) making it easier to navigate through screens without the possibility of accidentally skipping one, (2) enabling the possibility to insert an answer by tapping on the text underneath a photograph instead of just touching the photograph itself, and (3) making it easier to correct wrong answers. This study shows the importance of including less skilled participants in a usability study when striving for inclusive design and the importance of measuring not just satisfaction but also efficiency and effectiveness during such studies.

Characterizing Consumer Behavior in Leveraging Social Media for E-Patient and Health-Related Activities

The emergence of e-patients has encouraged consumers, people who are non-medical experts, to be more engaged in healthcare needs by utilizing online sources via social media. However, the nature of social media and regulation issues have caused concerns for the reliability and validity of the shared information. These phenomena shape consumers behavior in leveraging social media for e-patient activities. This study investigates consumer behavior using an integrated model based on the Unified Theory of Acceptance and Use of Technology (UTAUT) and the Protection Motivation Theory (PMT). The data collected from the participants (N = 312) was analyzed using partial least square structural equation modelling. The results showed that behavioral intention to use social media for e-patient activities was significantly affected by performance expectancy, effort expectancy, perceived severity, perceived susceptibility, and response efficacy; and that behavioral intention corresponded positively to usage intention. In addition, the results also indicate that the intention to use social media for health-related purposes is driven by awareness of preventing health problems and attempts to reduce the risk of developing an illness. Based on findings, this study recommends strategies and initiatives to optimize social media for promoting a healthy lifestyle and educating society about public health and healthcare management.

Assessing Mobile Phone Digital Literacy and Engagement in User-Centered Design in a Diverse, Safety-Net Population: Mixed Methods Study

BACKGROUND

Health care systems are rapidly deploying digital tools for disease management; however, few studies have evaluated their usability by vulnerable populations. To understand the barriers to app usage among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app.

OBJECTIVE

The study aimed to describe variations in patients' engagement in the app design process, focusing on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL).

METHODS

We conducted 20 in-depth semistructured interviews with primary care patients at a public health care system, used open-ended discussions and card sorting tasks to seek input about mobile phones and text messaging, and used open coding to categorize the patterns of mobile phone usage and to evaluate engagement in the card sorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content and calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy.

RESULTS

The average age of the 20 participants was 59 (SD 8) years; 13 (65%) were female, 18 (90%) were nonwhite, 16 (80%) had LHL, and 13 (65%) had LEP. All had depression, and 14 (70%) had diabetes. Most participants had smartphones (18/20, 90%) and regularly used text messaging (15/20, 75%), but 14 (70%) of them reported having difficulty texting because of inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP, and all 10 had LHL. Half of the participants required a modification of the card sorting activity owing to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (4/13, 30% vs 5/7, 71%), limited versus adequate health literacy (7/16, 44% vs 3/4, 75%), and limited versus adequate digital literacy (4/10, 40% vs 6/10, 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (8/16, 50% vs 4/4, 100%); there were no statistical differences by any subgroup.

CONCLUSIONS

Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the card sorting activity varied among participants and appeared to be lower among those with LHL, LEP, and LDL. Researchers employing traditional UCD methods should routinely measure these communication domains among their end-user samples. Future work is needed to replicate our findings in larger samples, but augmentation of card sorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.

A qualitative study of chronic obstructive pulmonary disease patient perceptions of the barriers and facilitators to adopting digital health technology

Objective

Non-adherence to self-management plans in chronic obstructive pulmonary disease (COPD) results in poorer outcomes for patients. Digital health technology (DHT) promises to support self-management by enhancing the sense of control patients possess over their disease. COPD digital health studies have yet to show significant evidence of improved outcomes for patients, with many user-adoption issues still present in the literature. To help better address the adoption needs of COPD patients, this paper explores their perceived barriers and facilitators to the adoption of DHT.

Methods

A sample of convenience was chosen and patients (n = 30) were recruited from two Dublin university hospitals. Each patient completed a qualitative semi-structured interview. Thematic analysis of the data was performed using NVivo 12 software.

Results

Barrier sub-themes included lack of perceived usefulness, digital literacy, illness perception, and social context; facilitator sub-themes included existing digital self-efficacy, personalised education, and community-based support.

Conclusion

The findings represent a set of key considerations for researchers and clinicians to inform the design of patient-centred study protocols that aim to account for the needs and preferences of patients in the development of implementation and adoption strategies for DHT in COPD.

Comparing Characteristics of Patients Who Connect Their iPhones to an Electronic Health Records System Versus Patients Who Connect Without Personal Devices: Cohort Study

BACKGROUND

While individual access to health records has traditionally been through paper and other physical media, there has been a recent push toward digitizing this process. Direct patient access to health data through application programming interfaces (APIs) is an important part of current United States policy initiatives, and Apple has created the product "Health Records on iPhone" to leverage APIs for this purpose.

OBJECTIVE

The objective of this study was to examine the characteristics of patients at our institution who connected their personal iPhone devices to our electronic health records (EHRs) system through "Health Records on iPhone", as compared to patients at our institution who used our patient portal but did not connect a personal device to our system.

METHODS

We examined adult patients at our institution who had authorized an iPhone device to download their health data from the Partners HealthCare EHR via APIs through "Health Records on iPhone" from February 18, 2018 (the date this feature was enabled at our health system) until February 17, 2019. We compared these patients to adult patients who used our portal at least once during this period but did not authorize an iPhone device to download their data via APIs.

RESULTS

Variables associated with an increased likelihood of using "Health Records on iPhone" included male gender (adjusted OR 3.36; 95% CI 3.11-3.62; P<.001) and younger age, particularly below 50 years of age. With each decade of age over 50, people were less likely to be "Health Records on iPhone" product users. Asian patients were more likely to use the product than Caucasian patients (adjusted OR 1.32; 95% CI 1.16-1.51; P<.001), though there was no significant difference between African Americans and Caucasians (adjusted OR 1.15; 95% CI 0.94-1.41; P=.17). Patients who resided in higher ZIP code income quartiles were more likely to be users than those in the lowest quartile.

CONCLUSIONS

Early results from the implementation of patient-facing APIs at a single institution suggest that there are opportunities for expanding these technologies to ensure all patients are aware of, and have access to, their health data on their personal devices. More work is needed on expanding these technologies to different patient populations.

How Resource Scarcity and Accessibility Affect Patients' Usage of Mobile Health in China: Resource Competition Perspective

BACKGROUND

The last decade has witnessed many achievements in China's health care industry, but the industry still faces major challenges among which the uneven distribution of medical resources and the imbalance between supply and demand are the most pressing problems. Although mobile health (mHealth) services play a significant role in mitigating problems associated with health care delivery, their adoption rates have been low.

OBJECTIVE

The objective of this study was to explore the impact of resource scarcity and resource accessibility on the adoption of mHealth from the perspective of resource competition, to examine the concerning factors, and to provide a theoretical basis for promoting mHealth in China.

METHODS

We used 229,516 original registration records of outpatients to conduct an empirical analysis to examine the adoption of mHealth services from the perspective of resource competition.

RESULTS

The adoption rate of mobile services for outpatients was low, accounting for only 31.5% (N=71,707). The empirical results indicated that resource scarcity (beta=.435, P=.01) and accessibility (beta=-.134, P=.02) have a significant impact on the adoption of mHealth. In addition, gender (beta=.073, P=.01) and age (beta=-.009, P<.001) are significantly related to adoption of mHealth. Experience with mHealth has a moderating role in the relationship between resource scarcity (beta=-.129, P=.02), accessibility (beta=.138, P=.04), and adoption of mHealth.

CONCLUSIONS

In this study we demonstrate that the external environment (resource scarcity and resource accessibility) has a significant impact on the adoption of mHealth. This study also demonstrates that experience with mHealth has a moderating role in the relationship between the elements of the external environment. Finally, we confirm that mHealth is a key factor in the delivery and allocation of medical resources and provide a theoretical basis for government agencies to develop policies on mHealth.

Perspectives on implementing mobile health technology for living kidney donor follow-up: In-depth interviews with transplant providers

BACKGROUND

United States transplant centers are required to report follow-up data for living kidney donors for 2 years post-donation. However, living kidney donor (LKD) follow-up is often incomplete. Mobile health (mHealth) technologies could ease data collection burden but have not yet been explored in this context.

METHODS

We conducted semi-structured in-depth interviews with a convenience sample of 21 transplant providers and thought leaders about challenges in LKD follow-up, and the potential role of mHealth in overcoming these challenges.

RESULTS

Participants reported challenges conveying the importance of follow-up to LKDs, limited data from international/out-of-town LKDs, and inadequate staffing. They believed the 2-year requirement was insufficient, but expressed difficulty engaging LKDs for even this short time and inadequate resources for longer-term follow-up. Participants believed an mHealth system for post-donation follow-up could benefit LKDs (by simplifying communication/tasks and improving donor engagement) and transplant centers (by streamlining communication and decreasing workforce burden). Concerns included cost, learning curves, security/privacy, patient language/socioeconomic barriers, and older donor comfort with mHealth technology.

CONCLUSIONS

Transplant providers felt that mHealth technology could improve LKD follow-up and help centers meet reporting thresholds. However, designing a secure, easy to use, and cost-effective system remains challenging.

Psychometric properties of the Hungarian version of the eHealth Literacy Scale

BACKGROUND

We adapted the eHealth Literacy Scale (eHEALS) for Hungary and tested its psychometric properties on a large representative online sample of the general population.

METHODS

The Hungarian version of eHEALS was developed using forward-backward translation. For the valuation study, 1000 respondents were recruited in early 2019 from a large online panel by a survey company. We tested internal consistency, test-retest reliability and construct and criterion validity using classical test theory, as well as item characteristics using an item-response theory (IRT) graded response model (GRM).

RESULTS

55% of respondents were female, and 22.1% were ≥ 65 years old. Mean eHEALS score was 29.2 (SD: 5.18). Internal consistency was good (Cronbach's α = 0.90), and test-retest reliability was moderate (intraclass correlation r = 0.64). We identified a single-factor structure by exploratory factor analysis, explaining 85% of test variance. Essential criteria for GRM analysis were met. Items 3 and 4 (search of health resources) were the least difficult, followed by items 5 and 8 (utilisation of health information), and then items 1 and 2 (awareness of health resources). Items 6 and 7 (appraisal of health resources) were most difficult. The measurement properties of eHEALS were not affected by gender, age, education or income levels. Female gender, older age, intensity of health information seeking, formal health education and visit at the electronic health-record website were associated with higher eHEALS scores, as well as best and worst self-perceived health states, BMI < 25 and participation at health screenings over the past year.

CONCLUSIONS

The Hungarian eHEALS is a useful and valid tool for measuring subjective eHealth literacy.

Non-English Language Availability of Community Health Center Websites

BACKGROUND

For limited English-proficient (LEP) patients, the digital divide has narrowed, creating a new population of Internet users. However, language-appropriate health information is difficult to find. Community health center (CHC) websites are health information resources and their homepages are critical access points for patients. CHCs supported by Health Resources and Services Administration (HRSA) care for many LEP patients.

OBJECTIVE

We sought to determine the number of HRSA-supported CHC websites providing translated homepage content.

RESEARCH DESIGN

In February 2017, we performed a cross-sectional analysis of the language availability of CHC homepages.

MEASURES

The primary outcome was availability of translated content on CHC homepages. Secondary outcomes were method of translation and associations between homepage translation and CHC demographics, including percent LEP population and socioeconomic and Internet access characteristics.

RESULTS

Of the 1400 CHC homepages, 480 (34.3%) provided translated information with half using Google Translate. We found higher odds of having a translated homepage as the LEP population by county increased [odds ratio (OR): 1.26, confidence interval (CI): 1.07-1.49, P=0.005], Internet subscription at the state level increased (OR: 1.19, CI: 1.02-1.38, P=0.026), and if health centers were in metropolitan areas (OR: 1.81, CI: 1.31-2.51, P<0.001). There was also higher likelihood of having a homepage translated to Spanish in counties with higher Spanish LEP populations (OR: 1.39, CI: 1.19-1.63, P<0.001), but this did not extend to non-Spanish languages (OR: 0.85, CI: 0.71-1.04, P=0.131).

CONCLUSIONS

Despite increased Internet use among LEP patients and linguistic diversity of the CHC populations, there is a lack of language-appropriate content on CHC website homepages.

Health information technology use and influenza vaccine uptake among US adults

OBJECTIVE

This study aims to estimate the association between health information technology (HIT) use and influenza vaccine uptake among US adults.

MATERIALS AND METHODS

Data analysis was conducted using 2011-2015 National Health Interview Survey (NHIS) adult data (n = 169,912). HIT use was defined as having used computers (past 12 months) to seek health information, fill prescriptions, schedule appointments, communicate with health providers via email, and/or use online health chat groups. Crude and multivariable logistic regression models were used to estimate the odds of influenza vaccine uptake among HIT users versus non-users. Interactions were tested and stratified results were reported.

RESULTS

Among US adults, 39.8% received an influenza vaccine in the past 12 months, while 48.6% reported any HIT use. After adjusting for covariates, any HIT users had 1.23 times greater odds (95% CI = 1.19, 1.27) of influenza vaccine uptake relative to non-HIT users. HIT use for looking up health information on the internet (OR = 1.19, 95% CI = 1.15, 1.23), filling prescriptions (OR = 1.56; 95% CI = 1.50, 1.66), scheduling appointments (OR = 1.56; 95% CI = 1.50, 1.66), and communicating with providers via email (OR = 1.51; 95% CI = 1.44, 1.59) were significantly associated with influenza vaccine uptake.

DISCUSSION

HIT use is positively associated with influenza vaccine uptake. Each category of HIT use was independently associated with influenza vaccine uptake. To our knowledge, no other studies have evaluated the relationship between HIT use and influenza vaccine uptake. Our results are exploratory and represent an association, not a causal relationship. Longitudinal, confirmatory studies are also needed to verify our cross-sectional findings.

Using Electronic Health Records Data to Evaluate the Impact of Information Technology on Improving Health Equity: Evidence from China

This study evaluates the impact of health information technology in accessing medical resources and identifies its role in improving health equity. We used 262, 771 records from the electronic medical records and outpatient appointment systems of three clinics for logistic regression to analyze the impact of information technology on patients' access to medical care. We interviewed a few health professionals to gauge their reactions and to validate and understand our quantitative results. The proportion of inpatients affected by information technology is low, accounting for only 16.7% (N = 43, 870). The difference between rural and urban groups is statistically significant, and rural households are more susceptible to information technology. In addition, distance has a significant positive effect. We demonstrate an inverted U-shaped relationship between severity of disease and the impact of information technology. Moreover, our interview results are consistent with our quantitative results. Quantitative and interview results suggest that health information technology plays a positive role in accessing medical care for patients with rural household and those in remote areas. Meanwhile, this effect is complex for patients with different severities of illnesses. Governments and managers should vigorously promote health information technology for healthcare delivery in the future and focus their attention on patients with serious diseases.