mHealth versus face-to-face: study protocol for a randomized trial to test a gender-focused intervention for young African American women at risk for HIV in North Carolina

" … They cannot help you because you're at McDonald's and you're asking for pizza". A qualitative exploration of the acceptability and appropriateness of integrating of pharmacotherapy for mental health treatment in HIV care among patients living with HIV and co-morbid mental health and substance use disorders

Mental health disorders contribute to a lack of HIV care retention and adherence. Pharmacotherapy for mental health treatment may increase retention and adherence. However, there is often a lack of pharmacotherapy services for mental health treatment available in HIV care. The current study explores the extent to which people living with HIV find the integration of pharmacotherapy for mental health treatment into HIV care acceptable and appropriate. We conducted in-depth interviews with ten patients living with HIV and comorbid mental health or substance use challenges. We used rapid qualitative analysis to analyze the transcript data. Patients cited several barriers to mental health treatment, including having to coordinate and establish rapport with other providers. Participants' perspectives about whether HIV care providers should provide pharmacotherapy for mental health treatment varied. However, most respondents agreed that it would be beneficial for HIV care providers to maintain existing regimens or address lapses in mental health care. Patients also cited benefits to integration, including the ability to receive care from a trusted provider and increased access. These findings add to previous literature and demonstrate the nuanced nature of the acceptability of receiving pharmacotherapy for mental health treatment from an HIV care provider.

Condom Use at Last Sex and Sexual Negotiation Among Young African American Women in North Carolina: Context or Personal Agency

African American women are 10.8 times more likely to be diagnosed with HIV compared with White women. This descriptive study fills a gap by examining associations among social and contextual factors and sexual communication, condom use, and safer sex negotiation among African American women. Study participants between 18 and 25 years of age and who reported recent substance use were recruited from three North Carolina counties. A risk behavior survey was administered via audio computer-assisted self-interview, and logistic regression analyses were conducted to assess associations between social and contextual variables and condom use at last sex with a main partner. Education (AOR: 2.078; 95% CI: 1.214, 3.556), sexual communication with a main partner (AOR: 1.079; 95% CI: 1.050, 1.109), and condom use relationship scale (AOR: 1.059; 95% CI: 1.023, 1.098) were positively associated with condom use at last sex, whereas living with a main partner (AOR: 0.447; 95% CI: 0.210, 0.950) and the alcohol and drug problem scale (AOR: 0.971; 95% CI: 0.944, 0.998) were negatively associated with condom use (p < 0.05). The study findings show that among young African American women at risk for HIV, contextual and personal factors may influence condom use. A socio-ecological approach combining personal empowerment, interpersonal, structural, and biobehavioral strategies is necessary in implementing holistic gender-focused HIV prevention programs.

Assessing Differences in mHealth Usability and App Experiences Among Young African American Women: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

In North Carolina, HIV continues to disproportionately affect young African American women. Although mobile health (mHealth) technology appears to be a tool capable of making public health information more accessible for key populations, previous technology use and social determinants may impact users' mHealth experiences.

OBJECTIVE

The objective of this study was to evaluate mHealth usability, assessing differences based on previous technology use and social determinants among a sample of African American women in emerging adulthood.

METHODS

As part of a National Institute on Drug Abuse-funded randomized controlled trial with African American women (aged 18-25 years), counties were assigned to receive an evidence-based HIV risk reduction intervention through mHealth and participants were asked to complete usability surveys at 6- and 12-month follow-ups. Participants' first survey responses were analyzed through 2-tailed t tests and linear regression models to examine associations with previous technology use and social determinants (P<.05).

RESULTS

The mean System Usability Scale (SUS) score was 69.2 (SD 17.9; n=159), which was higher than the threshold of acceptability (68.0). Participants who had previously used a tablet indicated higher usability compared to participants without previous use (mean 72.9, SD 18.1 vs mean 57.6, SD 11.4; P<.001), and participants with previous smartphone use also reported higher usability compared to participants without previous use (mean 71.9, SD 18.3 vs mean 58.0, SD 10.7; P<.001). Differences in SUS scores were observed among those reporting homelessness (mean 58.3, SD 19.0 vs mean 70.8, SD 17.2; P=.01), unemployment (mean 65.9, SD 17.2 vs mean 71.6, SD 18.1; P=.04), or current school enrollment (mean 73.2, SD 18.5 vs mean 65.4, SD 16.5; P=.006). Statistically significant associations were not observed for food insecurity (mean 67.3, SD 18.6 vs mean 69.9, SD 17.7; P=.45).

CONCLUSIONS

Although above-average usability was observed overall, these findings demonstrate differences in mHealth usability based on past and current life experiences. As mHealth interventions become more prevalent, these findings may have important implications for ensuring that mHealth apps improve the reach of evidence-based interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02965014; https://clinicaltrials.gov/study/NCT02965014.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-018-5796-8.

Addressing Health Inequities in Digital Clinical Trials: A Review of Challenges and Solutions From the Field of HIV Research

Clinical trials are considered the gold standard for establishing efficacy of health interventions, thus determining which interventions are brought to scale in health care and public health programs. Digital clinical trials, broadly defined as trials that have partial to full integration of technology across implementation, interventions, and/or data collection, are valued for increased efficiencies as well as testing of digitally delivered interventions. Although recent reviews have described the advantages and disadvantages of and provided recommendations for improving scientific rigor in the conduct of digital clinical trials, few to none have investigated how digital clinical trials address the digital divide, whether they are equitably accessible, and if trial outcomes are potentially beneficial only to those with optimal and consistent access to technology. Human immunodeficiency virus (HIV), among other health conditions, disproportionately affects socially and economically marginalized populations, raising questions of whether interventions found to be efficacious in digital clinical trials and subsequently brought to scale will sufficiently and consistently reach and provide benefit to these populations. We reviewed examples from HIV research from across geographic settings to describe how digital clinical trials can either reproduce or mitigate health inequities via the design and implementation of the digital clinical trials and, ultimately, the programs that result. We discuss how digital clinical trials can be intentionally designed to prevent inequities, monitor ongoing access and utilization, and assess for differential impacts among subgroups with diverse technology access and use. These findings can be generalized to many other health fields and are practical considerations for donors, investigators, reviewers, and ethics committees engaged in digital clinical trials.

Digital Health Screening in People With HIV in Uganda to Increase Alcohol Use Reporting: Qualitative Study on the Development and Testing of the Self-administered Digital Screener for Health

Background

Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting.

Objective

This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy.

Methods

We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy.

Results

A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener.

Conclusions

We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions.

Alcohol, drug use, and sexual risk among young African American women in North Carolina: Is educational attainment protective?

Previous research shows that educational attainment is a protective factor for substance use and sexual risk among adolescents and young adults. Evidence also shows that this relationship may differ by race/ethnicity and gender. This study aimed to elucidate the relationship between educational attainment, substance use and sexual risk among African American women in emerging adulthood. This study uses cross-sectional data from 646 African American women (aged 18 to 25) enrolled in a randomized trial of a behavioral HIV risk-reduction intervention. At enrollment, participants completed a risk behavior assessment via audio-computer assisted self-interview and provided a urine sample for drug screening. Bivariate logistic regression analyses were conducted to examine substance use and sexual risk factors associated with educational attainment: completing some college or more vs. completing high school or less). Participants who completed some college or more (52%) were more likely to report heavy alcohol use (four or more drinks in one day) in the past 30 days (OR=1.48; p=0.014) and more likely to report alcohol or other drug use just before or during last sex (OR=1.43; p=0.026) compared with participants who completed high school or less. Completing some college or more was protective for having a positive urine screen for cocaine (OR=0.43; p=0.018) and reporting condomless sex at last sex (OR=0.71; p=0.041). Differences in positive marijuana screens, reporting a previous STI, or reporting their partner used alcohol or other drugs at last sex were not statistically significant. The findings reveal notable differences in the magnitude and direction of associations between educational attainment and substance use and sexual risk. Although educational attainment is subject to change because of the frequent pursuit of education during emerging adulthood, the findings may have important implications for tailoring HIV risk-reduction interventions to key populations, such as African American women.

A Scoping Review of Computer-Based and Telecommunication Technology Interventions to Address Drug and Alcohol Misuse and Smoking in Women

BACKGROUND

Computer-based and telecommunication technology has become increasingly common to address addiction among women. This review assessed the effect of technology-based interventions on substance misuse, alcohol use, and smoking outcomes among women.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guideline was used to conduct the scoping review. Four databases (PubMed, Web of Science, PsycINFO, and Scopus) were used to search for peer-reviewed articles published in English on computer-based and telecommunication technology use to address substance misuse, alcohol use, and smoking among women.

RESULTS

A total of 30 articles were selected after the final full-text review from the U.S., England, Japan, and the Netherlands. The types of technology used in the interventions included computer software (standalone or web-based), mobile applications, video calling, phone, and text messaging. Intervention outcomes included alcohol and other substance misuse reduction as polysubstance misuse (n = 5), smoking cessation (n = 10), substance misuse reduction only (n = 6), and alcohol use reduction only (n = 9). The populations reached included women who were pregnant (n = 13), postpartum (n = 4), or non-pregnant (n = 14) ranging from adolescent to adulthood. Interventions that targeted polysubstance misuse showed statistically significant reductions (p < .05).

CONCLUSION

Although effective in reducing alcohol and other substance misuse, mixed findings were identified for other outcomes targeting a single substance. Technology-based interventions might maximize their effects by targeting polysubstance misuse and addressing associated contextual issues in the form of a computer-delivered module(s).

The mHealth Development of an Evidence-Based HIV Risk-Reduction Intervention for Young African American Women in the US South (Preprint)

Background

Young African American women have higher rates of sexually transmitted infections, including HIV, than those of young women of other racial and ethnic groups. Gender-, culture-, and age-specific interventions are needed to end the HIV epidemic. The Women’s CoOp (WC) is an HIV risk–reduction intervention that is proven to be efficacious in various face-to-face formats.

Objective

This study aims to adapt the delivery method of an evidence-based intervention, the WC, from an in-person format to a self-guided mobile health (mHealth) format while ensuring that core elements are maintained for intervention comparability and fidelity.

Methods

Several adaptation phases were conducted by using the Personal Health Informatics and Intervention Toolkit (PHIT) as a guiding point to create the mobile app version of the WC. Throughout 5 phases, we established the implementation groundwork for the app; conducted formative research activities to test the initial draft of the app and obtain feedback; applied the PHIT toolkit programming structure to produce the mHealth version of the WC intervention; conducted usability testing and pretesting with interested parties, followed by in-house testing by WC interventionists and PHIT developers; and deployed the app to tablets and distributed it to study participants. The app underwent regular maintenance updates during the study.

Results

The team converted the seven elements of the WC as accurately as possible for comparability to determine efficacy in a mobile app format while changing little about the basic delivery methods. For instance, cue card presentations of the materials delivered by the intervention staff were presented within the app but with voice-over narration and in a self-guided format rather than being led by a staff member. Other aspects of the intervention did not lend themselves to such straightforward adaptation, such as hands-on condom proficiency practice and one-on-one goal-setting activities. In these cases, the subject matter experts and app developers worked together to find comparable analogs to be used within the app. Once developed, tested, and finalized, the mHealth WC app was deployed into local health departments as part of a randomized trial.

Conclusions

This systematic adaptation process created an accurate mHealth equivalent of an existing, in-person behavioral health intervention. Although participants’ reception of the app during the formative developmental phase was overall positive, maintaining fidelity to the in-person delivery compromised the natural capabilities of a mobile app, such as further gamification, different types of interactivity, and integrated notifications and messaging, which could be helpful for participants’ adherence to the intervention schedule. Given the development and implementation of the app, the next step is to examine the impact of the app and its efficacy in HIV and substance use risk-reduction.

Barriers associated with failed completion of an acute care general surgery telehealth clinic visit

BACKGROUND

A form of telehealth, a surgical electronic clinic (E-clinic, video or telephone visit) is a safe and efficient way for delivering care; however, factors leading to poor clinic utilization are not well-described. This study was performed to gather electronic clinic utilization data and to better define barriers to visit completion.

METHODS

A retrospective review of 199 patients cared for by a general surgery service with subsequent referral to the electronic clinic (January 2019 to June 2019) was performed. Data regarding demographics, medical characteristics, travel distance, and postoperative complications were collected. Patients were categorized based upon visit completion. The χ² and Fisher exact analyses were performed as appropriate. Reasons for cancellations were categorized.

RESULTS

More than 1/5 of all patients (21.6%) failed to complete the visit. No differences were observed in completion rates according to the type of operation, American Society of Anesthesiologists classification, and age. The failed-completion group had a significantly (P < .05) higher proportion of non-Caucasian patients and those with a marital status of single. Travel distance had no impact. Complication rates were low. Pre-clinic readmission within 30 days contributed to failed completion. Reasons for cancellation included medical issues, technical difficulties, and patient preference to have no follow-up in the electronic clinic.

CONCLUSION

Several factors contribute to a patient's failure to complete an electronic clinic visit including marital status, medical complications, technical issues, and patient preference. Electronic clinic utilization patterns also demonstrate racial disparities. Successful electronic clinic program implementation requires understanding the factors that contribute to failed visits to address them and improve access.

A Community-Engaged Approach to Creating a Mobile HIV Prevention App for Black Women: Focus Group Study to Determine Preferences via Prototype Demos

Background

Black women are an important but relatively overlooked at-risk group in HIV prevention efforts. Although there is an aggregate decline of HIV diagnoses among women in the United States, there are persistent disparate rates of new HIV infections among Black women compared to any other cisgender female subgroup. Strategies to end the HIV epidemic—as outlined in the Ending the HIV Epidemic initiative—for all communities must consider HIV prevention messaging and message delivery mediums that are created with community input. Although mobile health (mHealth) is a popular platform for delivering HIV interventions, there are currently no mobile apps that consider cisgender Black women with the goal of promoting a comprehensive women’s reproductive health and HIV prevention lifestyle. Previous research recommends inclusion of the target population from project inception and iteratively throughout development, to promote use of the intervention.

Objective

The purpose of this study is to understand cisgender Black women’s preferences for functionality, format, and design of a mobile HIV prevention app and to examine their willingness to use an app for HIV prevention.

Methods

We conducted a series of four focus groups with 23 Black cisgender women. Focus groups included discussion and demonstration elements to address cisgender women’s general preference for apps, HIV prevention content that would be useful in an app, and preferred app features that would promote use of an HIV-centric app. During focus group discussions, participants were shown narrated, custom wireframes of HIV prevention app prototypes to demonstrate potential app function.

Results

Findings indicated the presence of eight subthemes within the coding structure of three overall themes: (1) health content within the mobile app, (2) mobile app functionality, format, and design, and (3) other suggested features. Specifically, participants detailed preferred educational content, content distribution, app aesthetics, privacy considerations, and marketing of the app.

Conclusions

Findings suggest that Black cisgender women preferred an app that integrated HIV prevention and optimal sexual health promotion. Participants provided a range of preferences for content integration and facilitators of app engagement with an HIV prevention app. Preferences centered on gender and cultural congruency of information and content, evidenced by visuals, language, and resources. Black cisgender women are viable consumers for a mobile app–based HIV prevention intervention.

Electronic and other new media technology interventions for HIV care and prevention: a systematic review

INTRODUCTION

Electronic and other new media technologies (eHealth) can facilitate large-scale dissemination of information and effective delivery of interventions for HIV care and prevention. There is a need to both monitor a rapidly changing pipeline of technology-based care and prevention methods and to assess whether the interventions are appropriately diversified. We systematically review and critically appraise the research pipeline of eHealth interventions for HIV care and prevention, including published studies and other funded projects.

METHODS

Two peer-reviewed literature databases were searched for studies describing the development, trial testing or implementation of new technology interventions, published from September 2014 to September 2018. The National Institutes of Health database of grants was searched for interventions still in development. Interventions were included if eHealth was utilized and an outcome directly related to HIV treatment or prevention was targeted. We summarized each intervention including the stage of development, eHealth mode of delivery, target population and stage of the HIV care and prevention continua targeted.

RESULTS AND DISCUSSION

Of 2178 articles in the published literature, 113 were included with 84 unique interventions described. The interventions utilize a variety of eHealth technologies and target various points on the prevention and care continua, with greater emphasis on education, behaviour change and testing than linkage to medical care. There were a variety of interventions for HIV care support but none for PrEP care. Most interventions were developed for populations in high income countries. An additional 62 interventions with funding were found in the development pipeline, with greater emphasis on managing HIV and PrEP care.

CONCLUSIONS

Our systematic review found a robust collection of eHealth interventions in the published literature as well as unpublished interventions still in development. In the published literature, there is an imbalance of interventions favouring education and behaviour change over linkage to care, retention in care, and adherence, especially for PrEP. The next generation of interventions already in the pipeline might address these neglected areas of care and prevention, but the development process is slow. Researchers need new methods for more efficient and expedited intervention development so that current and future needs are addressed.