mHealth Interventions for Disadvantaged and Vulnerable People with Type 2 Diabetes

The potential and paradoxes of eHealth research for digitally marginalised groups: A qualitative meta-review

Whilst the transformation towards digital healthcare is accelerating, there is still a substantial risk of excluding people with a distance to the online world. Groups like people with a low socioeconomic position, people with a migrant background or the elderly, who are already most at risk of experiencing health inequalities, are simultaneously experiencing increased digital exclusion. Researchers play a role in determining how eHealth access is framed and can thus impact how the barriers to its use are addressed. This qualitative meta-review critically evaluates the way researchers (as authors) discuss eHealth use in digitally marginalised groups. Specifically, it seeks to understand how eHealth is framed to address existing health systems problems; how the barriers to eHealth use are presented and which solutions are provided in response; and who authors suggest should be responsible for making eHealth work. The results of this review found four paradoxes in how current literature views eHealth use. Firstly, that health systems problems are complex and nuanced, yet eHealth is seen as a simple answer. Secondly, that there are many political, social and health systems-based solutions suggested to address eHealth use, however most of the identified barriers are individually framed. This focus on personal deficits results in misallocating responsibility for making these systemic improvements. Thirdly, although eHealth is meant to simplify the tasks of patients and healthcare workers, these are the groups most often burdened with the responsibility of ensuring its success. Lastly, despite tailoring eHealth to the user being the most suggested solution, researchers generally speak about groups as a homogenous entity - thus rendering tailoring difficult. Ultimately, this review finds that a shift to focus research on addressing systemic issues on a systems level is necessary to prevent further exacerbating existing health inequalities.

Influence of mHealth-Based Lifestyle Interventions on Symptoms of Anxiety and Depression of Women With Gestational Diabetes: A Meta-Analysis

BACKGROUND

Symptoms of anxiety and depression are common in women with gestational diabetes mellitus (GDM). Mobile health (mHealth)-based lifestyle interventions have been shown to be effective in improving glycemic control of these women.

PURPOSE/OBJECTIVE

The aim of the study was to evaluate the influence of mHealth-based lifestyle interventions on symptoms of anxiety and depression in women with GDM.

DESIGN

A systematic review and meta-analysis or randomized controlled trials.

SETTING

Clinical or community-based settings.

SAMPLE

Nine studies involving 1,168 pregnant women with GDM were included.

INTERVENTION

mHealth-based lifestyle interventions.

MEASURES

Symptoms of anxiety and depression quantitatively analyzed in clinical scales.

ANALYSIS

A systematic literature search was performed in electronic databases, including PubMed, Cochrane library, Embase, Web of Science, Wanfang, and China National Knowledge Infrastructure to obtain relevant randomized controlled studies. A random-effects model was used to pool the results by incorporating the impact of the potential heterogeneity.

RESULTS

Findings revealed that when compared to usual care, women who received mHealth-based lifestyle interventions had significant improvements in symptoms of anxiety (standardized mean difference [SMD]: -0.55, 95% CI [-0.77, -0.33], p < .001; I2 = 67%) and depression (SMD: -0.51, [-0.72, -0.29], p < .001; I2 = 65%). Sensitivity analyses by excluding one study at a time showed consistent results. Subgroup analyses showed similar results in mHealth achieved by phone, websites, and applications, in mHealth targeting diet and exercise with and without psychological support, in mHealth lead by nurse with and without other clinical specialists, and in studies with different evaluating tools for anxiety and depression.

CONCLUSIONS

mHealth-based lifestyle interventions could significantly improve the symptoms of anxiety and depression in women with GDM.

Trends in telemedicine visits among pediatric asthma patients during COVID-19

Background

Environmental and social factors, including lack of access to asthma care, contribute to persistent inequities in asthma outcomes among children from historically marginalized ethnoracial groups. Telemedicine, which expanded rapidly during the coronavirus disease 2019 (COVID-19) pandemic, may be an approach to augment access to pediatric asthma care.

Objectives

We sought to describe characteristics of pediatric (0-17 years) telemedicine users with asthma and characterize use trends throughout the COVID-19 pandemic.

Methods

We conducted a retrospective analysis using electronic health record data of pediatric patients with asthma seen at University of California, Los Angeles, Medical Center between March 2019 to March 2022 describing telemedicine user characteristics, trends of asthma-related telemedicine use, and associations between user characteristics and having a telemedicine visit.

Results

Among 6,777 patients with asthma, the percentage of asthma-related telemedicine visits peaked early in the pandemic, comprising 74.3% of visits, before decreasing to 13.6% in 2022. Compared to White patients, Black patients had lower odds of an asthma telemedicine visit (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.26, 0.94). Those with public insurance (OR, 1.7; 95% CI, 1.19, 2.43), severe persistent asthma (OR, 3.03; 95% CI, 1.70, 5.42), or comorbidities (OR, 1.59; 95% CI, 1.08, 2.33) had higher odds. Time to first emergency department visit and hospitalization comparing those with at least one telemedicine visit to those with none were similar.

Conclusions

More pediatric asthma patients are using telemedicine since the COVID-19 pandemic, particularly those with medical complexity and comorbidities, and outcomes appear similar. However, Black patients at our institution have lower odds of using telemedicine.

Characterizing Technology Use and Preferences for Health Communication in South Asian Immigrants With Prediabetes or Diabetes: Cross-Sectional Descriptive Study

BACKGROUND

Type 2 diabetes disproportionately affects South Asian subgroups. Lifestyle prevention programs help prevent and manage diabetes; however, there is a need to tailor these programs for mobile health (mHealth).

OBJECTIVE

This study examined technology access, current use, and preferences for health communication among South Asian immigrants diagnosed with or at risk for diabetes, overall and by sex. We examined factors associated with interest in receiving diabetes information by (1) text message, (2) online (videos, voice notes, online forums), and (3) none or skipped, adjusting for sociodemographic characteristics and technology access.

METHODS

We used baseline data collected in 2019-2021 from two clinical trials among South Asian immigrants in New York City (NYC), with one trial focused on diabetes prevention and the other focused on diabetes management. Descriptive statistics were used to examine overall and sex-stratified impacts of sociodemographics on technology use. Overall logistic regression was used to examine the preference for diabetes information by text message, online (videos, voice notes, or forums), and no interest/skipped response.

RESULTS

The overall sample (N=816) had a mean age of 51.8 years (SD 11.0), and was mostly female (462/816, 56.6%), married (756/816, 92.6%), with below high school education (476/816, 58.3%) and limited English proficiency (731/816, 89.6%). Most participants had a smartphone (611/816, 74.9%) and reported interest in receiving diabetes information via text message (609/816, 74.6%). Compared to male participants, female participants were significantly less likely to own smartphones (317/462, 68.6% vs 294/354, 83.1%) or use social media apps (Viber: 102/462, 22.1% vs 111/354, 31.4%; WhatsApp: 279/462, 60.4% vs 255/354, 72.0%; Facebook: Messenger 72/462, 15.6% vs 150/354, 42.4%). A preference for receiving diabetes information via text messaging was associated with male sex (adjusted odds ratio [AOR] 1.63, 95% CI 1.01-2.55; P=.04), current unemployment (AOR 1.62, 95% CI 1.03-2.53; P=.04), above high school education (AOR 2.17, 95% CI 1.41-3.32; P<.001), and owning a smart device (AOR 3.35, 95% CI 2.17-5.18; P<.001). A preference for videos, voice notes, or online forums was associated with male sex (AOR 2.38, 95% CI 1.59-3.57; P<.001) and ownership of a smart device (AOR 5.19, 95% CI 2.83-9.51; P<.001). No interest/skipping the question was associated with female sex (AOR 2.66, 95% CI 1.55-4.56; P<.001), high school education or below (AOR 2.02, 95% CI 1.22-3.36; P=.01), not being married (AOR 2.26, 95% CI 1.13-4.52; P=.02), current employment (AOR 1.96, 95% CI 1.18-3.29; P=.01), and not owning a smart device (AOR 2.06, 95% CI 2.06-5.44; P<.001).

CONCLUSIONS

Technology access and social media usage were moderately high in primarily low-income South Asian immigrants in NYC with prediabetes or diabetes. Sex, education, marital status, and employment were associated with interest in mHealth interventions. Additional support to South Asian women may be required when designing and developing mHealth interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03333044; https://classic.clinicaltrials.gov/ct2/show/NCT03333044, ClinicalTrials.gov NCT03188094; https://classic.clinicaltrials.gov/ct2/show/NCT03188094.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3711-y.

Empowering patients in primary care: a qualitative exploration of the usability and utility of an online diabetes self-management tool

BACKGROUND

Despite the potential advantages of Internet-based diabetes self-management education, its adoption was not widespread among Singapore's public primary care clinics (polyclinics). An interactive online tool was thus developed to help educate patients with Type 2 diabetes mellitus (T2DM), and was now ready for user testing before implementation.

AIM

To explore the perceived utility and usability of the educational tool in patients with suboptimally-controlled T2DM in a Singapore primary care setting.

METHODS

In-depth interviews were used to gather qualitative data from multi-ethnic Asian adults who had suboptimally-controlled T2DM. A total of 17 IDIs were conducted between April 2022 to March 2023, audio-recorded, transcribed, and analyzed to identify emergent themes via thematic analysis.

RESULTS

Regarding utility, users found the educational tool useful because it provided them with information that was comprehensive, accessible, reliable, and manageable. Regarding usability, the majority of users reported that the educational tool was easy to use, and suggested ways to improve navigational cues, visual clarity, readability and user engagement.

CONCLUSION

Participants generally found the educational tool useful and easy to use. A revised educational tool will be developed based on their feedback and implemented in clinical practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of smartphone app-based interventions on adolescents' dietary intake: a systematic review and evaluation of equity factor reporting in intervention studies

CONTEXT

Adolescence is a critical stage for improving nutrition. The popularity of smartphones makes them an ideal platform for administering interventions to adolescents. A systematic review has yet to assess the impact of smartphone app-based interventions exclusively on adolescents' dietary intake. Furthermore, despite the impact of equity factors on dietary intake and the claim for mobile health of increased accessibility, there is minimal research on the reporting of equity factors in the evaluation of smartphone app-based nutrition-intervention research.

OBJECTIVES

This systematic review examines the effectiveness of smartphone app-based interventions on adolescents' dietary intake and the frequency with which equity factors and statistical analyses specific to equity factors are reported in these intervention studies.

DATA SOURCES

Databases (ie, Scopus, CINAHL, EMBASE, MEDLINE, PsycINFO, ERIC, and Cochrane Central Register for Randomized Control Trials) were searched for studies published from January 2008 to October 2022. Smartphone app-based intervention studies that were nutrition focused, evaluated at least 1 dietary intake variable, and included participants with a mean age between 10 and 19 years were included. All geographic locations were included.

DATA EXTRACTION AND ANALYSIS

Study characteristics, intervention results, and reported equity factors were extracted. Because of the heterogeneity of dietary outcomes, findings were reported as a narrative synthesis.

CONCLUSION

In total, 3087 studies were retrieved, 14 of which met the inclusion criteria. Eleven studies reported a statistically significant improvement in at least 1 dietary outcome because of the intervention. Reporting of at least 1 equity factor across articles' Introduction, Methods, Results, and Discussion sections was minimal (n = 5), and statistical analyses specific to equity factors were rare, occurring in only 4 of the 14 included studies. Future interventions should include a measurement of intervention adherence and report the impact of equity factors on the effectiveness and applicability of interventions for equity-deserving groups.

Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all?

Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.

Digitally Delivered Interventions to Improve Nutrition Behaviors Among Resource-Poor and Ethnic Minority Groups With Type 2 Diabetes: Systematic Review

BACKGROUND

Resource-poor individuals, such as those with a low income, are disproportionately affected by diabetes and unhealthy eating patterns that contribute to poor disease self-management and prognosis. Digitally delivered interventions have the potential to address some of the barriers to healthy eating experienced by this group. However, little is known about their effectiveness in disadvantaged populations.

OBJECTIVE

This systematic review is conducted to assess the effectiveness of digitally delivered interventions in improving nutritional behaviors and nutrition-related health outcomes among disadvantaged people with type 2 diabetes (T2D).

METHODS

MEDLINE complete, Global Health, Embase, CINAHL complete, Informit Health, IEEE Xplore, and Applied Science and Technology Source databases were searched for studies published between 1990 and 2022 on digitally delivered nutrition interventions for disadvantaged people with T2D. Two reviewers independently assessed the studies for eligibility and determined the study quality using the Cochrane Risk-of-Bias Assessment Tool. The Behavioral Change Technique Taxonomy V1 was used to identify behavior change techniques used in the design of interventions.

RESULTS

Of the 2434 identified records, 10 (0.4%), comprising 947 participants, met the eligibility criteria and were included in the review. A total of 2 digital platforms, web and messaging services (eg, SMS text messaging interventions or multimedia messaging service), were used to deliver interventions. Substantial improvements in dietary behaviors were reported in 5 (50%) of the 10 studies, representing improvements in healthier food choices or increases in dietary knowledge and skills or self-efficacy. Of the 10 studies, 7 (70%) examined changes in blood glucose levels, of which 4 (57%) out of 7 achieved significant decreases in hemoglobin A1C levels ranging from 0.3% to 1.8%. The most frequently identified behavior change techniques across all studies were instruction on how to perform the behavior, information about health consequences, and social support.

CONCLUSIONS

This review provided some support for the efficacy of digitally delivered interventions in improving healthy eating behaviors in disadvantaged people with T2D, an essential dietary prerequisite for changes in clinical metabolic parameters. Further research is needed into how disadvantaged people with T2D may benefit more from digital approaches and to identify the specific features of effective digital interventions for supporting healthy behaviors among disadvantaged populations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020149844; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=149844.

Effectiveness of mHealth interventions for improving health attendance: an umbrella review protocol

OBJECTIVE

The objective of this umbrella review is to assess the effectiveness of mobile health (mHealth) interventions for improving health care attendance.

INTRODUCTION

Health attendance is a critical part of health service delivery and is considered a behavior influenced by personal characteristics, service availability, nature of the treatment and consultation, and social determinants. Various interventions are available to foster good health attendance behavior, and mHealth interventions are one of the common go-to solutions; however, there is ambiguity regarding their effectiveness.

INCLUSION CRITERIA

Systematic reviews, with or without meta-analysis, that specifically examine the impact of mHealth interventions on health care attendance will be considered. The review will not be restricted to any particular disease, health problem, stream, or system of care, nor will it be limited by population characteristics (eg, age, gender, socio-economic status) or context (setting can be at any level of care).

METHODS

The JBI methodology for umbrella reviews will be followed, and MEDLINE (Ovid), Scopus, CINAHL, Cochrane Central, and JBI Evidence Synthesis will be searched for sources of evidence. Unpublished and gray literature sources, such as ProQuest Dissertations and Theses, OAIster, and Google Scholar, will also be searched. The review will be limited to English-language articles published from the inception of the databases to the present. Two independent reviewers will perform title, abstract, and full-text screening, while a customized data extraction form will be used for data extraction. The JBI critical appraisal checklist for systematic reviews and research syntheses will be applied. Certainty of evidence for health attendance outcomes will be assessed following GRADE approach.

REVIEW REGISTRATION

PROSPERO CRD42023405677.

Current evidence for designing self-management support for underserved populations: an integrative review using the example of diabetes

AIMS

With numerous and continuing attempts at adapting diabetes self-management support programmes to better account for underserved populations, its important that the lessons being learned are understood and shared. The work we present here reviews the latest evidence and best practice in designing and embedding culturally and socially sensitive, self-management support programmes.

METHODS

We explored the literature with regard to four key design considerations of diabetes self-management support programmes: Composition - the design and content of written materials and digital tools and interfaces; Structure - the combination of individual and group sessions, their frequency, and the overall duration of programmes; Facilitators - the combination of individuals used to deliver the programme; and Context - the influence and mitigation of a range of individual, socio-cultural, and environmental factors.

RESULTS

We found useful and recent examples of design innovation within a variety of countries and models of health care delivery including Brazil, Mexico, Netherlands, Spain, United Kingdom, and United States of America. Within Composition we confirmed the importance of retaining best practice in creating readily understood written information and intuitive digital interfaces; Structure the need to offer group, individual, and remote learning options in programmes of flexible duration and frequency; Facilitators where the benefits of using culturally concordant peers and community-based providers were described; and finally in Context the need to integrate self-management support programmes within existing health systems, and tailor their various constituent elements according to the language, resources, and beliefs of individuals and their communities.

CONCLUSIONS

A number of design principles across the four design considerations were identified that together offer a promising means of creating the next generation of self-management support programme more readily accessible for underserved communities. Ultimately, we recommend that the precise configuration should be co-produced by all relevant service and patient stakeholders and its delivery embedded in local health systems.

Effectiveness and Process Evaluation of Using Digital Health Technologies in Pharmaceutical Care in Low- and Middle-Income Countries: A Systematic Review of Quantitative and Qualitative Studies

Introduction: Digital health technology (DHT) has the potential to enhance remote health care delivery. However, little is known about the effectiveness of DHTs and factors that contribute to the limited uptake of DHTs in low- and middle-income countries (LMICs). Therefore, the objective of this study was to systematically review the effectiveness and evaluation process concerning the use of DHTs in pharmaceutical care in LMICs. Methods: A literature search on PubMed and Embase was conducted to identify experimental, descriptive, qualitative, and mixed-method studies that focused on the use of DHTs in pharmaceutical care as the main intervention, reported on the effects and/or the process of the DHT intervention, were performed by pharmacists, were conducted in LMICs, and had been published in English. Two reviewers independently conducted the study selection process. A qualitative narrative review of the effectiveness of using DHTs was conducted evaluating the population, intervention, comparators, and outcomes. We summarized the content and identified themes of the evaluation process under two categories-challenges and opportunities. Results: The search produced 589 studies, of which 16 met the eligibility criteria. The most common type of DHT was mobile health application (mHealth app; n = 8), followed by mobile phone call (n = 6) and mobile video call (n = 2). Eight studies assessed the effectiveness of using DHTs in pharmaceutical care. mHealth app, mobile phone call, mobile video call, text messages, home telemonitoring, and internet-based drug information centers improved some health-related outcomes. Two of these eight studies, however, did not find significant effects of a phone call or an mHealth app on certain health-related outcomes. Of the seven quantitative studies conducting a process evaluation, all showed that patients were satisfied with the use of DHTs in pharmaceutical care provided by pharmacists. Of the two mixed-methods and one qualitative study assessing the process evaluation concerning DHT usage, three distinct themes of challenges (patient-, DHT-, and health care system-related challenges) and opportunities (patient-, DHT-, and pharmacist-related opportunities) were identified. Conclusions: DHT is a promising approach in pharmaceutical care toward improving health-related outcomes in LMICs, despite the variable intervention effects. The challenges and opportunities identified are important considerations when developing and implementing DHTs in pharmaceutical care in LMICs.

Who needs what (features) when? Personalizing engagement with data-driven self-management to improve health equity

OBJECTIVES

To examine the feasibility of promoting engagement with data-driven self-management of health among individuals from minoritized medically underserved communities by tailoring the design of self-management interventions to individuals' type of motivation and regulation in accordance with the Self-Determination Theory.

METHODS

Fifty-three individuals with type 2 diabetes from an impoverished minority community were randomly assigned to four different versions of an mHealth app for data-driven self-management with the focus on nutrition, Platano; each version was tailored to a specific type of motivation and regulation within the SDT self-determination continuum. These versions included financial rewards (external regulation), feedback from expert registered dietitians (RDF, introjected regulation), self-assessment of attainment of one's nutritional goals (SA, identified regulation), and personalized meal-time nutrition decision support with post-meal blood glucose forecasts (FORC, integrated regulation). We used qualitative interviews to examine interaction between participants' experiences with the app and their motivation type (internal-external).

RESULTS

As hypothesized, we found a clear interaction between the type of motivation and Platano features that users responded to and benefited from. For example, those with more internal motivation reported more positive experience with SA and FORC than those with more external motivation. However, we also found that Platano features that aimed to specifically address the needs of individuals with external regulation did not create the desired experience. We attribute this to a mismatch in emphasis on informational versus emotional support, particularly evident in RDF. In addition, we found that for participants recruited from an economically disadvantaged community, internal factors, such as motivation and regulation, interacted with external factors, most notably with limited health literacy and limited access to resources.

CONCLUSIONS

The study suggests feasibility of using SDT to tailor design of mHealth interventions for promoting data-driven self-management to individuals' motivation and regulation. However, further research is needed to better align design solutions with different levels of self-determination continuum, to incorporate stronger emphasis on emotional support for individuals with external regulation, and to address unique needs and challenges of underserved communities, with particular attention to limited health literacy and access to resources.

A Roadmap to an Equitable Digital Diabetes Ecosystem

OBJECTIVES

Diabetes management presents a substantial burden to individuals living with the condition and their families, health care professionals, and health care systems. Although an increasing number of digital tools are available to assist with tasks such as blood glucose monitoring and insulin dose calculation, multiple persistent barriers continue to prevent their optimal use.

METHODS

As a guide to creating an equitable connected digital diabetes ecosystem, we propose a roadmap with key milestones that need to be achieved along the way.

RESULTS

During the Coronavirus 2019 pandemic, there was an increased use of digital tools to support diabetes care, but at the same time, the pandemic also highlighted problems of inequities in access to and use of these same technologies. Based on these observations, a connected diabetes ecosystem should incorporate and optimize the use of existing treatments and technologies, integrate tasks such as glucose monitoring, data analysis, and insulin dose calculations, and lead to improved and equitable health outcomes.

CONCLUSIONS

Development of this ecosystem will require overcoming multiple obstacles, including interoperability and data security concerns. However, an integrated system would optimize existing devices, technologies, and treatments to improve outcomes.

Participants' and Health Care Providers' Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative Study

BACKGROUND

Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomically disadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully evaluated.

OBJECTIVE

This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered healthy eating behavior change support program, from the perspective of intervention participants living with T2D and health care providers (HCPs) involved in diabetes care.

METHODS

This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes were collected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%) and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators) were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs' views on successful and unsuccessful elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types of interventions; and feedback from their interactions with patients on the intervention's content, impact, or observed benefits. All data from the surveys and interviews were pooled and thematically analyzed.

RESULTS

In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction with the program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions, and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressed high satisfaction with its content and delivery. The educational and motivational content was considered the most useful part of the program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes in their food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described the intervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.

CONCLUSIONS

The findings suggested that this digitally delivered intervention with supportive educational modules and SMS text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could feasibly be rolled out on a broader scale to augment usual diabetes care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19488.

[Mobile health technologies, social justice and population-based vulnerabilities : A public health ethics perspective on mHealth using the example of type 2 diabetes mellitus]

Mobile health technologies (mHealth) promote the trend towards personal responsibility and self-management. By using the example of type 2 diabetes mellitus (T2DM), the article aims to deepen the discussion on mHealth, personal responsibility and justice-which has so far only been rudimentary-from a public health ethical perspective. It shows that in the field of T2DM, mHealth can on the one hand improve social health justice, but on the other hand can also exacerbate social health injustices. From a justice-focused, public health ethical perspective on T2DM mHealth, it is necessary to better understand whether and how vulnerable population groups are considered in mHealth development and implementation, how these groups experience the use of the technology, what social-epidemiological impacts the increasing use of mHealth can have, which health inequalities in the area of T2DM are unfair, to what extent personal responsibility should be placed in the hands of the users, and where the limits of personal responsibility lie. Considering social diversity and the social determinants of health is an ongoing process and must permeate all phases of mHealth development and implementation.

Rationale, design, and recruitment outcomes for the Family/Friend Activation to Motivate Self-care (FAMS) 2.0 randomized controlled trial among adults with type 2 diabetes and their support persons

BACKGROUND

Self-care behaviors help reduce hemoglobin A1c (HbA1c) and prevent or delay type 2 diabetes (T2D) complications. Individualized interventions that support goal setting and self-monitoring improve self-care and HbA1c in the short-term; engaging family and friends may enhance and/or sustain effects. Family/Friend Activation to Motivate Self-care (FAMS) is a mobile phone-delivered intervention (i.e., phone coaching and text message support) based on Family Systems Theory which was successfully piloted among diverse adults with T2D.

METHODS

We made improvements to FAMS and conducted iterative usability testing to finalize FAMS 2.0 before evaluation in a randomized controlled trial (RCT). Adult persons with diabetes (PWDs) who enrolled were asked to invite a support person (friend or family member) to participate alongside them. For the RCT, dyads were randomly assigned to FAMS 2.0 or enhanced treatment as usual (control) for the first 9 months of the 15-month trial. Outcomes include PWDs' HbA1c and psychosocial well-being (including diabetes distress) and support persons' own diabetes distress and support burden.

RESULTS

We recruited RCT participants from April 2020 through October 2021 (N = 338 PWDs with T2D; 89% [n = 300] with a support person). PWDs were 52% male, 62% non-Hispanic White, aged 56.9 ± 11.0 years with HbA1c 8.7% ± 1.7% at enrollment; 73% cohabitated with their enrolled support person. Data collection is ongoing through January 2023.

CONCLUSION

Findings will inform the utility of engaging family/friends in self-care behaviors for both PWD and support person outcomes. Using widely available mobile phone technology, FAMS 2.0, if successful, has potential for scalability.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04347291 posted April 15, 2020.

mHealth-Supported Gender- and Culturally Sensitive Weight Loss Intervention for Hispanic Men With Overweight and Obesity: Single-Arm Pilot Study

BACKGROUND

Hispanic men have disproportionate rates of overweight and obesity compared with other racial and ethnic subpopulations. However, few weight loss interventions have been developed specifically for this high-risk group. Furthermore, the use of mobile health (mHealth) technologies to support lifestyle behavior changes in weight loss interventions for Hispanic men is largely untested.

OBJECTIVE

This single-arm pilot study examined the feasibility and acceptability of integrating mHealth technology into a 12-week gender- and culturally sensitive weight loss intervention (GCSWLI) for Hispanic men with overweight and obesity.

METHODS

A total of 18 Hispanic men (mean age 38, SD 10.9 years; mean BMI 34.3, SD 5.5 kg/m²; 10/18, 56% Spanish monolingual) received a GCSWLI, including weekly in-person individual sessions, a daily calorie goal, and prescription of ≥225 minutes of moderate-intensity physical activity per week. mHealth technology support included tailored SMS text messaging, behavior self-monitoring support using Fitbit Charge 2, and weight tracking using a Fitbit Aria Wi-Fi Smart Scale. Changes in weight from baseline to 12 weeks were estimated using a paired 2-tailed t test. Descriptive analyses characterized the use of Fitbit and smart scales. Semistructured interviews were conducted immediately after intervention to assess the participants' weight loss experiences and perspectives on mHealth technologies.

RESULTS

Of 18 participants, 16 (89%) completed the 12-week assessments; the overall attrition rate was 11.1%. The mean weight loss at week 12 was -4.7 kg (95% CI 7.1 to -2.4 kg; P<.001). Participants wore the Fitbit 71.58% (962/1344) of the intervention days and logged their body weight using the smart scale (410/1344, 30.51% of the intervention days). Participants identified barriers to the use of the technology, such as lack of technological literacy and unreliable internet access for the smart scale.

CONCLUSIONS

Although clinically significant weight loss was achieved by integrating mHealth technology into the GCSWLI, adherence to the prescribed use of technology was modest. Addressing barriers to the use of such technologies identified in our work may help to refine an mHealth intervention approach for Hispanic men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02783521; https://clinicaltrials.gov/ct2/show/NCT02783521.

Commercial mHealth Apps and Unjust Value Trade-offs: A Public Health Perspective

Mobile health (mHealth) apps for self-monitoring increasingly gain relevance for public health. As a mobile technology, they promote individual participation in health monitoring with the aim of disease prevention and the mitigation of health risks. In this paper, I argue that users of mHealth apps must engage in value trade-offs concerning their fundamental dimensions of well-being when using mobile health apps for the self-monitoring of health parameters. I particularly focus on trade-offs regarding the user's self-determination as well as their capacity to form personal attachments. Depending on the user's level of advantage or disadvantage, value trade-offs can pose a threat to the users' sufficient fulfillment of the dimensions of well-being. As such, value trade-offs can entrench existing structural injustices and prevent disadvantaged users to benefit from this technology. I argue that value trade-offs are, to some, a type of injustice that can drive disadvantaged users away from a sufficiency threshold of well-being, risk users to fall below the threshold, or have an accumulative effect on different dimensions of the user's well-being.

Exploring mHealth potential to improve kidney function: secondary analysis of a randomized trial of diabetes self-care in diverse adults

BACKGROUND

Many individuals living with chronic kidney disease (CKD) have comorbid Type 2 diabetes (T2D). We sought to explore if efficacious interventions that improve glycemic control may also have potential to reduce CKD progression.

METHODS

REACH is a text message-delivered self-management support intervention, which focused on medication adherence, diet, and exercise that significantly improved glycemic control in N = 506 patients with T2D. Using data from the trial, we characterized kidney health in the full sample and explored the intervention's effect on change in estimated glomerular filtration rate (eGFR) at 12 months in a subsample of N=271 patients with eGFR data.

RESULTS

In a diverse sample with respect to race/ethnicity and socioeconomic status, 37.2% had presence of mild or heavy proteinuria and/or an eGFR < 60 mL/min/1.73 m². There was a trending interaction effect between intervention and presence of proteinuria at baseline (b = 6.016, p = .099) such that patients with proteinuria at baseline who received REACH had less worsening of eGFR.

CONCLUSIONS

Future research should examine whether diabetes directed self-management support reduces CKD progression in ethnically diverse individuals with albuminuria. In highly comorbid populations, such as T2D and CKD, text-based support can be further tailored according to individuals' multimorbid disease self-management needs and is readily scalable for individuals with limited resources.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov ( NCT02409329 ).

Technological Proficiencies, Engagement, and Practical Considerations for mHealth Programs at an Urban Safety-Net Hospital Emergency Departments: Data Analysis

Background

Safety-net emergency departments often serve as the primary entry point for medical care for low income predominantly minority patient populations. Herein, we sought to provide insight into the feasibility, technological proficiencies, engagement characteristics, and practical considerations for a mHealth intervention at a safety-net emergency department.

Objective

We aimed to analyze patient technological proficiency to understand the feasibility of and draw practical considerations for mobile phone technology (mHealth) solutions for patients with chronic disease served by safety-net emergency departments.

Methods

We analyzed data from a previous diabetes randomized clinical mHealth trial for a diabetes social support intervention. Patients from a safety-net emergency department with preexisting diabetes who used SMS text messages, owned a mobile phone, and with hemoglobin A_1c levels >8.5% were enrolled. A text message–based mHealth program to improve disease self-management was provided to all patients. Supporters of patients were randomized to receive a mailed copy or mHealth-based curriculum designed to improve diabetes support. Among enrolled patients, we surveyed mobile technological capacity and frequency of use. We performed latent class analysis to identify classes of patients by level of technological proficiency and compared demographic characteristics between the latent classes to identify demographic subgroups that may require more training or tailoring of the mHealth approach. Study engagement between classes was assessed by comparing the mean number of text messages exchanged, loss to follow-up, and early termination.

Results

Of 1876 patients who were approached, 44.2% (n=829) of patients had a stable mobile phone and were able to use text messages. Among them 166 met the trial inclusion and enrolled, 90% (149/166) of the cohort were ethnically diverse. Significant variance was found in technology capacity and frequency of use. Our latent class analysis classified 75% (124/166) of patients as highly technologically proficient and 25% (42/166) patients as minimally technologically proficient. Age (P<.001) and level of education (P<.001) were associated with class membership. Highly technologically proficient patients were younger and had higher levels of education (45.74 years old; high school or more: 90%) than minimally technologically proficient patients (53.64 years old; high school or more: 18%). Highly technologically proficient participants exchanged a mean of 40 text messages with the system coordinators compared to a mean of 10 text messages by minimally technologically proficient patients (P<.001).

Conclusions

This study found that nearly half of the patients screened at the safety-net emergency department were equipped for an SMS text message–based mHealth intervention. In the small sample of patients who were enrolled, the majority were classified as highly technologically proficient. These highly proficient patients had greater study engagement. mHealth use in emergency departments may be an opportunity to improve health of ethnically diverse populations by pairing sophisticated chronic disease self-management program with SMS text message–based and traditional in-person interventions to reach patients through the method that is most familiar and comfortable.

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2019.03.003

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention

OBJECTIVE

We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence.

METHODS

We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey. We defined engagement via responses to texts. We examined participant characteristics associated with text preferences, engagement, and feedback.

RESULTS

Participants (N = 101) were 57% female and 46% non-White. Most participants (71%) chose to receive both reminder and informational texts; 94% chose reminder texts once per day and 97% chose informational texts three times per week. Median text message response rate was 56% (IQR 26-80%). Participants who were Black (p < 0.01), had lower income (p = 0.03), or had lower medication adherence (p < 0.01) rated the program as more helpful and wanted additional functionalities for adherence support.

CONCLUSIONS AND PRACTICE IMPLICATIONS

While overall engagement was modest, participants at risk of worse health outcomes expressed more value and interest in the program. Findings inform the design of text messaging interventions for antihypertensive medication adherence and support targeting vulnerable patients to reduce health disparities.

CLINICAL TRIALS REGISTRATION

NCT02672787.

Teleneurology and Health Disparities

The disparate access to, and use of, telemedicine reflects those of in-person health. These disparities are perpetuated as a result of individual, social, and structural factors like low digital literacy, unequal availability of broadband services, and systemic racism. This review focuses on extant literature on disparities in teleneurology, including racial or ethnic disparities, language inequities, and the global context. Understanding social and structural barriers to equitable access to quality teleneurology is critical to addressing and preventing health disparities, ensuring effective and equitable neurological care for all patients.

A Social Media-Based Diabetes Intervention for Low-Income Mandarin-Speaking Chinese Immigrants in the United States: Feasibility Study

BACKGROUND

Chinese immigrants bear a high diabetes burden and face significant barriers to accessing diabetes self-management education (DSME) and counseling programs.

OBJECTIVE

The goal of this study was to examine the feasibility and acceptability and to pilot test the potential efficacy of a social media-based DSME intervention among low-income Chinese immigrants with type 2 diabetes (T2D) in New York City.

METHODS

This was a single group pretest and posttest study in 30 Chinese immigrants with T2D. The intervention included 24 culturally and linguistically tailored DSME videos, focusing on diabetes education and behavioral counseling techniques. Over 12 weeks, participants received 2 brief videos each week via WeChat, a free social media app popular among Chinese immigrants. Primary outcomes included the feasibility and acceptability of the intervention. Feasibility was evaluated by recruitment processes, retention rates, and the video watch rate. Acceptability was assessed via a satisfaction survey at 3 months. Secondary outcomes, that is, hemoglobin A_1c (HbA_1c), self-efficacy, dietary intake, and physical activity, were measured at baseline, 3 months, and 6 months. Descriptive statistics and paired 2-sided t tests were used to summarize the baseline characteristics and changes before and after the intervention.

RESULTS

The sample population (N=30) consisted of mostly females (21/30, 70%) who were married (19/30, 63%), with limited English proficiency (30/30, 100%), and the mean age was 61 (SD 7) years. Most reported an annual household income of <US $25,000 (24/30, 80%) and a high school education or less (19/30, 63%). Thirty participants were recruited within 2 months (January and February 2020), and 97% (29/30) of the participants were retained at 6 months. A video watch rate of 92% (28/30) was achieved. The mean baseline HbA_1c level was 7.3% (SD 1.3%), and this level declined by 0.5% (95% CI -0.8% to -0.2%; P=.003) at 6 months. The mean satisfaction score was 9.9 (SD 0.6) out of 10, indicating a high level of satisfaction with the program. All strongly agreed or agreed that they preferred this video-based DSME over face-to-face visits. Compared to baseline, there were significant improvements in self-efficacy, dietary, and physical activity behaviors at 6 months.

CONCLUSIONS

This pilot study demonstrated that a social media-based DSME intervention is feasible, acceptable, and potentially efficacious in a low-income Chinese immigrant population with T2D. Future studies need to examine the efficacy in an adequately powered clinical trial.

A Community Health Worker-Led mHealth-Enabled Diabetes Self-Management Education and Support Intervention in Rural Latino Adults: Single-Arm Feasibility Trial (Preprint)

Background

Latinos living in rural South Texas have a higher prevalence of diabetes, but their access to diabetes self-management education and support (DSMES) is limited.

Objective

We aimed to test the feasibility of a community health worker-led, mobile health (mHealth)-based DSMES intervention to reduce disparities in accessing DSMES in underserved rural Latino residents in South Texas.

Methods

This 12-week, single-arm, pre-post trial was delivered by trained community health workers to 15 adults with type 2 diabetes. The intervention consisted of digital diabetes education, self-monitoring, a cloud-based connected platform, and community health worker support. Feasibility was evaluated as retention, actual intervention use, program satisfaction, and barriers to implementation. We also explored the intervention’s effect on weight loss and hemoglobin A_1c (HbA_1c).

Results

All 15 participants were Latino (mean age 61.87 years, SD 10.67; 9/15 female, 60%). The retention rate at posttest was 14 of 15 (93%). On average, the participants completed 37 of 42 (88%) digital diabetes education lessons with 8 participants completing all lessons. Participants spent 81/91 days (89%) step tracking, 71/91 days (78%) food logging, 43/91 days (47%) blood glucose self-monitoring, and 74/91 days (81%) weight self-monitoring. The level of program satisfaction was high. On average, participants lost 3.5 (SD 3.2) kg of body weight (P=.001), while HbA_1c level remained unchanged from baseline (6.91%, SD 1.28%) to posttest (7.04%, SD 1.66%; P=.668).

Conclusions

A community health worker-led mHealth-based intervention was feasible and acceptable to improve access to DSMES services for Latino adults living in rural communities. Future randomized controlled trials are needed to test intervention efficacy on weight loss and glycemic control.

FHIRedApp: a LEAP in health information technology for promoting patient access to their medical information

Objective

Our aim is to develop a patient engagement technology that makes it easy for patients to access their own medical information and share it with others.

Materials and Methods

This paper describes our design through an adapted Community Engagement Studio methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American individuals in the community. We use Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients.

Results

We designed and developed FHIRedApp, an app platform, that allows patients to access their data and to share that access as HL7^® FHIR^® application programming interfaces with third-party app developers. We accomplished 2 major tasks: first, to demonstrate the use of interoperability and authentication standards, such as HL7^® FHIR and OAuth2, to help develop patient engagement technologies, and second, to co-develop and co-design FHIRedApp with active involvement of African–American, Latinx, and Asian–American community members. Usability results show high satisfaction rates for FHIRedApp.

Conclusion

The development of FHIRedApp demonstrates how technology innovations using national interoperability standards can be informed through a methodology of community engagement and human-centered design that involves local racial and ethnic groups.

Our aim is to develop a patient engagement technology (PET) that makes it easy for patients to access their own medical information and share it with others. We adapted a methodology to identify the needs and preferences of a diverse group of Latinx, African–American, and Asian–American patients. We used Human-Centered Design to interpret these needs and preferences to build a digital app platform, using national data standards, clinical data aggregators, and privacy-preserving solutions while maintaining the security and confidentiality of patients. We designed and developed FHIRedApp, a platform that allows other applications to work on it. Patients showed high satisfaction with the use of FHIRedApp. The development of FHIRedApp demonstrates how technology innovations using national standards for exchanging data can be informed through a methodology of community engagement and human-centered design.

Mobile Device Ownership, Current Use, and Interest in Mobile Health Interventions Among Low-Income Older Chinese Immigrants With Type 2 Diabetes: Cross-sectional Survey Study

Background

Chinese immigrants suffer a disproportionately high type 2 diabetes (T2D) burden and tend to have poorly controlled disease. Mobile health (mHealth) interventions have been shown to increase access to care and improve chronic disease management in minority populations. However, such interventions have not been developed for or tested in Chinese immigrants with T2D.

Objective

This study aims to examine mobile device ownership, current use, and interest in mHealth interventions among Chinese immigrants with T2D.

Methods

In a cross-sectional survey, Chinese immigrants with T2D were recruited from Chinese community centers in New York City. Sociodemographic characteristics, mobile device ownership, current use of social media software applications, current use of technology for health-related purposes, and interest in using mHealth for T2D management were assessed. Surveys were administered face-to-face by bilingual study staff in the participant’s preferred language. Descriptive statistics were used to characterize the study sample and summarize technology use.

Results

The sample (N=91) was predominantly female (n=57, 63%), married (n=68, 75%), and had a high school education or less (n=58, 64%); most participants had an annual household income of less than US $25,000 (n=63, 69%) and had limited English proficiency (n=78, 86%). The sample had a mean age of 70 (SD 11) years. Almost all (90/91, 99%) participants had a mobile device (eg, basic cell phones, smart devices), and the majority (n=83, 91%) reported owning a smart device (eg, smartphone or tablet). WeChat was the most commonly used social media platform (65/91, 71%). When asked about their top source for diabetes-related information, 63 of the 91 participants (69%) reported health care providers, followed by 13 who reported the internet (14%), and 10 who reported family, friends, and coworkers (11%). Less than one-quarter (21/91, 23%) of the sample reported using the internet to search for diabetes-related information in the past 12 months. About one-third of the sample (34/91, 37%) reported that they had watched a health-related video on their cell phone or computer in the past 12 months. The majority (69/91, 76%) of participants reported interest in receiving an mHealth intervention in the future to help with T2D management.

Conclusions

Despite high mobile device ownership, the current use of technology for health-related issues remained low in older Chinese immigrants with T2D. Given the strong interest in future mHealth interventions and high levels of social media use (eg, WeChat), future studies should consider how to leverage these existing low-cost platforms and deliver tailored mHealth interventions to this fast-growing minority group.

Maximizing diabetes education efforts in vulnerable populations - newer delivery concepts

PURPOSE OF REVIEW

Patients from ethnic/minority backgrounds or low socioeconomic status face numerous barriers to achieving ideal diabetes care goals. The purpose of this review is to describe the burden of diabetes in vulnerable populations; discuss the etiologic factors leading to health disparities in diabetes; and present challenges and solutions to improving diabetes care through novel diabetes self-management education and support interventions.

RECENT FINDINGS

Recent interventions to alleviate health disparities utilize a combination of community health workers, peer leaders and technology-based approaches to provide diabetes self-management education and support and overcome barriers to diabetes control such as low literacy, difficulty with transportation, and cultural beliefs. These interventions achieve clinically meaningful improvements in blood glucose control as measured by haemoglobin A1C and are effective in addressing psychosocial outcomes such as diabetes distress. Research is underway to address food insecurity through food delivery and use behavioural economics principles to provide financial incentives to diabetes control.

SUMMARY

Combining human interaction through peer or community health worker led diabetes educational efforts and support with technology-based interventions shows promise in improving diabetes outcomes for vulnerable populations.

Use of Health Information Technology by Adults With Diabetes in the United States: Cross-sectional Analysis of National Health Interview Survey Data (2016-2018)

BACKGROUND

The use of health information technology (HIT) has been proposed to improve disease management in patients with type 2 diabetes mellitus.

OBJECTIVE

This study aims to report the prevalence of HIT use in adults with diabetes in the United States and examine the factors associated with HIT use.

METHODS

We analyzed data from 7999 adults who self-reported a diabetes diagnosis as collected by the National Health Interview Survey (2016-2018). All analyses were weighted to account for the complex survey design.

RESULTS

Overall, 41.2% of adults with diabetes reported looking up health information on the web, and 22.8% used eHealth services (defined as filled a prescription on the web, scheduled an appointment with a health care provider on the web, or communicated with a health care provider via email). In multivariable models, patients who were female (vs male: prevalence ratio [PR] 1.16, 95% CI 1.10-1.24), had higher education (above college vs less than high school: PR 3.61, 95% CI 3.01-4.33), had higher income (high income vs poor: PR 1.40, 95% CI 1.23-1.59), or had obesity (vs normal weight: PR 1.11, 95% CI 1.01-1.22) were more likely to search for health information on the web. Similar associations were observed among age, race and ethnicity, education, income, and the use of eHealth services. Patients on insulin were more likely to use eHealth services (on insulin vs no medication: PR 1.21, 95% CI 1.04-1.41).

CONCLUSIONS

Among adults with diabetes, HIT use was lower in those who were older, were members of racial minority groups, had less formal education, or had lower household income. Health education interventions promoted through HIT should account for sociodemographic factors.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study

Background

Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation.

Objective

This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation.

Methods

Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society.

Results

Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon).

Conclusions

The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.

Challenges of conducting a remote behavioral weight loss study: Lessons learned and a practical guide

OBJECTIVES

To describe challenges and lessons learned in conducting a remote behavioral weight loss trial.

METHODS

The Personal Diet Study is an ongoing randomized clinical trial which aims to compare two mobile health (mHealth) weight loss approaches, standardized diet vs. personalized feedback, on glycemic response. Over a six-month period, participants attended dietitian-led group meetings via remote videoconferencing and were encouraged to self-monitor dietary intake using a smartphone app. Descriptive statistics were used to report adherence to counseling sessions and self-monitoring. Challenges were tracked during weekly project meetings.

RESULTS

Challenges in connecting to and engaging in the videoconferencing sessions were noted. To address these issues, we provided a step-by-step user manual and video tutorials regarding use of WebEx, encouraged alternative means to join sessions, and sent reminder emails/texts about the WebEx sessions and asking participants to join sessions early. Self-monitoring app-related issue included inability to find specific foods in the app database. To overcome this, the study team incorporated commonly consumed foods as "favorites" in the app database, provided a manual and video tutorials regarding use of the app and checked the self-monitoring app dashboard weekly to identify nonadherent participants and intervened as appropriate. Among 135 participants included in the analysis, the median attendance rate for the 14 remote sessions was 85.7% (IQR: 64.3%-92.9%).

CONCLUSIONS

Experience and lessons shared in this report may provide critical and timely guidance to other behavioral researchers and interventionists seeking to adapt behavioral counseling programs for remote delivery in the age of COVID-19.

Analysis of Effectiveness and Psychological Techniques Implemented in mHealth Solutions for Middle-Aged and Elderly Adults with Type 2 Diabetes: A Narrative Review of the Literature

BACKGROUND

in diabetes, multiple mHealth solutions were produced and implemented for self-management behaviors. However, little research on the effectiveness of psychological techniques implemented within these mHealth solutions was carried out, and even less with the elderly population where technological barriers might exist. Reliable evidence generated through a comprehensive evaluation of mHealth interventions may accelerate its growth for successful long-term implementation and to help to experience mHealth benefits in an enhanced way in all ages.

OBJECTIVE

this study aimed to review mHealth solutions for diabetes self-management in older adults (adherence to treatments and glycemic control) by analyzing the effectiveness of specific psychological techniques implemented.

METHODS

a narrative review was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed (Medline) and American Psychological Association (APA) PsycInfo databases were searched for published papers that addressed eHealth solutions' effectiveness for diabetes self-management. Studies in English, Spanish, and/or German of any design were screened, with no time constraints regarding the year of publication. A qualitative analysis of the selected papers was conducted in several steps.

RESULTS

this review found 38 studies setting up and analyzing mHealth solutions for older adults. Most research showed improvements in HbA1c, self-management behaviors, and medication adherence in T2DM patients post intervention. However, different mid-to-long term effects were found across studies, specifically concerning the maintenance and adherence to healthy behaviors. The most employed psychological framework was CBT, including techniques such as self-monitoring of outcome behaviors (mostly targeting glycemia measurements and healthy habits as physical activity and/or diet), tailored motivational feedback from medical staff, and psychoeducation or health coaches. The most successful mHealth intervention combined the feature of tailored feedback messages, interactive communication with healthcare professionals, and multifaceted functions.

CONCLUSIONS

there is a lack of elaborate and detailed information in the literature regarding the factors considered in the design and development of mHealth solutions used as interventions for T2DM self-management in the elderly. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of useful and user-friendly self-management apps that can enhance the quality of life for diabetes patients. Further research adapting mHealth solutions to older adults' sensory deficits is necessary.

Latinos understanding the need for adherence in diabetes (LUNA-D): a randomized controlled trial of an integrated team-based care intervention among Latinos with diabetes

We developed and tested a culturally appropriate, team-based, integrated primary care and behavioral health intervention in low income, Spanish-speaking Latinos with type 2 diabetes, at a federally qualified health center. This pragmatic randomized controlled trial included 456 Latino adults, 23-80 years, 63.7% female, with diabetes [recruitment glycosylated hemoglobin (HbA1c) ≥ 7.0%/53.01 mmol/mol)]. The Special Intervention occurred over 6 months and targeted improvement of HbA1c, blood pressure, and lipids. The intervention included: (i) four, same-day integrated medical and behavioral co-located visits; (ii) six group diabetes self-management education sessions addressing the cultural dimensions of diabetes and lifestyle messages; (iii) and care coordination. Usual Care participants received primary care provider led standard diabetes care, with referrals to health education and behavioral health as needed. HbA1c and lipids were obtained through electronic health records abstraction. Blood pressure was measured by trained research staff. Multi-level models showed a significant group by time interaction effect (B = -0.32, p < .01, 95% CI -0.49, -0.15), indicating statistically greater improvement in HbA1c level over 6 months in the Special Intervention group (ΔHbA1c = -0.35, p = <.01) versus Usual Care (ΔHbA1c = -0.02, p = .72). Marginally significant group by time interactions were also found for total cholesterol and diastolic blood pressure, with significant improvements in the Special Intervention group (p < .05). This culturally appropriate model of highly integrated care offers strategies that can assist with self-management goals and disease management for Latinos with diabetes in a federally qualified health center setting.

Retaining diverse adults with diabetes in a long-term trial: Strategies, successes, and lessons learned

Background Retention can be difficult in longitudinal trials, especially among minoritized groups and individuals with low socioeconomic status (SES) who may experience more barriers to research participation. Organized retention strategies may help; however, limited research has reported on this in detail. Methods We employed several strategies throughout a 15-month randomized controlled trial to encourage retention among a diverse sample of adults with type 2 diabetes. Participants were randomized to receive mobile health support for diabetes self-care for 12 months or an attention control. Participants completed assessments at 3, 6, 12, and 15 months post-baseline. We used three main categories of retention strategies: flexibility in participation (e.g., multiple methods for data collection), communication (e.g., tracking contacts), and community building (e.g., study branding, newsletters). We monitored participants' use of strategies and examined associations between participant characteristics and retention. Results Retention remained high (≥90%) at each follow-up assessment. Participants used various methods for survey completion: online (34%), in-person (31%), and mail (30%). Most (73%) used a mail-in A1c kit at least once. Multiple completion methods were important for retaining minoritized and lower SES participants who completed assessments in-person more frequently. Communication also facilitated retention; 39% of participants used a study Helpline and tracking systems helped maintain contact. Conclusions Retaining disadvantaged patients in clinical trials is necessary so findings generalize to and can benefit these populations. Retention strategies that reduce barriers to participation and engage participants and community partners can be successful. Future studies should assess the impact of retention strategies.

The Digital/Virtual Diabetes Clinic: The Future Is Now-Recommendations from an International Panel on Diabetes Digital Technologies Introduction

The increasing prevalence of diabetes, combined with a growing global shortage of health care professionals (HCP), necessitates the need to develop new approaches to diabetes care delivery to expand access to care, lessen the burden on people with diabetes, improve efficiencies, and reduce the unsustainable financial liability on health systems and payers. Use of digital diabetes technologies and telehealth protocols within a digital/virtual diabetes clinic has the potential to address these challenges. However, several issues must be resolved to move forward. In February 2020, organizers of the Advanced Technologies & Treatments for Diabetes Annual Conference convened an international panel of HCP, researchers, patient advocates, and industry representatives to review the status of digital diabetes technologies, characterize deficits in current technologies, and identify issues for consideration. Since that meeting, the importance of using telehealth and digital diabetes technologies has been demonstrated amid the global coronavirus disease (COVID-19) pandemic. This article summarizes the panel's discussion of the opportunities, obstacles, and requisites for advancing the use of these technologies as a standard of care for the management of diabetes.

Effects of a Tailored Text Messaging Intervention Among Diverse Adults With Type 2 Diabetes: Evidence From the 15-Month REACH Randomized Controlled Trial

OBJECTIVE

Text messaging interventions have high potential for scalability and for reductions in health disparities. However, more rigorous, long-term trials are needed. We examined the long-term efficacy and mechanisms of a tailored text messaging intervention.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes participated in a parallel-groups, 15-month randomized controlled trial and were assigned to receive Rapid Education/Encouragement and Communications for Health (REACH) for 12 months or control. REACH included interactive texts and tailored texts addressing medication adherence and nontailored texts supporting other self-care behaviors. Outcomes included hemoglobin A1c (HbA1c), diabetes medication adherence, self-care, and self-efficacy.

RESULTS

Participants (N = 506) were approximately half racial/ethnic minorities, and half were underinsured, had annual household incomes <$35,000, and had a high school education or less; 11% were homeless. Average baseline HbA1c was 8.6% ± 1.8%; 70.0 ± 19.7 mmol/mol) with n = 219 having HbA1c ≥8.5% (69 mmol/mol). Half were prescribed insulin. Retention was over 90%. Median response rate to interactive texts was 91% (interquartile range 75%, 97%). The treatment effect on HbA1c at 6 months (-0.31%; 95% CI -0.61%, -0.02%) was greater among those with baseline HbA1c ≥8.5% (-0.74%; 95% CI -1.26%, -0.23%), and there was no evidence of effect modification by race/ethnicity or socioeconomic disadvantage. REACH improved medication adherence and diet through 12 months and self-efficacy through 6 months. Treatment effects were not significant for any outcome at 15 months. REACH reduced barriers to adherence, but barrier reduction did not mediate outcome improvements.

CONCLUSIONS

REACH engaged at-risk patients in diabetes self-management and improved short-term HbA1c. More than texts alone may be needed to sustain the effects.

A Digital Innovation for the Personalized Management of Adherence: Analysis of Strengths, Weaknesses, Opportunities, and Threats

Introduction: Personalized medicine and management of adherence are potential solutions for the suboptimal use of medicines. Digital medication management innovations currently under development combine both aspects. This research aims to investigate facilitators for and barriers to the translation of digital innovations for personalized medicine and adherence management into clinical practice from the policymaker and regulator perspective.

Methods: A mixed-method study was used combining a scoping review to identify main interests, semi-structured interviews (n = 5) with representatives of European health policymaking and regulatory organizations, and a supplementary literature review to investigate key subthemes. The SWOT analysis was used for the qualitative analysis.

Results: The literature reviews and the qualitative interviews suggested that digital solutions can facilitate the personalized management of medications and improve quality and safety, especially as the openness for digital health solutions is increasing. Digital solutions may, on the other hand, add complexity to the treatment, which can be perceived as a potential barrier for their uptake. As more multidisciplinary and participative structures are emerging, digital solutions can promote the implementation of new services. Nevertheless, change progresses slowly in the task-oriented structures of health systems. Integration of digital solutions depends on all stakeholders' willingness and abilities to co-create this change. Patients have different capabilities to self-manage their medical conditions and use digital solutions. Personalization of digital health solutions and integration in existing service structures are crucial to ensure equality among population segments. Developments in the digital infrastructure, although they are partly slow and not well-aligned, enable the implementation of innovations in clinical practice leading to further advances in data generation and usage for future innovations.

Discussion: This study suggests that digital solutions have the potential to facilitate high-quality medication management and improve adherence to medications, enable new service structures, and are essential to drive further innovations in health care. Nevertheless, increasing the self-responsibility of patients can have undesirable effects on health outcomes, especially within vulnerable population segments. Digital health solutions can be an opportunity to optimize the use of medicines and thus their efficiency. Well-conceived development and implementation processes are needed to also realize improvements in equality and solidarity within health systems.

Leveraging Technology to Improve Diabetes Care in Pregnancy

Pregnant women with diabetes are at higher risk of adverse outcomes. Prevention of such outcomes depends on strict glycemic control, which is difficult to achieve and maintain. A variety of technologies exist to aid in diabetes management for nonpregnant patients. However, adapting such tools to meet the demands of pregnancy presents multiple challenges. This article reviews the key attributes digital technologies must offer to best support diabetes management during pregnancy, as well as some digital tools developed specifically to meet this need. Despite the opportunities digital health tools present to improve the care of people with diabetes, in the absence of robust data and large research studies, the ability to apply such technologies to diabetes in pregnancy will remain imperfect.