Adaptation and Feasibility Study of a Digital Health Program to Prevent Diabetes among Low-Income Patients: Results from a Partnership between a Digital Health Company and an Academic Research Team

A systematic review of the mechanisms influencing engagement in diabetes prevention programmes for people with pre-diabetes

AIMS

To identify barriers and enablers that influence engagement in and acceptability of diabetes prevention programmes for people with pre-diabetes. The results will provide insights for developing strategies and recommendations to improve design and delivery of diabetes prevention programmes with enhanced engagement and acceptability for people with pre-diabetes.

METHODS

This review used a critical realist approach to examine context and mechanisms of diabetes prevention programmes. Medline, Embase, PsycInfo, Cinahl, Web of Science, Scopus and Pre-Medline were searched for English language studies published between 2000 and 2023. A quality assessment was conducted using Joanna Briggs Institute critical appraisal tools.

RESULTS

A total of 90 papers met inclusion criteria. The included studies used a variety of quantitative and qualitative methodologies. Data extracted focused on barriers and enablers to engagement in and acceptability of diabetes prevention programmes, with seven key mechanisms identified. These included financial, environmental, personal, healthcare, social and cultural, demographic and programme mechanisms. Findings highlighted diverse factors that influenced engagement in preventive programmes and the importance of considering these factors when planning, developing and implementing future diabetes prevention programmes.

CONCLUSIONS

Mechanisms identified in this review can inform design and development of diabetes prevention programmes for people with pre-diabetes and provide guidance for healthcare professionals and policymakers. This will facilitate increased participation and engagement in preventive programmes, potentially reducing progression and/or incidence of pre-diabetes to type 2 diabetes and improving health outcomes.

Lifestyle Interventions to Prevent Type 2 Diabetes in Women with a History of Gestational Diabetes: A Systematic Review and Meta-Analysis through the Lens of Health Equity

BACKGROUND

Type 2 diabetes mellites is one of the health problems disproportionally affecting people with low socioeconomic statuses. Gestational diabetes mellites increases the risk of type 2 diabetes by up to ten-fold for women. Lifestyle interventions prevent type 2 diabetes in women with prior gestational diabetes. However, it is unknown if similar effectiveness can be expected for all population subgroups.

OBJECTIVE

This study aims to assess the prevention of type 2 diabetes in women with prior gestational diabetes using population characteristics according to the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) criteria.

METHODS

MEDLINE, CINAHL, EMBASE, PubMed, PsycINFO, Web of Science, and EBM Reviews databases were searched for interventional studies of diet, physical activity, or behavioural interventions published up to 21 February 2023. Random effects subgroup meta-analysis was conducted to evaluate the association of population characteristics and intervention effects.

RESULTS

All studies were conducted in high-income countries or middle-income countries. Two-thirds of the studies reported on race/ethnicity and education level. Less than one-third reported on place (urban/rural), occupation, and socioeconomic status. None reported on religion or social capital. Studies from high-income countries (MD = -1.46; 95% CI: -2.27, -0.66, I2 = 70.46, p < 0.001) showed a greater reduction in bodyweight compared with the studies conducted in middle-income countries (MD = -0.11; 95% CI: -1.12, 0.89, I2 = 69.31, p < 0.001) (p for subgroup difference = 0.04).

CONCLUSION

There are significant equity gaps in the evidence for the prevention of type 2 diabetes in women with prior gestational diabetes due to reports on population characteristics being poor. Interventions may be less effective in reducing bodyweight in women from middle-income countries compared to high-income countries. Collecting and analysing data related to equity is needed to understand the effect of lifestyle interventions on type 2 diabetes for different population subgroups.

The characteristics and acceptance of Technology-Enabled diabetes prevention programs (t-DPP) amongst individuals with prediabetes: A scoping review

AIM AND OBJECTIVE

As rising global prevalence of diabetes burdens an overstrained healthcare system, it would be prudent to employ primary prevention strategies. This review aims to detail characteristics of technology-enabled diabetes prevention programs (t-DPP) and the technology acceptance amongst prediabetic individuals.

DESIGN

A scoping review.

REVIEW METHODS

Summative and direct content analysis.

DATA SOURCES

Seven electronic databases-PubMed, Cochrane, Embase, CINAHL, Scopus, PsycINFO and Web of Science-were searched from inception till 9 June 2022 for primary studies conducted on t-DPP. Initial search identified 2412 unique articles. Removal of duplicates and irrelevant articles resulted in 58 full text articles screened and 17 articles meeting the eligibility criteria. There was no limitation to study type or year of publication, but language was limited to English.

RESULTS

Common t-DPP characteristics include physical activity (n = 17), diet control (n = 16), coaching (n = 12), social support (n = 9) and skills acquisition (n = 12). Technological acceptance of t-DPPs were generally positive as participants found them useful (n = 5) and easy to use (n = 4), with majority of the participants interested (n = 5) and engaging well with it (n = 13). However, personal-, design- and technological-level factors were found to negatively influence t-DPPs acceptance.

CONCLUSION

This review reported a generally positive technological acceptance. The result encourages remote delivery of diabetes prevention programs, offering researchers a guide to t-DPP development. However, it also highlights the need for integration of behavioural change theories and socio-cultural considerations, with gaps in knowledge amongst men and young adults.

IMPLICATIONS FOR NURSING

The success of t-DPP can reinforce clinical advice and sustain health behaviours advocated by nurses. Involvement of diabetes-trained nurses would enable continual risk assessment, monitoring and timely intervention to prevent diabetes and potential complications.

REPORTING METHOD

PRISMA-ScR checklist.

Evaluation of feasibility and acceptability of a web-based diabetes prevention program (DPP) for diabetes risk reduction in Chinese Americans in New York City

Introduction

Intensive lifestyle intervention remains an effective modality to reduce diabetes incidence and delay the progression to type 2 diabetes. The primary aim of this study was to pilot-test the feasibility and acceptability of a culturally and linguistically tailored web-based DPP intervention among Chinese Americans with prediabetes living in New York City.

Methods

Thirteen Chinese American participants with prediabetes were recruited to complete a 1-year web-based Diabetes Prevention Program (DPP) lifestyle intervention. Quantitative and qualitative measures such as retention rate and data collected from web-based questionnaires and focus groups were collected and analyzed to assess study feasibility and acceptability.

Results and Discussion

Participants were receptive to the program through high engagement, retention and satisfaction. Retention rate was 85%. 92% of participants completed at least 16 sessions out of 22 sessions. Post-trial surveys indicated high satisfaction of 27.2/32 based on Client Satisfaction Questionnaire (CSQ-8) score. Participants expressed the program increased their knowledge and methods to prevent onset of type 2 diabetes such as incorporating healthy eating habits and increasing physical activities. Although not a primary outcome, there was a significant weight reduction of 2.3% at the end of month 8 of the program (p < 0.05). The culturally and linguistically adapted DPP via online platform successfully demonstrated feasibility and acceptability among Chinese Americans with prediabetes. Further evaluation of the web-based Chinese Diabetes Prevention Program in a larger trial is warranted.

Development of a Web-Based Diabetes Prevention Program (DPP) for Chinese Americans: A Formative Evaluation Approach

Increasing evidence demonstrates that an online Diabetes Prevention Program (DPP) can delay the onset of type 2 diabetes. However, little has been done for Chinese Americans. This study, using Community-Based Participatory Research and Intervention Mapping approaches, describes a formative research process in the development of a culturally and linguistically tailored online DPP program among Chinese Americans with prediabetes living in New York City. Using a triangulation approach, data were collected to inform the development of an online DPP curriculum through (1) a literature review, (2) three focus groups (n = 24), and (3) a community advisory board meeting among 10 key informants knowledgeable in community needs, diabetes care, and lifestyle interventions. Participants indicated online DPPs would be very useful and easily accessible. However, key barriers including low computer skills/literacy and technology self-efficacy were identified. In addition, taking meal photos and tracking pedometer steps daily were found to be acceptable self-motoring tools for sustaining a healthy lifestyle. Furthermore, the integration of features such as text message reminders and the creation of social support groups into the online DPP curriculum was proposed to minimize attrition. This theory-based formative research to develop a culturally and linguistically appropriate web-based DPP curriculum was well-received by Chinese Americans and warrants testing in future intervention studies.

Targeting resources efficiently and justifiably by combining causal machine learning and theory

Introduction

Efficient allocation of limited resources relies on accurate estimates of potential incremental benefits for each candidate. These heterogeneous treatment effects (HTE) can be estimated with properly specified theory-driven models and observational data that contain all confounders. Using causal machine learning to estimate HTE from big data offers higher benefits with limited resources by identifying additional heterogeneity dimensions and fitting arbitrary functional forms and interactions, but decisions based on black-box models are not justifiable.

Methods

Our solution is designed to increase resource allocation efficiency, enhance the understanding of the treatment effects, and increase the acceptance of the resulting decisions with a rationale that is in line with existing theory. The case study identifies the right individuals to incentivize for increasing their physical activity to maximize the population's health benefits due to reduced diabetes and heart disease prevalence. We leverage large-scale data from multi-wave nationally representative health surveys and theory from the published global meta-analysis results. We train causal machine learning ensembles, extract the heterogeneity dimensions of the treatment effect, sign, and monotonicity of its moderators with explainable AI, and incorporate them into the theory-driven model with our generalized linear model with the qualitative constraint (GLM_QC) method.

Results

The results show that the proposed methodology improves the expected health benefits for diabetes by 11% and for heart disease by 9% compared to the traditional approach of using the model specification from the literature and estimating the model with large-scale data. Qualitative constraints not only prevent counter-intuitive effects but also improve achieved benefits by regularizing the model.

The Challenges Toward Real-world Implementation of Digital Health Design Approaches: Narrative Review

BACKGROUND

Digital health represents an important strategy in the future of health care delivery. Over the past decade, mobile health has accelerated the agency of health care users. Despite prevailing excitement about the potential of digital health, questions remain on efficacy, uptake, usability, and patient outcome. This challenge is confounded by 2 industries, digital and health, which have vastly different approaches to research, design, testing, and implementation. In this regard, there is a need to examine prevailing design approaches, weigh their benefits and challenges toward implementation, and recommend a path forward that synthesizes the needs of this complex stakeholder group.

OBJECTIVE

In this review, we aimed to study prominent digital health intervention design approaches that mediate the digital health space. In doing so, we sought to examine the origins, perceived benefits, contrasting nuances, challenges, and typical use-case scenarios of each methodology.

METHODS

A narrative review of digital health design approaches was performed between September 2020 and April 2021 by referencing keywords such as "digital health design," "mHealth design," "e-Health design," "agile health," and "agile healthcare." The studies selected after screening were those that discussed the design and implementation of digital health design approaches. A total of 120 studies were selected for full-text review, of which 62 (51.6%) were selected for inclusion in this review.

RESULTS

A review identifying the 5 overarching digital health design approaches was compiled: user-centered design, person-based design, human-centered design, patient-centered design, and patient-led design. The findings were synthesized in a narrative structure discussing the origins, advantages, disadvantages, challenges, and potential use-case scenarios.

CONCLUSIONS

Digital health is experiencing the growing pains of rapid expansion. Currently, numerous design approaches are being implemented to harmonize the needs of a complex stakeholder group. Whether the end user is positioned as a person, patient, or user, the challenge to synthesize the constraints and affordances of both digital design and health care, built equally around user satisfaction and clinical efficacy, remains paramount. Further research that works toward a transdisciplinarity in digital health may help break down friction in this field. Until digital health is viewed as a hybridized industry with unique requirements rather than one with competing interests, the nuances that each design approach posits will be difficult to realize in a real-world context. We encourage the collaboration of digital and health experts within hybrid design teams, through all stages of intervention design, to create a better digital health culture and design ethos.

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review

Background

Promoting health behaviors and preventing chronic diseases through a healthy lifestyle among those with a low socioeconomic status (SES) remain major challenges. eHealth interventions are a promising approach to change unhealthy behaviors in this target group.

Objective

This review aims to identify key components, barriers, and facilitators in the development, reach, use, evaluation, and implementation of eHealth lifestyle interventions for people with a low SES. This review provides an overview for researchers and eHealth developers, and can assist in the development of eHealth interventions for people with a low SES.

Methods

We performed a scoping review based on Arksey and O’Malley’s framework. A systematic search was conducted on PubMed, MEDLINE (Ovid), Embase, Web of Science, and the Cochrane Library, using terms related to a combination of the following key constructs: eHealth, lifestyle, low SES, development, reach, use, evaluation, and implementation. There were no restrictions on the date of publication for articles retrieved upon searching the databases.

Results

The search identified 1323 studies, of which 42 met our inclusion criteria. An update of the search led to the inclusion of 17 additional studies. eHealth lifestyle interventions for people with a low SES were often delivered via internet-based methods (eg, websites, email, Facebook, and smartphone apps) and offline methods, such as texting. A minority of the interventions combined eHealth lifestyle interventions with face-to-face or telephone coaching, or wearables (blended care). We identified the use of different behavioral components (eg, social support) and technological components (eg, multimedia) in eHealth lifestyle interventions. Facilitators in the development included iterative design, working with different disciplines, and resonating intervention content with users. Facilitators for intervention reach were use of a personal approach and social network, reminders, and self-monitoring. Nevertheless, barriers, such as technological challenges for developers and limited financial resources, may hinder intervention development. Furthermore, passive recruitment was a barrier to intervention reach. Technical difficulties and the use of self-monitoring devices were common barriers for users of eHealth interventions. Only limited data on barriers and facilitators for intervention implementation and evaluation were available.

Conclusions

While we found large variations among studies regarding key intervention components, and barriers and facilitators, certain factors may be beneficial in building and using eHealth interventions and reaching people with a low SES. Barriers and facilitators offer promising elements that eHealth developers can use as a toolbox to connect eHealth with low SES individuals. Our findings suggest that one-size-fits-all eHealth interventions may be less suitable for people with a low SES. Future research should investigate how to customize eHealth lifestyle interventions to meet the needs of different low SES groups, and should identify the components that enhance their reach, use, and effectiveness.

Using an Integrated Framework to Investigate the Facilitators and Barriers of Health Information Technology Implementation in Noncommunicable Disease Management: Systematic Review

BACKGROUND

Noncommunicable disease (NCD) management is critical for reducing attributable health burdens. Although health information technology (HIT) is a crucial strategy to improve chronic disease management, many health care systems have failed in implementing HIT. There has been a lack of research on the implementation process of HIT for chronic disease management.

OBJECTIVE

We aimed to identify the barriers and facilitators of HIT implementation, analyze how these factors influence the implementation process, and identify key areas for future action. We will develop a framework for understanding implementation determinants to synthesize available evidence.

METHODS

We conducted a systematic review to understand the barriers and facilitators of the implementation process. We searched MEDLINE, Cochrane, Embase, Scopus, and CINAHL for studies published between database inception and May 5, 2022. Original studies involving HIT-related interventions for NCD management published in peer-reviewed journals were included. Studies that did not discuss relevant outcome measures or did not have direct contact with or observation of stakeholders were excluded. The analysis was conducted in 2 parts. In part 1, we analyzed how the intrinsic attributes of HIT interventions affect the successfulness of implementation by using the intervention domain of the Consolidated Framework for Implementation Research (CFIR). In part 2, we focused on the extrinsic factors of HIT using an integrated framework, which was developed based on the CFIR and the levels of change framework by Ferlie and Shortell.

RESULTS

We identified 51 papers with qualitative, mixed-method, and cross-sectional methodologies. Included studies were heterogeneous regarding disease populations and HIT interventions. In part 1, having a relative advantage over existing health care systems was the most prominent intrinsic facilitator (eg, convenience, improvement in quality of care, and increase in access). Poor usability was the most noted intrinsic barrier of HIT. In part 2, we mapped the various factors of implementation to the integrated framework (the coordinates are shown as level of change-CFIR). The key barriers to the extrinsic factors of HIT included health literacy and lack of digital skills (individual-characteristics of individuals). The key facilitators included physicians' suggestions, cooperation (interpersonal-process), integration into a workflow, and adequate management of data (organizational-inner setting). The importance of health data security was identified. Self-efficacy issues of patients and organizational readiness for implementation were highlighted.

CONCLUSIONS

Internal factors of HIT and external human factors of implementation interplay in HIT implementation for chronic disease management. Strategies for improvement include ensuring HIT has a relative advantage over existing health care; tackling usability issues; and addressing underlying socioeconomic, interpersonal, and organizational conditions. Further research should focus on studying various stakeholders, such as service providers and administrative workforces; various disease populations, such as those with obesity and mental diseases; and various countries, including low- and middle-income countries.

Addressing and evaluating health literacy in mHealth: a scoping review

BACKGROUND

Recent surveys have revealed many adults have basic or below basic health literacy, which is linked to medical errors, increased illness, and compromised public health. Health literacy as a concept is multi-faceted extending beyond the individual to include social structures and the context in which health information is being accessed. Delivering health information via mobile devices (mHealth) expands the amount of information available while presenting challenges to ensuring these materials are suitable for a variety of literacy needs. The aims of this study are to discover how health literacy is addressed and evaluated in mHealth app development.

METHODS

A scoping review of 5 peer-reviewed databases was conducted. Eligible articles were written in English, addressed general literacy or mHealth/digital/eHealth literacy, and collected literacy information in order to incorporate literacy into the design and/or modification of an app or collected literacy information to describe the population being studied. The "Health Literacy Online" (HLO) United States (U.S.) government guide was used as a framework.

RESULTS

Thirty-two articles were reviewed. Articles included health literacy recommendations for all HLO categories and some recommendations not aligned with these categories. Most articles addressed health literacy using specific HLO categories though none incorporated every HLO category. The most common categories addressed engagement and testing of mHealth content. Though several studies addressed health literacy through a formal assessment tool, most did not. Evaluation of health literacy in mHealth was end-user focused and did not extensively evaluate content for fit to a variety of individuals with limited health literacy.

CONCLUSIONS

The recommendations seen consistently in our results in conjunction with formal HLO categories can act as beginning steps towards development of a health literacy evaluation tool for mHealth apps themselves. It is clear efforts are being made to reduce barriers to using mHealth for those with literacy deficits, however, it was also clear that this space has room to be more pragmatic in evaluation of mHealth tools for literacy. End user engagement in design and testing is necessary in future mHealth literacy tool development.

Communication strategies in the prevention of type 2 diabetes and gestational diabetes in vulnerable groups: a scoping review

BACKGROUND

The global prevalence of diabetes is nearly 9%, with an upward trend in type 2 diabetes mellitus (T2DM) and gestational diabetes (GDM). Although evidence shows that vulnerable groups are affected disproportionally, these groups are difficult to reach in terms of preventive measures. Currently, there is no gold standard regarding communication strategies and/or public awareness campaigns.

METHODS

We conducted a scoping review in September 2019. Two reviewers independently screened the results of the electronic literature search in several databases, including Medline, EMBASE, and PsycINFO. Extracted data were charted, categorized, and summarized.

RESULTS

All of the included articles (n=24) targeted T2DM; none targeted GDM. We identified the following five different vulnerable groups within the identified studies: migrants (n=9), ethnic groups such as African Americans (n=8), people with low socioeconomic status (n=3), older people (n=1), and people in need of care (n=1). Three categories of communication strategies were identified as follows: adapted diabetes prevention programs (n=21), community health workers (n=5), and technical approaches (n=9).

CONCLUSION

We found different approaches for preventive interventions for T2DM. Some of these approaches were already adapted to known barriers. Communication strategies should be adapted to barriers and facilitating factors to increase participation and motivation.

Prevention of Type 2 Diabetes

The global diabetes burden is staggering, and prevention efforts are needed to reduce the impact on individuals and populations. There is strong evidence from efficacy trials showing that lifestyle interventions promoting increased physical activity, improvements in diet, and/or weight loss significantly reduce diabetes incidence and improve cardiometabolic risk factors. Implementation research assessing the feasibility, effectiveness, and cost-effectiveness of delivering these proven programs at the community level has shown success, but more research is needed to overcome barriers to implementation in different settings globally. New avenues of research should be considered to combat this public health issue.

Real-world insights from launching remote peer-to-peer mentoring in a safety net healthcare delivery setting

Peer mentors have been proven to improve diabetes outcomes, especially among diverse patients. Delivering peer mentoring via remote strategies (phone, text, mobile applications) is critical, especially in light of the recent pandemic. We conducted a real-world evaluation of a remote diabetes intervention in a safety-net delivery system in New York. We summarized the uptake, content, and pre-post clinical effectiveness for English- and Spanish-speaking participants. Of patients who could be reached, 71% (n = 690/974) were enrolled, and 90% of those (n = 618/690) participated in coaching. Patients and mentors had a mean of 32 check-ins, and each patient set an average of 10 goals. 29% of the participants accessed the program via the smartphone application. Among participants with complete hemoglobin A1c data (n = 179), there was an absolute 1.71% reduction (P < .01). There are multiple lessons for successful implementation of remote peer coaching into settings serving diverse patients, including meaningful patient-mentor matching and addressing social determinants.

Motivation and Problem Solving Versus Mobile 360° Videos to Promote Enrollment in the National Diabetes Prevention Program's Lifestyle Change Program Among People With Prediabetes: Protocol for a Randomized Trial

Background

More than 88 million Americans are at risk of developing type 2 diabetes mellitus (T2DM). The National Diabetes Prevention Program’s Lifestyle Change Program (DPP LCP) has been shown to be effective in reducing the risk of progressing from prediabetes to T2DM. However, most individuals who could benefit from the program do not enroll.

Objective

The aim of this trial is to test the real-world efficacy of 3 mobile phone–based approaches to increasing enrollment in the DPP LCP including a best-practice condition and 2 novel approaches.

Methods

We will conduct a 3-armed randomized clinical trial comparing enrollment and 1-month engagement in the DPP LCP among adults with prediabetes from 2 health care settings. Participants in the best-practice condition will receive SMS-based notifications that they have prediabetes and a link to a website that explains prediabetes, T2DM, and the DPP LCP. This will be followed by a single question survey, “Would you like the DPP LCP to call you to enroll?” Participants in the 2 intervention arms will receive the same best-practice intervention plus either 2 mobile 360° videos or up to 5 brief phone calls from a health coach trained in a motivational coaching approach known as Motivation and Problem Solving (MAPS). We will collect measures of diabetes-related knowledge, beliefs in the controllability of risk for T2DM, risk perceptions for T2DM, and self-efficacy for lifestyle change pre-intervention and 4 weeks later. The primary outcomes of the study are enrollment in the DPP LCP and 4-week engagement in the DPP LCP. In addition, data on the person-hours needed to deliver the interventions as well as participant feedback about the interventions and their acceptability will be collected. Our primary hypotheses are that the 2 novel interventions will lead to higher enrollment and engagement in the DPP LCP than the best-practice intervention. Secondary hypotheses concern the mechanisms of action of the 2 intervention arms: (1) whether changes in risk perception are associated with program enrollment among participants in the mobile 360° video group and (2) whether changes in self-efficacy for lifestyle change are associated with program enrollment among participants in the MAPS coaching group. Finally, exploratory analyses will examine the cost effectiveness and acceptability of the interventions.

Results

The project was funded in September 2020; enrollment began in February 2021 and is expected to continue through July 2022.

Conclusions

We are conducting a test of 2 novel, scalable, mobile phone–based interventions to increase enrollment in the DPP LCP. If effective, they have tremendous potential to be scaled up to help prevent T2DM nationwide.

Trial Registration

ClinicalTrials.gov NCT04746781; https://clinicaltrials.gov/ct2/show/NCT04746781

International Registered Report Identifier (IRRID)

DERR1-10.2196/28884

Conducting Internet-Based Visits for Onboarding Populations With Limited Digital Literacy to an mHealth Intervention: Development of a Patient-Centered Approach

Background

The COVID-19 pandemic has propelled patient-facing research to shift to digital and telehealth strategies. If these strategies are not adapted for minority patients of lower socioeconomic status, health inequality will further increase. Patient-centered models of care can successfully improve access and experience for minority patients.

Objective

This study aims to present the development process and preliminary acceptability of altering in-person onboarding procedures into internet-based, remote procedures for a mobile health (mHealth) intervention in a population with limited digital literacy.

Methods

We actively recruited safety-net patients (English- and Spanish-speaking adults with diabetes and depression who were receiving care at a public health care delivery system in San Francisco, United States) into a randomized controlled trial of text messaging support for physical activity. Because of the COVID-19 pandemic, we modified the in-person recruitment and onboarding procedures to internet-based, remote processes with human support. We conducted a preliminary evaluation of how the composition of the recruited cohort might have changed from the pre–COVID-19 period to the COVID-19 enrollment period. First, we analyzed the digital profiles of patients (n=32) who had participated in previous in-person onboarding sessions prior to the COVID-19 pandemic. Next, we documented all changes made to our onboarding processes to account for remote recruitment, especially those needed to support patients who were not very familiar with downloading apps onto their mobile phones on their own. Finally, we used the new study procedures to recruit patients (n=11) during the COVID-19 social distancing period. These patients were also asked about their experience enrolling into a fully digitized mHealth intervention.

Results

Recruitment across both pre–COVID-19 and COVID-19 periods (N=43) demonstrated relatively high rates of smartphone ownership but lower self-reported digital literacy, with 32.6% (14/43) of all patients reporting they needed help with using their smartphone and installing apps. Significant changes were made to the onboarding procedures, including facilitating app download via Zoom video call and/or a standard phone call and implementing brief, one-on-one staff-patient interactions to provide technical assistance personalized to each patient’s digital literacy skills. Comparing recruitment during pre–COVID-19 and COVID-19 periods, the proportion of patients with digital literacy barriers reduced from 34.4% (11/32) in the pre–COVID-19 cohort to 27.3% (3/11) in the COVID-19 cohort. Differences in digital literacy scores between both cohorts were not significant (P=.49).

Conclusions

Patients of lower socioeconomic status have high interest in using digital platforms to manage their health, but they may require additional upfront human support to gain access. One-on-one staff-patient partnerships allowed us to provide unique technical assistance personalized to each patient’s digital literacy skills, with simple strategies to troubleshoot patient barriers upfront. These additional remote onboarding strategies can mitigate but not eliminate digital barriers for patients without extensive technology experience.

Trial Registration

Clinicaltrials.gov NCT0349025, https://clinicaltrials.gov/ct2/show/NCT03490253

Su salud a la mano (your health at hand): patient perceptions about a bilingual patient portal in the Los Angeles safety net

OBJECTIVES

Driven by beneficial patient-centered outcomes associated with patient portal use and the Affordable Care Act, portal implementation has expanded into safety nets-health systems that offer access to care to a large share of uninsured, Medicaid, and other vulnerable populations. However, little attention has been paid to the factors that affect portal accessibility by the vulnerable patients served by these health systems-including those who are limited English proficient (LEP).

MATERIALS AND METHODS

The Los Angeles County Department of Health Services (LAC DHS), the second-largest safety net system in the nation, launched its first patient portal, and one of the few bilingual English-Spanish interfaces in existence, in March of 2015. To explore portal awareness and perceptions, we conducted focus groups with LAC DHS patients, in English and Spanish (LEP). The Technology Acceptance Model was used to guide thematic analysis of focus group data.

RESULTS

Of the 46 participants, 37 were patients and 9 were caretakers; 23 were English-speaking and 23 Spanish-speaking LEP. All patients had diabetes or hypertension. Over half had an annual household income <$10 000, yet 78% of English-speaking and 65% of Spanish-speaking LEP participants reported at-home Internet access. Participants' discussion centered around 3 major thematic narratives: (1) participants' awareness or attitudes about the LAC DHS portal; (2) role of culture, language, or community with regard to portal accessibility and utility; and (3) perceived needs for successful portal implementation.

CONCLUSIONS

Safety net participants identified concrete benefits to the portal and emphasized the need for portal engagement that offered accessible education, support, and resources in clinical and community settings. The portal offers an additional opportunity to engage the patient and family with trusted and validated health information, and should be further developed in this capacity. This study provides a better understanding of preferred improvements of patient portal engagement that guide broader health technology efforts to address electronic health disparities.

eHealth Delivery of Educational Content Using Selected Visual Methods to Improve Health Literacy on Lifestyle-Related Diseases: Literature Review

BACKGROUND

Lifestyle-related diseases, such as stroke, heart disease, and diabetes, are examples of noncommunicable diseases. Noncommunicable diseases are now the leading cause of death in the world, and their major causes are lifestyle related. The number of eHealth interventions is increasing, which is expected to improve individuals' health literacy on lifestyle-related diseases.

OBJECTIVE

This literature review aims to identify existing literature published in the past decade on eHealth interventions aimed at improving health literacy on lifestyle-related diseases among the general population using selected visual methods, such as educational videos, films, and movies.

METHODS

A systematic literature search of the PubMed database was conducted in April 2019 for papers written in English and published from April 2, 2009, through April 2, 2019. A total of 538 papers were identified and screened in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. Finally, 23 papers were included in this review.

RESULTS

The 23 papers were characterized according to study characteristics (author and year of publication, study design and region where the study was conducted, study objective, service platform, target disease and participant age, research period, outcomes, and research method); the playback time of the educational videos, films, and movies; and the evaluation of the study's impacts on health literacy. A total of 7 studies compared results using statistical methods. Of these, 5 studies reported significant positive effects of the intervention on health literacy and health-related measures (eg, physical activity, body weight). Although most of the studies included educational content aimed at improving health literacy, only 7 studies measured health literacy. In addition, only 5 studies assessed literacy using health literacy measurement tools.

CONCLUSIONS

This review found that the provision of educational content was satisfactory in most eHealth studies using selected visual methods, such as videos, films, and movies. These findings suggest that eHealth interventions influence people's health behaviors and that the need for this intervention is expected to increase. Despite the need to develop eHealth interventions, standardized measurement tools to evaluate health literacy are lacking. Further research is required to clarify acceptable health literacy measurements.

Mobile Virtual reality vs. Mobile 360 Video to Promote Enrollment in the Diabetes Prevention Program Amongst Hispanic Adults (Preprint)

Background

Hispanic adults are at increased risk of developing type 2 diabetes. The Diabetes Prevention Program (DPP) reduces the risk of developing type 2 diabetes; however, the rate of enrollment is very low.

Objective

The goal of this pilot project was to determine whether presenting brief motivational mobile videos in virtual reality vs 360° video has differential effects on risk perceptions and enrollment in the DPP.

Methods

Adults with prediabetes were recruited at a clinic serving a low-income Hispanic community. After consenting, the participants completed a baseline survey that collected information about demographics and risk perceptions. All participants then viewed 2 videos. Per random assignment, the videos were presented either using the participant’s smartphone alone (360° video) or were viewed with their smartphone in a virtual reality (VR) cardboard headset. Two weeks later, a follow-up survey collected measures of enrollment in the DPP, risk perceptions, health literacy, the importance of contextual factors related to the decision of whether to enroll in the DPP (eg, distance to the class), and qualitative feedback on the interventions. We used logistic regression to determine whether enrollment in the DPP differed by intervention mode, while accounting for health literacy and contextual factors related to the DPP. We used unpaired t tests to examine differences in change in risk perceptions between groups. Paired t tests were used to examine within-subject changes in risk perceptions.

Results

A total of 116 participants provided complete data. Most participants were middle-aged (mean age 44.6 years; SD 11.9) Hispanic (114/116), female (79/116), with low health literacy (mean score 12.3/20; SD 3.4). Enrollment in the DPP was 44/116 (37.9%) overall but did not differ by group (odds ratio for enrolling in VR group 1.78, 95% CI 0.75-4.3; P=.19). Individuals who rated the distance needed to travel to attend the DPP as more important were less likely to enroll in the DPP (odds ratio 0.56, 95% CI 0.33-0.92; P=.03). Risk perceptions did not differ by group (mean change in 360° video group -0.07, mean change in VR group 0.03, t=0.6, P=.54) and did not change within subjects (mean 0.02, t=0.21, P=.83). Participant feedback suggested that the videos are emotionally engaging and educational.

Conclusions

The videos presented in 360° video and mobile VR had equal efficacy in promoting enrollment in the DPP. Future work to rigorously evaluate this intervention, its mechanism of action, and potential moderators of the efficacy are discussed.

The PCORnet Blood Pressure Control Laboratory: A Platform for Surveillance and Efficient Trials

BACKGROUND

Uncontrolled blood pressure (BP) is a leading preventable cause of death that remains common in the US population despite the availability of effective medications. New technology and program innovation has high potential to improve BP but may be expensive and burdensome for patients, clinicians, health systems, and payers and may not produce desired results or reduce existing disparities in BP control.

METHODS AND RESULTS

The PCORnet Blood Pressure Control Laboratory is a platform designed to enable national surveillance and facilitate quality improvement and comparative effectiveness research. The platform uses PCORnet, the National Patient-Centered Clinical Research Network, for engagement of health systems and collection of electronic health record data, and the Eureka Research Platform for eConsent and collection of patient-reported outcomes and mHealth data from wearable devices and smartphones. Three demonstration projects are underway: BP track will conduct national surveillance of BP control and related clinical processes by measuring theory-derived pragmatic BP control metrics using electronic health record data, with a focus on tracking disparities over time; BP MAP will conduct a cluster-randomized trial comparing effectiveness of 2 versions of a BP control quality improvement program; BP Home will conduct an individual patient-level randomized trial comparing effectiveness of smartphone-linked versus standard home BP monitoring. Thus far, BP Track has collected electronic health record data from over 826 000 eligible patients with hypertension who completed ≈3.1 million ambulatory visits. Preliminary results demonstrate substantial room for improvement in BP control (<140/90 mm Hg), which was 58% overall, and in the clinical processes relevant for BP control. For example, only 12% of patients with hypertension with a high BP measurement during an ambulatory visit received an order for a new antihypertensive medication.

CONCLUSIONS

The PCORnet Blood Pressure Control Laboratory is designed to be a reusable platform for efficient surveillance and comparative effectiveness research; results from demonstration projects are forthcoming.

Outcomes of a Weight Loss Intervention to Prevent Diabetes Among Low-Income Residents of East Harlem, New York

There is a need for diabetes prevention efforts targeting vulnerable populations. Our community-academic partnership, the East Harlem Partnership for Diabetes Prevention, conducted a randomized controlled trial to study the impact of peer led diabetes prevention workshops on weight and diabetes risk among an economically and racially diverse population in East Harlem, New York. We recruited overweight/obese adults from more than 50 community sites and conducted oral glucose tolerance testing and completed other clinical assessments and a health and lifestyle survey. We randomized prediabetic participants to intervention or delayed intervention groups. Intervention participants attended eight 90-minute peer-led workshop sessions at community sites. Participants in both groups returned for follow-up assessments 6 months after randomization. The main outcomes were the proportion of participants who achieved 5% weight loss, percentage weight loss, and change in the probability of developing diabetes over the next 7.5 years according to the San Antonio Diabetes Prediction Model. We enrolled 402 participants who were mainly female (85%), Latino (73%) or Black (23%), foreign born (64%), and non-English speaking (58%). At 6 months, the intervention group lost a greater percentage of their baseline weight, had significantly lower rise in HbA1c (glycated hemoglobin), decreased risk of diabetes, larger decreases in fat and fiber intake, improved confidence in nutrition label reading, and decrease in sedentary behavior as compared with the control group. Thus, in partnership with community stakeholders, we created an effective low-resource program that was less intensive than previously studied programs by incorporating strategies to engage and affect our priority population.

Evaluation of a Digital Diabetes Prevention Program Adapted for Low-Income Patients, 2016-2018

INTRODUCTION

We examined the effects of a digitally delivered, type 2 diabetes mellitus prevention program (DPP) for a low-income population.

METHODS

We conducted a nonrandomized clinical trial with matched controls. The intervention group was offered a digital DPP, a web-based and mobile-based program including 52 weeks of participation in an educational curriculum, health coaching, and peer support.

RESULTS

A total of 227 participants enrolled. At baseline, 34.6 was the mean body mass index, and 5.8 was the mean HbA_1c. For the intervention group, mean weight loss was 4.4% at the 12-month follow-up.

CONCLUSION

The modified DPP successfully engaged participants and resulted in weight loss. Low-income patients with prediabetes benefitted from a digitally delivered diabetes intervention. This prevention method should be accessible to a low-income population.

The Diabetes Prevention Program for Underserved Populations: A Brief Review of Strategies in the Real World

IN BRIEF This review highlights examples of the translation of the Diabetes Prevention Program (DPP) to underserved populations. Here, underserved populations are defined as groups whose members are at greater risk for health conditions such as diabetes but often face barriers accessing treatment. Strategies to develop and evaluate future DPP translations are discussed.

Behavioral Feasibility of the Clinical Nursing Information System

Background:

Analysis of humanitarian issues affecting the implementation time of information systems to increase the acceptance of these systems is essential.

Objective:

The aim of this study was to assess the behavioral feasibility of the clinical nursing information system.

Methods:

An applied cross-sectional study was conducted with 348 nurses in 2015. Data were collected by face to face interviews and a questionnaire containing 33 questions, which were rated on a 5-point Likert scale. Face and content validity of the questionnaire was confirmed, and its reliability was estimated 0.90 through Cronbach's alpha coefficient. Data were analyzed using chi-square tests and t-test.

Results:

An average score of behavioral feasibility was 67.44%. The rate of supply provided for implementing the clinical nursing information system was 55.2%, which was in a semi-favorable level. The necessity of system deployment in the clinical nursing sector had the highest frequency (88.2%) and interference of redesigning structures with the current work had the lowest frequency (43.6%).

Conclusion:

The possibility of implementation of the clinical nursing information system in a behavioral dimension is at a semi-favorable level. To increase the acceptance of the system, presenting a new system as a positive change and further training of the nurses is recommended.

Academia-industry digital health collaborations: A cross-cultural analysis of barriers and facilitators

Background

Development and uptake of digital health technologies benefit from cross-sectoral efforts from academia and industry. Our study aims to identify the barriers and facilitators associated with academia–industry collaborations in digital health in middle- and high-income countries.

Methods

Trained personnel conducted semi-structured interviews with 23 stakeholders who were active in industry, academia or both. Stakeholders were based in middle-income countries (including China) and high-income countries (including the United States) as defined by the World Bank. Interviews were conducted in the stakeholder’s language of choice (Chinese, n = 12; English, n = 11). Qualitative interview questions elicited perspectives on stakeholders’ experience with academia–industry collaboration, challenges faced, and factors that facilitated the process. Interviews were audiotaped, transcribed verbatim, thematically coded by bilingual coders and analyzed using inductive content analysis.

Results

Stakeholders in both academia and industry identified complementary roles, authentic communication between partners, and clearly outlined goals or expectations prior to the collaboration as primary facilitators for success. Misaligned goals or expectations, differences in timelines for productivity and difficulties balancing expectations for business outcomes versus generation of scientific evidence were identified as primary barriers. Stakeholders in high-income countries reported inauthentic communication as a significant barrier to collaboration, whereas those in middle-income countries did not.

Conclusion

Outlining and communicating openly about goals and expectations for timeline and priorities as well as establishing complementary roles will facilitate fruitful academia–industry collaborations in the future. Best practices for communication styles may be dependent on the cultural setting, and thus should be adopted accordingly.

Digital Health-Supported Lifestyle Change Programs to Prevent Type 2 Diabetes

IN BRIEF Type 2 diabetes can be prevented or delayed in people with prediabetes through participation in an intensive lifestyle change program (LCP), particularly one based on the Diabetes Prevention Program research study. Digital health offers opportunities to extend the reach of such LCPs and possibly improve on these programs, which traditionally have been delivered in person. In this review, we describe the current state of evidence regarding digital health-supported LCPs and discuss gaps in research and opportunities for future efforts.

Considerations for Evaluation of Diabetes Prevention Programs in Hispanic Adults in the United States

Hispanics are at high risk for diabetes. While there have been a number of diabetes prevention programs targeting Hispanics in the United States, not all recent studies focused on evaluating such programs have made use of validated tools to examine behavior change or examined acceptability and feasibility of the intervention. Tools used to assess behavioral outcomes such as diet should be tested to ensure validity and reliability. Acceptability may be examined using qualitative and quantitative measures to obtain feedback on the content of the intervention. Feasibility of the intervention may be evidenced by the enrollment, attendance, and attrition rates, as well as barriers or facilitators to participating in the program. Appropriate and comprehensive evaluation of such programs will allow for continued improvement of prevention efforts to address high rates of diabetes in this at-risk population.

Practical Tips for Implementing the Diabetes Prevention Program in Clinical Practice

PURPOSE OF REVIEW

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for prediabetes that is associated with a 58% reduction in 3-year diabetes incidence, and it has been supported by the American Medical Association and the Centers for Disease Control and Prevention. However, 9 in 10 patients are unaware they have the condition.

RECENT FINDINGS

With the passage of the Affordable Care Act (ACA) and broadened coverage for preventive services, the DPP has emerged as an accessible intervention in patients at risk. In 2018, Medicare began to cover the DPP, making it widely available for the first time to any patient over the age of 65 meeting eligibility criteria. The DPP is an evidence-based, widely available, frequently covered benefit, for lifestyle change for patients with prediabetes. To take advantage of this intervention, providers need to develop prediabetes screening and DPP referral workflows.

Barriers to and Facilitators of Engagement With Remote Measurement Technology for Managing Health: Systematic Review and Content Analysis of Findings

BACKGROUND

Remote measurement technology refers to the use of mobile health technology to track and measure change in health status in real time as part of a person's everyday life. With accurate measurement, remote measurement technology offers the opportunity to augment health care by providing personalized, precise, and preemptive interventions that support insight into patterns of health-related behavior and self-management. However, for successful implementation, users need to be engaged in its use.

OBJECTIVE

Our objective was to systematically review the literature to update and extend the understanding of the key barriers to and facilitators of engagement with and use of remote measurement technology, to guide the development of future remote measurement technology resources.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving original studies dating back to the last systematic review published in 2014. We included studies if they met the following entry criteria: population (people using remote measurement technology approaches to aid management of health), intervention (remote measurement technology system), comparison group (no comparison group specified), outcomes (qualitative or quantitative evaluation of the barriers to and facilitators of engagement with this system), and study design (randomized controlled trials, feasibility studies, and observational studies). We searched 5 databases (MEDLINE, IEEE Xplore, EMBASE, Web of Science, and the Cochrane Library) for articles published from January 2014 to May 2017. Articles were independently screened by 2 researchers. We extracted study characteristics and conducted a content analysis to define emerging themes to synthesize findings. Formal quality assessments were performed to address risk of bias.

RESULTS

A total of 33 studies met inclusion criteria, employing quantitative, qualitative, or mixed-methods designs. Studies were conducted in 10 countries, included male and female participants, with ages ranging from 8 to 95 years, and included both active and passive remote monitoring systems for a diverse range of physical and mental health conditions. However, they were relatively short and had small sample sizes, and reporting of usage statistics was inconsistent. Acceptability of remote measurement technology according to the average percentage of time used (64%-86.5%) and dropout rates (0%-44%) was variable. The barriers and facilitators from the content analysis related to health status, perceived utility and value, motivation, convenience and accessibility, and usability.

CONCLUSIONS

The results of this review highlight gaps in the design of studies trialing remote measurement technology, including the use of quantitative assessment of usage and acceptability. Several processes that could facilitate engagement with this technology have been identified and may drive the development of more person-focused remote measurement technology. However, these factors need further testing through carefully designed experimental studies.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42017060644; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=60644 (Archived by WebCite at http://www.webcitation.org/70K4mThTr).

Implementing Systematically Collected User Feedback to Increase User Retention in a Mobile App for Self-Management of Low Back Pain: Retrospective Cohort Study

BACKGROUND

Promising first results for Kaia, a mobile app digitalizing multidisciplinary rehabilitation for low back pain, were recently published. It remains unclear whether the implementation of user feedback in an updated version of this app leads to desired effects in terms of increased app usage and clinical outcomes.

OBJECTIVE

The aim is to elucidate the effect on user retention and clinical outcomes of an updated version of the Kaia app where user feedback was included during development.

METHODS

User feedback of the initial app versions (0.x) was collected in a quality management system and systematically analyzed to define requirements of a new version. For this study, the anonymized data of Kaia users was analyzed retrospectively and users were grouped depending on the available version at the time of the sign-up (0.x vs 1.x). The effect on the duration of activity of users in the app, the number of completed exercises of each type, and user-reported pain levels were compared.

RESULTS

Overall, data of 1251 users fulfilled the inclusion criteria, of which 196 users signed up using version 0.x and 1055 users signed up with version 1.x. There were significant differences in the demographic parameters for both groups. A log-rank test showed no significant differences for the duration of activity in the app between groups (P=.31). Users signing up during availability of the 1.x version completed significantly more exercises of each type in the app (physical exercises: 0.x mean 1.99, SD 1.61 units/week vs 1.x mean 3.15, SD1.72 units/week; P<.001; mindfulness exercises: 0.x mean 1.36, SD 1.43 units/week vs 1.x mean 2.42, SD 1.82 units/week; P<.001; educational content: 0.x mean 1.51, SD 1.42 units/week vs 1.x mean 2.71, SD 1.89 units/week; P<.001). This translated into a stronger decrease in user-reported pain levels in versions 1.x (F1,1233=7.084, P=.008).

CONCLUSIONS

Despite the limitations of retrospective cohort studies, this study indicates that the implementation of systematically collected user feedback during development of updated versions can contribute to improvements in terms of frequency of use and potentially even clinical endpoints such as pain level. The clinical efficiency of the Kaia app needs to be validated in prospective controlled trials to exclude bias.

Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial

Previous studies have shown that lifestyle modification can successfully prevent or delay development of type 2 diabetes. This trial aimed to test if an underserved, low-income population would engage in a digital diabetes prevention program and successfully achieve lifestyle changes to reduce their risk of type 2 diabetes. Participants were recruited from three health care facilities serving low-income populations. The inclusion criteria were: a recent blood test indicating prediabetes, body mass index (BMI) > 24 kg/m², age 18-75 years, not pregnant, not insured, Medicaid insured or Medicaid-eligible, internet or smartphone access, and comfort reading and writing in English or Spanish. A total of 230 participants were enrolled and started the intervention. Participants' average age was 48 years, average BMI = 34.8, average initial HbA1c = 5.8, 81% were female, and 45% were Spanish speaking. Eighty percent had Medicaid insurance, 18% were uninsured, and 2% were insured by a medical safety net plan. Participants completed a health assessment including measured anthropometrics, HbA1c test, and self-report questionnaires at baseline, 6 and 12 months. The 52-week digital diabetes prevention program included weekly educational curriculum, human health coaching, connected tracking tools, and peer support from a virtual group. Qualitative data on implementation was collected with semi-structured interviews with key informants to understand the barriers, keys to success, and best practices in the adoption of the program within the clinical setting. This paper describes the study design and methodology of a digital diabetes prevention program and early lessons learned related to recruitment, enrollment, and data collection.

Addressing Disparities in Diabetes Management Through Novel Approaches to Encourage Technology Adoption and Use

Type 2 diabetes (T2D) is one of the nation’s leading drivers of disability and health care utilization, with elevated prevalence among individuals with lower education, income, and racial/ethnic minorities. Health information technology (HIT) holds vast potential for helping patients, providers, and payers to address T2D and the skyrocketing rates of chronic illness and associated health care costs. Patient portals to electronic health records (EHRs) serve as a gateway to consumer use of HIT. We found that disparities in portal use portend growing T2D disparities. Little progress has been made in addressing identified barriers to technology adoption, especially among populations with elevated risk of T2D. Patients often lack digital literacy skills and continuous connectivity and fear loss of the relationship with providers. Providers may experience structural disincentives to promoting patient use of HIT and apply hidden biases that inhibit portal use. Health care systems often provide inadequate training to patients and providers in use of HIT, and lack resources devoted to obtaining and optimizing use of data generated by HIT. Lastly, technology-related barriers include inadequate consideration of user perspectives, lack of evidence for patient-focused apps, and lack of features to enable providers and health care systems to readily obtain aggregate data to improve care and facilitate research. After discussing these barriers in detail, we propose possible solutions and areas where further research is needed to ensure that individuals and health care systems obtain the full benefit of the nation’s planned $38 billion HIT investment. A digital inclusion framework sheds new light on barriers posed for patients with social health inequalities. We have determined that partnerships with community organizations focused on digital inclusion could help health systems explore and study new approaches, such as universal screening and referral of patients for digital skills, health literacy, and Internet connectivity.