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Hu L, Wyatt LC, Mohsin F, Lim S, Zanowiak J, Mammen S, Hussain S, Ali SH, Onakomaiya D, Belli HM, Aifah A, Islam NS. Characterizing Technology Use and Preferences for Health Communication in South Asian Immigrants With Prediabetes or Diabetes: Cross-Sectional Descriptive Study. JMIR Form Res 2024; 8:e52687. [PMID: 38669062 PMCID: PMC11087851 DOI: 10.2196/52687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
- Lu Hu
- Department of Population Health, Center for Healthful Behavior Change, Institute for Excellence in Health Equity, New York University Grossman School of Medicine, New York, NY, United States
| | - Laura C Wyatt
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Farhan Mohsin
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Sahnah Lim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Jennifer Zanowiak
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Shinu Mammen
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Sarah Hussain
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Shahmir H Ali
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, United States
| | - Deborah Onakomaiya
- Vilcek Institute of Graduate Biomedical Sciences, New York University Grossman School of Medicine, New York, NY, United States
| | - Hayley M Belli
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Angela Aifah
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Nadia S Islam
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
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Mokaya M, Kyallo F, Yiga P, Koole JL, Boedt T, Vangoitsenhoven R, Matthys C. Designing Mobile Phone Text Messages Using the Behavior Change Wheel Framework to Influence Food Literacy in Adults With Type 2 Diabetes in Kenya: Protocol for a Systematic Development Study. JMIR Res Protoc 2023; 12:e48271. [PMID: 38048150 PMCID: PMC10728794 DOI: 10.2196/48271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The worldwide prevalence of type 2 diabetes (T2D) has increased in the past decade, and it is projected to increase by 126% by 2045 in Africa. At the same time, mobile phone use has increased in Africa, providing a potential for innovative mobile health interventions to support diabetes care. OBJECTIVE This study aimed to apply the Behavior Change Wheel (BCW) framework to develop text messages to influence food literacy in adults with T2D in urban Kenya. METHODS The 8 steps of the BCW framework guided the development of text messages: (1) Define the problem in behavioral terms; (2) select target behaviors; (3) specify the target behaviors based on who needs to perform the behaviors, what needs to change, and when, where, how often, and with whom; (4) identify what needs to change; (5) identify intervention functions; (6) select policy categories; (7) select behavior change techniques (BCTs); and (8) select the mode of delivery. Recent exploratory studies in Kenya and other low- and middle-income countries provided information that was used to contextualize the intervention. RESULTS In step 1, the behavioral problem was defined as unhealthy dietary patterns among adults with T2D. In step 2, based on a qualitative study in the target population, the target behavior was selected to be evaluation of reliable sources of information, and selection and preparation of healthy food. In step 3, unhealthy dietary patterns were selected. In step 4, 10 domains of the Theoretical Domains Framework were identified, and in step 5, 5 intervention functions were linked to the domains and unhealthy dietary patterns were specified. In step 6, communication and regulations were identified as policy categories, while in step 7, 9 BCTs were selected from the Behavior Change Technique Taxonomy version 1. In step 8, the most suitable mode of delivery was determined to be mobile text messages. A total of 36 mobile text messages were developed based on the 9 BCTs. CONCLUSIONS This study shows the step-by-step application of the BCW framework to develop mobile text messages to influence food literacy in adults with T2D. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/48271.
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Affiliation(s)
- Moses Mokaya
- Department of Human Nutrition Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Experimental and Clinical Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Florence Kyallo
- Department of Human Nutrition Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Peter Yiga
- Mildmay Research Centre, Kampala, Uganda
| | - Janna Lena Koole
- Experimental and Clinical Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Tessy Boedt
- Experimental and Clinical Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Roman Vangoitsenhoven
- Experimental and Clinical Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals, Leuven, Belgium
| | - Christophe Matthys
- Experimental and Clinical Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Nelson LA, Reale C, Anders S, Beebe R, Rosenbloom ST, Hackstadt A, Harper KJ, Mayberry LS, Cobb JG, Peterson N, Elasy T, Yu Z, Martinez W. Empowering patients to address diabetes care gaps: formative usability testing of a novel patient portal intervention. JAMIA Open 2023; 6:ooad030. [PMID: 37124675 PMCID: PMC10139764 DOI: 10.1093/jamiaopen/ooad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/22/2023] [Accepted: 04/13/2023] [Indexed: 05/02/2023] Open
Abstract
Objective The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services. Materials and Methods We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0-worst to 100-best. All testing occurred remotely via Zoom. Results We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering. Conclusions Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carrie Reale
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shilo Anders
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Russ Beebe
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - S Trent Rosenbloom
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amber Hackstadt
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kryseana J Harper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jared G Cobb
- HealthIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Neeraja Peterson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tom Elasy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zhihong Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William Martinez
- Corresponding Author: William Martinez, MD, MSc, Department of Medicine, Vanderbilt University Medical Center, 2525 West End Ave., Suite 450, Nashville, TN 37203, USA;
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Trinquart L, Liu C, McManus DD, Nowak C, Lin H, Spartano NL, Borrelli B, Benjamin EJ, Murabito JM. Increasing Engagement in the Electronic Framingham Heart Study: Factorial Randomized Controlled Trial. J Med Internet Res 2023; 25:e40784. [PMID: 36662544 PMCID: PMC9898831 DOI: 10.2196/40784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/02/2022] [Accepted: 12/01/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Smartphone apps and mobile health devices offer innovative ways to collect longitudinal cardiovascular data. Randomized evidence regarding effective strategies to maintain longitudinal engagement is limited. OBJECTIVE This study aimed to evaluate smartphone messaging interventions on remote transmission of blood pressure (BP) and heart rate (HR) data. METHODS We conducted a 2 × 2 × 2 factorial blinded randomized trial with randomization implemented centrally to ensure allocation concealment. We invited participants from the Electronic Framingham Heart Study (eFHS), an e-cohort embedded in the FHS, and asked participants to measure their BP (Withings digital cuff) weekly and wear their smartwatch daily. We assessed 3 weekly notification strategies to promote adherence: personalized versus standard; weekend versus weekday; and morning versus evening. Personalized notifications included the participant's name and were tailored to whether or not data from the prior week were transmitted to the research team. Intervention notification messages were delivered weekly automatically via the eFHS app. We assessed if participants transmitted at least one BP or HR measurement within 7 days of each notification after randomization. Outcomes were adherence to BP and HR transmission at 3 months (primary) and 6 months (secondary). RESULTS Of the 791 FHS participants, 655 (82.8%) were eligible and randomized (mean age 53, SD 9 years; 392/655, 59.8% women; 596/655, 91% White). For the personalized versus standard notifications, 38.9% (126/324) versus 28.8% (94/327) participants sent BP data at 3 months (difference=10.1%, 95% CI 2.9%-17.4%; P=.006), but no significant differences were observed for HR data transmission (212/324, 65.4% vs 209/327, 63.9%; P=.69). Personalized notifications were associated with increased BP and HR data transmission versus standard at 6 months (BP: 107/291, 36.8% vs 66/295, 22.4%; difference=14.4%, 95% CI 7.1- 21.7%; P<.001; HR: 186/281, 66.2% vs 158/281, 56.2%; difference=10%, 95% CI 2%-18%; P=.02). For BP and HR primary or secondary outcomes, there was no evidence of differences in data transmission for notifications sent on weekend versus weekday or morning versus evening. CONCLUSIONS Personalized notifications increased longitudinal adherence to BP and HR transmission from mobile and digital devices among eFHS participants. Our results suggest that personalized messaging is a powerful tool to promote adherence to mobile health systems in cardiovascular research. TRIAL REGISTRATION ClinicalTrials.gov NCT03516019; https://clinicaltrials.gov/ct2/show/NCT03516019.
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Affiliation(s)
- Ludovic Trinquart
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, United States
| | - Chunyu Liu
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
- Cardiology Division, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
- Department of Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | | | - Honghuang Lin
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Nicole L Spartano
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, United States
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Belinda Borrelli
- Center for Behavioral Science Research, Department of Health Policy and Health Services Research, Henry M Goldman School of Dental Medicine, Boston University, Boston, MA, United States
| | - Emelia J Benjamin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, United States
- Section of Cardiovascular Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, United States
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Joanne M Murabito
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, United States
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Framingham, MA, United States
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Rey Velasco E, Pedersen HS, Skinner T. Analysis of Patient Cues in Asynchronous Health Interactions: Pilot Study Combining Empathy Appraisal and Systemic Functional Linguistics. JMIR Form Res 2022; 6:e40058. [PMID: 36538352 PMCID: PMC9812272 DOI: 10.2196/40058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Lifestyle-related diseases are among the leading causes of death and disability. Their rapid increase worldwide has called for low-cost, scalable solutions to promote health behavior changes. Digital health coaching has proved to be effective in delivering affordable, scalable programs to support lifestyle change. This approach increasingly relies on asynchronous text-based interventions to motivate and support behavior change. Although we know that empathy is a core element for a successful coach-user relationship and positive patient outcomes, we lack research on how this is realized in text-based interactions. Systemic functional linguistics (SFL) is a linguistic theory that may support the identification of empathy opportunities (EOs) in text-based interactions, as well as the reasoning behind patients' linguistic choices in their formulation. OBJECTIVE This study aims to determine whether empathy and SFL approaches correspond and complement each other satisfactorily to study text-based communication in a health coaching context. We sought to explore whether combining empathic assessment with SFL categories can provide a means to understand client-coach interactions in asynchronous text-based coaching interactions. METHODS We retrieved 148 text messages sent by 29 women who participated in a randomized trial of telecoaching for the prevention of gestational diabetes mellitus (GDM) and postnatal weight loss. We conducted a pilot study to identify users' explicit and implicit EOs and further investigated these statements using the SFL approach, focusing on the analysis of transitivity and thematic analysis. RESULTS We identified 164 EOs present in 42.37% (3478/8209) of the word count in the corpus. These were mainly negative (n=90, 54.88%) and implicit (n=55, 60.00%). We distinguished opening, content and closing messages structures. Most of the wording was found in the content (n=7077, 86.21%) with a declarative structure (n=7084, 86.30%). Processes represented 22.4% (n=1839) of the corpus, with half being material (n=876, 10.67%) and mostly related to food and diet (n=196, 54.92%), physical activity (n=96, 26.89%), and lifestyle goals (n=40, 11.20%). CONCLUSIONS Our findings show that empathy and SFL approaches are compatible. The results from our transitivity analysis reveal novel insights into the meanings of the users' EOs, such as their seek for help or praise, often missed by health care professionals (HCPs), and on the coach-user relationship. The absence of explicit EOs and direct questions could be attributed to low trust on or information about the coach's abilities. In the future, we will conduct further research to explore additional linguistic features and code coach messages. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620001240932; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380020.
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Affiliation(s)
- Elena Rey Velasco
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Liva Healthcare, Copenhagen, Denmark
| | | | - Timothy Skinner
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
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Bucher A, Blazek ES, West AB. Feasibility of a Reinforcement Learning-Enabled Digital Health Intervention to Promote Mammograms: Retrospective, Single-Arm, Observational Study. JMIR Form Res 2022; 6:e42343. [PMID: 36441579 DOI: 10.2196/42343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Preventive screenings such as mammograms promote health and detect disease. However, mammogram attendance lags clinical guidelines, with roughly one-quarter of women not completing their recommended mammograms. A scalable digital health intervention leveraging behavioral science and reinforcement learning and delivered via email was implemented in a US health system to promote uptake of recommended mammograms among patients who were 1 or more years overdue for the screening (ie, 2 or more years from last mammogram). OBJECTIVE The aim of this study was to establish the feasibility of a reinforcement learning-enabled mammography digital health intervention delivered via email. The research aims included understanding the intervention's reach and ability to elicit behavioral outcomes of scheduling and attending mammograms, as well as understanding reach and behavioral outcomes for women of different ages, races, educational attainment levels, and household incomes. METHODS The digital health intervention was implemented in a large Catholic health system in the Midwestern United States and targeted the system's existing patients who had not received a recommended mammogram in 2 or more years. From August 2020 to July 2022, 139,164 eligible women received behavioral science-based email messages assembled and delivered by a reinforcement learning model to encourage clinically recommended mammograms. Target outcome behaviors included scheduling and ultimately attending the mammogram appointment. RESULTS In total, 139,164 women received at least one intervention email during the study period, and 81.52% engaged with at least one email. Deliverability of emails exceeded 98%. Among message recipients, 24.99% scheduled mammograms and 22.02% attended mammograms (88.08% attendance rate among women who scheduled appointments). Results indicate no practical differences in the frequency at which people engage with the intervention or take action following a message based on their age, race, educational attainment, or household income, suggesting the intervention may equitably drive mammography across diverse populations. CONCLUSIONS The reinforcement learning-enabled email intervention is feasible to implement in a health system to engage patients who are overdue for their mammograms to schedule and attend a recommended screening. In this feasibility study, the intervention was associated with scheduling and attending mammograms for patients who were significantly overdue for recommended screening. Moreover, the intervention showed proportionate reach across demographic subpopulations. This suggests that the intervention may be effective at engaging patients of many different backgrounds who are overdue for screening. Future research will establish the effectiveness of this type of intervention compared to typical health system outreach to patients who have not had recommended screenings as well as identify ways to enhance its reach and impact.
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Nelson LA, Roddy MK, Bergner EM, Gonzalez J, Gentry C, LeStourgeon LM, Kripalani S, Hull PC, Mayberry LS. Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics. J Clin Transl Sci 2022; 6:e126. [PMID: 36590364 PMCID: PMC9794969 DOI: 10.1017/cts.2022.503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/28/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Text message-delivered interventions for chronic disease self-management have potential to reduce health disparities, yet limited research has explored implementing these interventions into clinical care. We partnered with safety net clinics to evaluate a texting intervention for type 2 diabetes called REACH (Rapid Encouragement/Education And Communications for Health) in a randomized controlled trial. Following evaluation, we explored potential implementation determinants and recommended implementation strategies. Methods We interviewed clinic staff (n = 14) and a subset of intervention participants (n = 36) to ask about REACH's implementation potential. Using the Consolidated Framework for Implementation Research (CFIR) as an organizing framework, we coded transcripts and used thematic analysis to derive implementation barriers and facilitators. We integrated the CFIR-ERIC (Expert Recommendations for Implementing Change) Matching Tool, interview feedback, and the literature to recommend implementation strategies. Results Implementation facilitators included low complexity, strong evidence and quality, available clinic resources, the need for a program to support diabetes self-management, and strong fit between REACH and both the clinics' existing workflows and patients' needs and resources. The barriers included REACH only being available in English, a lack of interoperability with electronic health record systems, patients' concerns about diabetes stigma, limited funding, and high staff turnover. Categories of recommended implementation strategies included training and education, offering flexibility and adaptation, evaluating key processes, and securing funding. Conclusion Text message-delivered interventions have strong potential for integration in low-resource settings as a supplement to care. Pursuing implementation can ensure patients benefit from these innovations and help close the research to practice gap.
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Affiliation(s)
- Lyndsay A. Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - McKenzie K. Roddy
- Quality Scholars Program, VA Tennessee Valley Healthcare System, US Department of Veteran Affairs, Nashville, TN, USA
| | - Erin M. Bergner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesus Gonzalez
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Chad Gentry
- Department of Pharmacy, College of Pharmacy and Health Sciences, Lipscomb University, Nashville, TN, USA
| | | | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pamela C. Hull
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Lindsay S. Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Mayberry LS, El-Rifai M, Nelson LA, Parks M, Greevy RA, LeStourgeon L, Molli S, Bergner E, Spieker A, Aikens JE, Wolever RQ. 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. Contemp Clin Trials 2022; 122:106956. [PMID: 36208719 PMCID: PMC10364455 DOI: 10.1016/j.cct.2022.106956] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/11/2022] [Accepted: 10/01/2022] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Merna El-Rifai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Makenzie Parks
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren LeStourgeon
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Samuel Molli
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin Bergner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James E Aikens
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ruth Q Wolever
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN, USA; Osher Center for Integrative Health at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Ford KL, West AB, Bucher A, Osborn CY. Personalized Digital Health Communications to Increase COVID-19 Vaccination in Underserved Populations: A Double Diamond Approach to Behavioral Design. Front Digit Health 2022; 4:831093. [PMID: 35493533 PMCID: PMC9051039 DOI: 10.3389/fdgth.2022.831093] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/25/2022] [Indexed: 12/14/2022] Open
Abstract
The COVID-19 pandemic exacerbated pre-existing health disparities. People of historically underserved communities, including racial and ethnic minority groups and people with lower incomes and educational attainments, experienced disproportionate premature mortality, access to healthcare, and vaccination acceptance and adoption. At the same time, the pandemic increased reliance on digital devices, offering a unique opportunity to leverage digital communication channels to address health inequities, particularly related to COVID-19 vaccination. We offer a real-world, systematic approach to designing personalized behavior change email and text messaging interventions that address individual barriers with evidence-based behavioral science inclusive of underserved populations. Integrating design processes such as the Double Diamond model with evidence-based behavioral science intervention development offers a unique opportunity to create equitable interventions. Further, leveraging behavior change artificial intelligence (AI) capabilities allows for both personalizing and automating that personalization to address barriers to COVID-19 vaccination at scale. The result is an intervention whose broad component library meets the needs of a diverse population and whose technology can deliver the right components for each individual.
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10
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Blair RA, Horn CE, Dias JM, McDonnell ME, Seely EW. Development and Usability of a Text Messaging Program for Women With Gestational Diabetes: Mixed Methods Study. JMIR Hum Factors 2022; 9:e32815. [PMID: 35191851 PMCID: PMC8905478 DOI: 10.2196/32815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/29/2021] [Accepted: 12/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background Gestational diabetes mellitus (GDM) affects 5%-10% of pregnancies and can lead to serious fetal and maternal complications. SMS text messaging is an effective way to improve diabetes management outside of pregnancy, but has not been well studied in GDM. Objective This study aimed to perform user experience testing and assess usability and acceptability of an SMS text messaging program (Text 4 Success) for women with GDM. Methods An automated 2-way texting program was developed. It included (1) reminders to check blood glucose levels, (2) positive feedback to user-reported glucose levels, (3) weekly educational messages, and (4) weekly motivational messages. For the user experience testing, women received simulated messages. For the usability study, women were enrolled in the program and received messages for 2 weeks. All women participated in semistructured interviews. For women in the usability study, data from glucose measuring devices were downloaded to assess adherence to self-monitoring of blood glucose (SMBG), measured as the percentage of recommended SMBG checks performed (a secondary outcome). Results Ten women participated in user experience testing. Suggestions for optimization included further customization of message timing and minimization of jargon, which were incorporated. Ten women participated in the usability study. All 10 would recommend the program to other women with GDM. Participants liked the immediate feedback to glucose values. Suggestions included further flexibility of messages related to mealtimes and the ability to aggregate blood glucose data into a table or graph. Overall, adherence to SMBG testing was high at baseline (222/238 recommended checks, 93%). In comparing the week prior to the trial with the 2 weeks during the trial, there was a small but statistically insignificant difference (P=.48) in the percentage of recommended SMBG performed (median 93% [25th-75th IQR 89%-100%] vs median 97% [25th-75th IQR 92%-100%]). Conclusions Overall, women with GDM would recommend the Text 4 Success in GDM program and think it is helpful for GDM self-management. The program was usable and acceptable. The program may be better suited to those who have low levels of adherence to SMBG at baseline or to women at time of their diagnosis of GDM. Adaptations to the program will be made based on user suggestions. Further study of SMS text messaging to improve SMBG in GDM is needed.
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Affiliation(s)
- Rachel A Blair
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Christine E Horn
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jennifer M Dias
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ellen W Seely
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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11
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Mayberry LS, Nelson LA, Gonzalez JS. Adults with type 2 diabetes benefit from self-management support intervention regardless of depressive symptoms. J Diabetes Complications 2021; 35:108024. [PMID: 34521578 PMCID: PMC8511161 DOI: 10.1016/j.jdiacomp.2021.108024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 01/02/2023]
Abstract
AIMS Elevated depressive symptoms are common among adults with type 2 diabetes (T2D). In a secondary analysis from an RCT of a diabetes self-management support intervention that did not target depressive symptoms, we sought to determine if depressive symptoms were reduced by the intervention (i.e., depressive symptoms an outcome) or, alternatively, if intervention effects on hemoglobin A1c were lesser among persons with clinically elevated depressive symptoms (i.e., depressive symptoms an effect modifier). METHODS We evaluated a text messaging intervention, REACH, in a diverse (half non-white, half underinsured) sample of N = 506 adults with T2D. Participants completed the Patient Health Questionnaire-8 (PHQ) and A1c tests at baseline and 6 months. We conducted a factor analysis to identify somatic- and cognitive-affective symptoms on the PHQ. We tested our hypotheses with regression models, using interaction terms and subgroup analyses. RESULTS REACH improved depressive symptoms among participants with lower baseline A1c (<8.5%; β = -0.133, p = .007; cognitive β = -0.107, p = .038; somatic β = -0.131, p = .014) but not among participants with higher baseline A1c (≥8.5%; β = 0.040, p = .468). Baseline depressive symptoms did not modify the effect on A1c. CONCLUSIONS We found support for the hypothesis that depressive symptoms - both somatic- and cognitive-affective - may be an outcome, rather than an effect modifier, of effective diabetes self-management support interventions.
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Affiliation(s)
- Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt Center for Diabetes Translation Research, Nashville, TN, United States of America.
| | - Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Vanderbilt Center for Diabetes Translation Research, Nashville, TN, United States of America
| | - Jeffrey S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States of America; Departments of Medicine (Endocrinology) and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, United States of America; New York Regional Center for Diabetes Translation Research, Bronx, NY, United States of America
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12
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Forman R, Sheth K. Race/Ethnicity Considerations in the Prevention and Treatment of Stroke. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00684-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Reshma P, Rajkumar E, John R, George AJ. Factors influencing self-care behavior of socio-economically disadvantaged diabetic patients: A systematic review. Health Psychol Open 2021; 8:20551029211041427. [PMID: 34552758 PMCID: PMC8450690 DOI: 10.1177/20551029211041427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Diabetes mellitus and its complications carry broad financial misfortune to the diabetic patients and their family, to the well-being frameworks, and to the public economies through direct clinical expenses and decreased work efficiency. The present study systematically reviewed the possible factors that are influencing self-care behavior of disadvantaged diabetic patients that contribute heavily to the management of this chronic illness. Structured searches were conducted on PubMed, ScienceDirect, and manual searches on Google Scholar for articles published between the years 2000 and 2020. The review was limited to a particular time frame due to the change in WHO criteria for diagnosis and classification of abnormal glucose tolerance. Initially, 96858 articles were identified, and following the screening and full-text reading, 10 studies that met the inclusion criteria were chosen for systematic review. Seven studies had reported the factors influencing self-care behavior among disadvantaged diabetic population. Three studies had reported the importance of intervention strategies and its impact on self-care behavior among them. Findings show that self-care management of socio-economically disadvantaged people entails dimensions including diabetes knowledge, lack of physical activities, social support, lack of access to services, life disruptions, denial of illness, societal attitudes, responsibilities, and treatment costs. It was additionally discovered that diabetes self-management support mediations are successful in drawing in lower economy patients, tending to contending life needs and hindrances to self-care, and encouraging behavior change. Taken together, future methodologically efficacious studies that establish health promoting behaviors and explorations of the factors influencing self-care behaviors of disadvantaged diabetic patients are needed.
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Affiliation(s)
- P Reshma
- Department of Psychology, Central University of Karnataka of Social and Behavioral Sciences, Kalaburagi, India
| | - Eslavath Rajkumar
- Department of Psychology, Central University of Karnataka of Social and Behavioral Sciences, Kalaburagi, India
| | - Romate John
- Department of Psychology, Central University of Karnataka of Social and Behavioral Sciences, Kalaburagi, India
| | - Allen J George
- Department of Psychology, Central University of Karnataka of Social and Behavioral Sciences, Kalaburagi, India
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14
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Gautier JF, Boitard C, Michiels Y, Raymond G, Vergez G, Guedon G. Impact of personalized text messages from pharmacists on medication adherence in type 2 diabetes in France: A real-world, randomized, comparative study. PATIENT EDUCATION AND COUNSELING 2021; 104:2250-2258. [PMID: 33750593 DOI: 10.1016/j.pec.2021.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 02/01/2021] [Accepted: 02/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE A real-world, randomized study assessing the impact of a new, personalized, pharmacist-led text messaging service for managing type 2 diabetes (T2D). METHODS Messages were tailored to patient's needs based on their disease management habits, propensity for reactance, and physical activity levels at baseline. Treatment adherence (assed using the Morisky Medication Adherence Scale, MMAS-8, questionnaire), clinical factors (body mass index and physical activity) and biological markers for T2D were compared between patients who received a text message daily for 3 months in addition to standard care (SMS group) and those who received standard care alone (control group). RESULTS 114 pharmacies recruited 499 patients. Greater increases in global MMAS-8 scores were observed after 3 months for the SMS group than for the control group, however, this improvement was not sustained after the text messages stopped. Body mass index was found to improve with the text messaging service. CONCLUSION This study indicated that personalized text messages provided by community pharmacists can have an impact on adherence levels among T2D patients. PRACTICE IMPLICATIONS Pharmacy-led innovations, such as text messaging services, could be used to accompany patients in their treatment and to improve patient understanding of their illness between healthcare appointments.
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Affiliation(s)
| | | | - Yves Michiels
- Unisanté - Centre Universitaire de Médecine Générale et Santé Publique, Département des Policliniques - Secteur Pharmacie Recherche, rue du Bugnon 44, Bureau BU44/08.2133, CH-1011 Lausanne, Switzerland.
| | - Gerard Raymond
- Association Française des Diabétiques, 88 rue de la Roquette, Paris 75544, France.
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Gatwood J, Shuvo S, Ross A, Riordan C, Smith P, Gutierrez ML, Coday M, Bailey J. The Management of Diabetes in Everyday Life (MODEL) program: development of a tailored text message intervention to improve diabetes self-care activities among underserved African-American adults. Transl Behav Med 2021; 10:204-212. [PMID: 30794316 DOI: 10.1093/tbm/ibz024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tailoring health-related materials is an effective mechanism to encourage behavior change; however, little research has described processes and critical characteristics for effective tailoring in underserved populations. The purpose of this study is to describe a process using input from content experts and lay patient advisors to tailor text messages focused on improving self-care behaviors of African-American adults with diabetes and identify characteristics of messages perceived to be most effective. An initial library of tailorable messages was created using theory-based approaches, expert opinion, and publicly available materials. A study-specific advisory council representing the program's intended population provided sequential individual and focus group review of a sample of draft messages focused on medication use, healthy eating, and physical activity. Messages were reviewed for content, tone, and applicability to African-American adults with diabetes from underserved communities. Based on this feedback, messages were revised and a final library of tailorable messages was constructed for use in a text messaging intervention. The initial library had over 5,000 tailorable messages. Participants preferred messages that included: (1) encouraging statements without condescension; (2) short sentences in lay language; (3) specific, actionable instructions; and (4) content relatable to daily activities of living. When possible, messages with similar themes should be repeated over short periods of time to improve the odds of material being absorbed and action being taken. Input from patient participants and advisors is essential for designing deeply tailored messages that honor the preferences, values, and norms of the population under study and promote health behavior change. TRIAL REGISTRATION NCT02957513.
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Affiliation(s)
- Justin Gatwood
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sohul Shuvo
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Alan Ross
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Carolyn Riordan
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Patti Smith
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Matilda Coday
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - James Bailey
- University of Tennessee Health Science Center, Memphis, TN, USA
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16
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Derksen ME, Jaspers MW, van Strijp S, Fransen MP. Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study. JMIR Form Res 2021; 5:e24112. [PMID: 34346895 PMCID: PMC8374659 DOI: 10.2196/24112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/26/2020] [Accepted: 05/31/2021] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Marloes E Derksen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Monique Wm Jaspers
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sander van Strijp
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Mirjam P Fransen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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17
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Martinez W, Hackstadt AJ, Hickson GB, Knoerl T, Rosenbloom ST, Wallston KA, Elasy TA. The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment. Appl Clin Inform 2021; 12:539-550. [PMID: 34192774 DOI: 10.1055/s-0041-1730324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources. OBJECTIVES We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. METHODS We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. RESULTS Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability (p < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p = 0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p = 0.01). CONCLUSION Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.
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Affiliation(s)
- William Martinez
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Amber J Hackstadt
- Department of Biostatistics, Vanderbilt University Medicine Center, Nashville, Tennessee, United States
| | - Gerald B Hickson
- Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Thomas Knoerl
- Upstate Medical University, State University of New York, Syracuse, New York, United States
| | - S Trent Rosenbloom
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Kenneth A Wallston
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Tom A Elasy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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18
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Nelson LA, Williamson SE, LeStourgeon LM, Mayberry LS. Retaining diverse adults with diabetes in a long-term trial: Strategies, successes, and lessons learned. Contemp Clin Trials 2021; 105:106388. [PMID: 33812991 DOI: 10.1016/j.cct.2021.106388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/25/2021] [Accepted: 03/28/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah E Williamson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA; DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, TN, USA
| | - Lauren M LeStourgeon
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
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19
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Mayberry LS, Bergner EM, Harper KJ, Laing S, Berg CA. Text messaging to engage friends/family in diabetes self-management support: acceptability and potential to address disparities. J Am Med Inform Assoc 2021; 26:1099-1108. [PMID: 31403688 DOI: 10.1093/jamia/ocz091] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/19/2019] [Accepted: 05/22/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Explore acceptability of engaging family/friends in patients' type 2 diabetes (T2D) self-management using text messaging. MATERIALS AND METHODS Participants (N = 123) recruited from primary care clinics for a larger trial evaluating mobile phone support for T2D completed self-report measures and a hemoglobin A1c test and then had the option to invite an adult support person to receive text messages. We examined characteristics and reasons of participants who did/did not invite a support person, responses to the invitation, and feedback from patients and support persons. RESULTS Participants were 55.9 ± 10.1 years old, 55% female, 53% minority, and 54% disadvantaged (low income, less than high school degree/GED, uninsured, and/or homeless). Participants who invited a support person (48%) were slightly younger, more likely to be partnered, and reported more depressive symptoms and more emergency department visits in the year prior to study enrollment as compared to participants who did not (all p <.05). Participants' reasons for inviting a support person included needing help and seeing benefits of engaging others, while reasons for not inviting a support person included concerns about being a "burden" and support person's ability or desire to text. Support persons reported the texts increased awareness, created dialogue, and improved their own health behaviors. DISCUSSION Patients inviting a support person had higher need and thus may stand to benefit most. Most support persons were open to engagement via text messages. CONCLUSION Across race and socioeconomic status, text messaging may engage support persons to increase health-related support-particularly for patients with higher levels of need. TRIAL REGISTRATION Clinicaltrials.gov NCT02409329.
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Affiliation(s)
- Lindsay S Mayberry
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Erin M Bergner
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kryseana J Harper
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Simone Laing
- Meharry Medical College, Nashville, Tennessee, USA
| | - Cynthia A Berg
- Department of Psychology, University of Utah, Salt Lake City, Utah, USA
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20
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Nelson LA, Greevy RA, Spieker A, Wallston KA, Elasy TA, Kripalani S, Gentry C, Bergner EM, LeStourgeon LM, Williamson SE, Mayberry LS. Effects of a Tailored Text Messaging Intervention Among Diverse Adults With Type 2 Diabetes: Evidence From the 15-Month REACH Randomized Controlled Trial. Diabetes Care 2021; 44:26-34. [PMID: 33154039 PMCID: PMC7783936 DOI: 10.2337/dc20-0961] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/02/2020] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Andrew Spieker
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Kenneth A Wallston
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Tom A Elasy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Chad Gentry
- Department of Pharmacy, College of Pharmacy and Health Sciences, Lipscomb University, Nashville, TN
| | - Erin M Bergner
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
| | - Lauren M LeStourgeon
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah E Williamson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
| | - Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN
- Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
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21
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Crimmins SD, Ginn-Meadow A, Jessel RH, Rosen JA. Leveraging Technology to Improve Diabetes Care in Pregnancy. Clin Diabetes 2020; 38:486-494. [PMID: 33384473 PMCID: PMC7755043 DOI: 10.2337/cd20-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Sarah D. Crimmins
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Angela Ginn-Meadow
- University of Maryland Center for Diabetes and Endocrinology, University of Maryland Medical Center Midtown Campus, Baltimore, MD
| | - Rebecca H. Jessel
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Julie A. Rosen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
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22
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Alwashmi MF, Fitzpatrick B, Davis E, Farrell J, Gamble JM, Hawboldt J. Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study. Ther Adv Respir Dis 2020; 14:1753466620951044. [PMID: 32894025 PMCID: PMC7479870 DOI: 10.1177/1753466620951044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: The use of mobile health (mHealth) interventions has the potential to enhance
chronic obstructive pulmonary disease (COPD) treatment outcomes. Further
research is needed to determine which mHealth features are required to
potentially enhance COPD self-management. Aim: The aim of this study was to explore the potential features of an mHealth
intervention for COPD management with healthcare providers (HCPs) and
patients with COPD. It could inform the development and successful
implementation of mHealth interventions for COPD management. Methods: This was a qualitative study. We conducted semi-structured individual
interviews with HCPs, including nurses, pharmacists and physicians who work
directly with patients with COPD. Interviews were also conducted with a
diverse sample of patients with COPD. Interview topics included
demographics, mHealth usage, the potential use of medical devices and
recommendations for features that would enhance an mHealth intervention for
COPD management. Results: A total of 40 people, including nurses, physicians and pharmacists,
participated. The main recommendations for the proposed mHealth intervention
were categorised into two categories: patient interface and HCP interface.
The prevalent features suggested for the patient interface include educating
patients, collecting baseline data, collecting subjective data, collecting
objective data via compatible medical devices, providing a
digital action plan, allowing patients to track their progress, enabling
family members to access the mHealth intervention, tailoring the features
based on the patient’s unique needs, reminding patients about critical
management tasks and rewarding patients for their positive behaviours. The
most common features of the HCP interface include allowing HCPs to track
their patients’ progress, allowing HCPs to communicate with their patients,
educating HCPs and rewarding HCPs. Conclusion: This study identifies important potential features so that the most
effective, efficient and feasible mHealth intervention can be developed to
improve the management of COPD. The reviews of this paper are available via the supplemental material
section.
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Affiliation(s)
- Meshari F Alwashmi
- Health Sciences Centre, Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL A1B 3V6, Canada
| | | | - Erin Davis
- Memorial University of Newfoundland, St John's, NL, Canada
| | - Jamie Farrell
- Memorial University of Newfoundland, St John's, NL, Canada
| | - John-Michael Gamble
- School of Pharmacy, Faculty of Science, University of Waterloo, Waterloo, ON, Canada
| | - John Hawboldt
- Memorial University of Newfoundland, St John's, NL, Canada
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23
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Yee L, Taylor S, Young M, Williams M, Niznik C, Simon M. Evaluation of a Text Messaging Intervention to Support Self-Management of Diabetes During Pregnancy Among Low-Income, Minority Women: Qualitative Study. JMIR Diabetes 2020; 5:e17794. [PMID: 32773367 PMCID: PMC7445621 DOI: 10.2196/17794] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/01/2020] [Accepted: 06/07/2020] [Indexed: 12/24/2022] Open
Abstract
Background Given the growing burden of diabetes in underserved communities and the complexity of diabetes self-management during pregnancy, the development of interventions to support low-income pregnant women with diabetes is urgently needed. Objective This study aims to develop and pilot test a theory-driven curriculum of SMS text messaging for diabetes support and education during pregnancy. Methods This was a prospective pilot investigation of a novel SMS text messaging intervention offered to pregnant women with pregestational or gestational diabetes mellitus and publicly funded prenatal care. Prior work yielded a conceptual model of diabetes self-management barriers and support factors in this population, which was used to guide curriculum development along with health behavior theories. Participants received three supportive or educational one-way text messages per week during pregnancy. In-depth semistructured interviews were performed at study exit to solicit feedback on the program. Narrative data were analyzed using the constant comparative technique to identify themes and subthemes. Results Participants (N=31 enrolled and n=26 completed both interviews) consistently reported that SMS text messaging provided enhanced motivation for diabetes self-care, reduced diabetes-related social isolation, increased perceived diabetes-associated knowledge, enhanced comfort with the health care team, and reduced logistical burdens of diabetes during pregnancy. Participants requested enhanced interactive and customizable features in future intervention iterations. Conclusions Pregnant women with diabetes who were enrolled in this pilot study of an SMS text messaging curriculum for diabetes support described enhanced motivation, knowledge, and comfort with diabetes self-care activities as a result of the health education intervention. The next steps include enriching the interactive features of the intervention and investigating the effect of the intervention on perinatal outcomes.
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Affiliation(s)
- Lynn Yee
- Northwestern University, Chicago, IL, United States
| | | | - Maria Young
- Northwestern University, Chicago, IL, United States
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24
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Tuvesson H, Eriksén S, Fagerström C. mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review. JMIR Mhealth Uhealth 2020; 8:e14315. [PMID: 32706686 PMCID: PMC7414402 DOI: 10.2196/14315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 04/30/2020] [Accepted: 05/14/2020] [Indexed: 01/13/2023] Open
Abstract
Background Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement. Objective The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions. Methods An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis. Results A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals. Conclusions mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population.
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Affiliation(s)
- Hanna Tuvesson
- Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Sara Eriksén
- Blekinge Institute of Technology, Karlskrona, Sweden
| | - Cecilia Fagerström
- Department of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden.,Blekinge Centre of Competence, Blekinge County Council, Karlskrona, Sweden
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25
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Mayberry LS, Berg CA, Greevy RA, Nelson LA, Bergner EM, Wallston KA, Harper KJ, Elasy TA. Mixed-Methods Randomized Evaluation of FAMS: A Mobile Phone-Delivered Intervention to Improve Family/Friend Involvement in Adults' Type 2 Diabetes Self-Care. Ann Behav Med 2020; 55:165-178. [PMID: 32706852 DOI: 10.1093/abm/kaaa041] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Family and friends have both helpful and harmful effects on adults' diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts. PURPOSE We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care. METHODS Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles. RESULTS Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group. CONCLUSIONS The promise of effectively engaging patients' family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects. TRIAL REGISTRATION NUMBER NCT02481596.
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Affiliation(s)
- Lindsay S Mayberry
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA.,Vanderbilt Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cynthia A Berg
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Robert A Greevy
- Vanderbilt Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | - Lyndsay A Nelson
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA.,Vanderbilt Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin M Bergner
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA
| | - Kenneth A Wallston
- Vanderbilt Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kryseana J Harper
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA
| | - Tom A Elasy
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA.,Vanderbilt Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, USA
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26
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Alwashmi MF, Fitzpatrick B, Farrell J, Gamble JM, Davis E, Nguyen HV, Farrell G, Hawboldt J. Perceptions of Patients Regarding Mobile Health Interventions for the Management of Chronic Obstructive Pulmonary Disease: Mixed Methods Study. JMIR Mhealth Uhealth 2020; 8:e17409. [PMID: 32706697 PMCID: PMC7413289 DOI: 10.2196/17409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/10/2020] [Accepted: 06/14/2020] [Indexed: 01/20/2023] Open
Abstract
Background Using a mobile health (mHealth) intervention consisting of a smartphone and compatible medical device has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes while mitigating health care costs. Objective This study aims to describe the demographics, use, and access to smartphones of patients with COPD. It also aims to explore and develop an understanding of potential facilitators and barriers that might influence patients using mHealth interventions for COPD management. Methods This was an explanatory, sequential mixed methods study. Patients who attended respirology clinics completed a questionnaire on technology access and use. We conducted semistructured individual interviews with the patients. Interview topics included the following: demographics, mHealth use, perceptions toward challenges of mHealth adoption, factors facilitating mHealth adoption, and preferences regarding features of mHealth interventions for COPD management. Results A total of 100 adults completed the survey but 22 participants were excluded because they were not diagnosed with COPD. Of these, 10 patients with COPD participated in the interview. The quantitative component revealed that many patients with COPD owned a mobile phone, but only about one-fourth of the participants (18/77, 23%) owned a smartphone. The likelihood of owning a smartphone was not associated with age, sex, marital status, or geographical location, but patients with high educational status were more likely to own a smartphone. The qualitative component found that patients with COPD, in general, had a positive attitude toward mHealth adoption for COPD management, but several facilitators and barriers were identified. The main facilitators of mHealth adoption are possible health benefits for patients, ease of use, educating patients, and credibility. Alternatively, the barriers to adoption are technical issues, lack of awareness, potential limited uptake from older adults, privacy and confidentiality issues, finances, and lack of interest in mHealth Conclusions It is important to understand the perceptions of patients with COPD regarding the adoption of innovative mHealth interventions for COPD management. This study identifies some potential facilitators and barriers that may inform the successful development and implementation of mHealth interventions for COPD management.
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Affiliation(s)
- Meshari F Alwashmi
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
| | | | - Jamie Farrell
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
| | - John-Michael Gamble
- School of Pharmacy, Faculty of Science, University of Waterloo, Waterloo, ON, Canada
| | - Erin Davis
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
| | - Hai Van Nguyen
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
| | - Gerard Farrell
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
| | - John Hawboldt
- Memorial University of Newfoundland and Labrador, St. John's, NL, Canada
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27
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Nelson LA, Spieker A, Greevy R, LeStourgeon LM, Wallston KA, Mayberry LS. User Engagement Among Diverse Adults in a 12-Month Text Message-Delivered Diabetes Support Intervention: Results from a Randomized Controlled Trial. JMIR Mhealth Uhealth 2020; 8:e17534. [PMID: 32706738 PMCID: PMC7404018 DOI: 10.2196/17534] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/06/2020] [Accepted: 06/03/2020] [Indexed: 01/17/2023] Open
Abstract
Background Text message–delivered interventions are a feasible and scalable approach for improving chronic disease self-care and reducing health disparities; however, information on long-term user engagement with these interventions is limited. Objective The aim of this study is to examine user engagement in a 12-month text message–delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), among racially and socioeconomically diverse patients with type 2 diabetes (T2D). We explored time trends in engagement, associations between patient characteristics and engagement, and whether the addition of a human component or allowing patients to change their text frequency affected engagement. Qualitative data informed patients’ subjective experience of their engagement. Methods We recruited patients with T2D for a randomized trial evaluating mobile phone support relative to enhanced treatment as usual. This analysis was limited to participants assigned to the intervention. Participants completed a survey and hemoglobin A1c (HbA1c) test and received REACH text messages, including self-care promotion texts, interactive texts asking about medication adherence, and adherence feedback texts. For the first 6 months, texts were sent daily, and half of the participants also received monthly phone coaching. After 6 months, coaching stopped, and participants had the option to receive fewer texts for the subsequent 6 months. We defined engagement via responses to the interactive texts and responses to a follow-up interview. We used regression models to analyze associations with response rate and thematic and structural analysis to understand participants’ reasons for responding to the texts and their preferred text frequency. Results The participants were, on average, aged 55.8 (SD 9.8) years, 55.2% (137/248) female, and 52.0% (129/248) non-White; 40.7% (101/248) had ≤ a high school education, and 40.7% (101/248) had an annual household income <US $25,000. The median response rate to interactive texts was 91% (IQR 75%-97%) over 12 months. Engagement gradually declined throughout the intervention but remained high. Engagement did not differ by age, gender, education, income, diabetes duration, insulin status, health literacy, or numeracy. Black race and worse baseline medication adherence and HbA1c were each associated with lower engagement, although the effects were small. Nearly half of the participants chose to continue receiving daily texts for the last 6 months of the intervention. Participants who continued daily text messages said they wanted to continue experiencing benefits to their health, whereas those who chose fewer texts said that the daily texts had helped them create routines and they no longer needed them as often. Engagement was not impacted by receiving coaching or by participants’ chosen text frequency. Conclusions Well-designed interactive text messages can engage diverse patients in a self-care intervention for at least 1 year. Variation in and reasons for frequency preference suggest that offering a frequency choice may be important to users’ engagement.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Andrew Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lauren M LeStourgeon
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kenneth A Wallston
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Diabetes Translation Research, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States
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28
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Gimbel RW, Rennert LM, Crawford P, Little JR, Truong K, Williams JE, Griffin SF, Shi L, Chen L, Zhang L, Moss JB, Marshall RC, Edwards KW, Crawford KJ, Hing M, Schmeltz A, Lumsden B, Ashby M, Haas E, Palazzo K. Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study. J Med Internet Res 2020; 22:e17968. [PMID: 32329438 PMCID: PMC7284404 DOI: 10.2196/17968] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/21/2020] [Accepted: 04/12/2020] [Indexed: 12/11/2022] Open
Abstract
Background Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. Objective The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. Methods A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. Results The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). Conclusions Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. Trial Registration ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 International Registered Report Identifier (IRRID) RR2-10.2196/resprot.6993
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Affiliation(s)
- Ronald W Gimbel
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Lior M Rennert
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Paul Crawford
- Nellis Family Medicine Residency Program, Mike O'Callaghan Federal Hospital, Las Vegas, NV, United States
| | - Jeanette R Little
- Mobile Health Innovation Center, Telemedicine & Advanced Technologies Research Center, U.S. Army Medical Research & Materials Command, Fort Gordon, GA, United States
| | - Khoa Truong
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Joel E Williams
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Sarah F Griffin
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Liwei Chen
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, United States
| | - LingLing Zhang
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, United States
| | - Jennie B Moss
- Nellis Family Medicine Residency Program, Mike O'Callaghan Federal Hospital, Las Vegas, NV, United States
| | - Robert C Marshall
- Clinical Informatics Fellowship Program, Madigan Army Medical Center, Tacoma, WA, United States
| | - Karen W Edwards
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Kristy J Crawford
- Nellis Family Medicine Residency Program, Mike O'Callaghan Federal Hospital, Las Vegas, NV, United States
| | - Marie Hing
- Department of Internal Medicine, Madigan Army Medical Center, Tacoma, WA, United States
| | - Amanda Schmeltz
- Mobile Health Innovation Center, Telemedicine & Advanced Technologies Research Center, U.S. Army Medical Research & Materials Command, Fort Gordon, GA, United States
| | - Brandon Lumsden
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Morgan Ashby
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Elizabeth Haas
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Kelly Palazzo
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
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Davies A, Mueller J, Hennings J, Caress AL, Jay C. Recommendations for Developing Support Tools With People Suffering From Chronic Obstructive Pulmonary Disease: Co-Design and Pilot Testing of a Mobile Health Prototype. JMIR Hum Factors 2020; 7:e16289. [PMID: 32410730 PMCID: PMC7260664 DOI: 10.2196/16289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/10/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Gaps exist between developers, commissioners, and end users in terms of the perceived desirability of different features and functionalities of mobile apps. OBJECTIVE The objective of this study was to co-design a prototype mobile app for people with chronic obstructive pulmonary disease (COPD). We present lessons learned and recommendations from working on a large project with various stakeholders to develop a mobile app for patients with COPD. METHODS We adopted a user-centered, participatory approach to app development. Following a series of focus groups and interviews to capture requirements, we developed a prototype app designed to enable daily symptom recording (experience sampling). The prototype was tested in a usability study applying the think aloud protocol with people with COPD. It was then released via the Android app store, and experience sampling data and event data were captured to gather further usability data. RESULTS A total of 5 people with COPD participated in the pilot study. Identified themes include familiarity with technology, appropriate levels for feeding back information, and usability issues such as manual dexterity. Moreover, 37 participants used the app over a 4-month period (median age 47 years). The symptoms most correlated to perceived well-being were tiredness (r=0.61; P<.001) and breathlessness (r=0.59; P<.001). CONCLUSIONS Design implications for COPD apps include the need for clearly labeled features (rather than relying on colors or symbols that require experience using smartphones), providing weather information, and using the same terminology as health care professionals (rather than simply lay terms). Target users, researchers, and developers should be involved at every stage of app development, using an iterative approach to build a prototype app, which should then be tested in controlled settings as well as in the wild (ie, when deployed and used in real-world settings) over longer periods.
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Affiliation(s)
- Alan Davies
- School of Health Sciences, University of Manchester, Manchester, United Kingdom.,Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Julia Mueller
- School of Health Sciences, University of Manchester, Manchester, United Kingdom.,Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Jean Hennings
- School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Ann-Louise Caress
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Caroline Jay
- Department of Computer Science, University of Manchester, Manchester, United Kingdom
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van Puffelen A, Kasteleyn M, de Vries L, Rijken M, Heijmans M, Nijpels G, Schellevis F. Self-care of patients with type 2 diabetes mellitus over the course of illness: implications for tailoring support. J Diabetes Metab Disord 2020; 19:81-89. [PMID: 32550159 DOI: 10.1007/s40200-019-00479-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 12/17/2019] [Indexed: 11/28/2022]
Abstract
Purpose Type 2 diabetes requires patients to make lifestyle changes and perform daily self-care. To determine at what stages patients may need particular self-management support, we examined (1) whether patients' performance of self-care related to their diabetes duration, and (2) whether illness characteristics (treatment and complications) and diabetes-related distress influenced this relationship. Methods Cross-sectional data from 590 type 2 diabetes patients were analysed through linear and logistic regression analysis. Self-care behaviours were assessed by the revised Summary of Diabetes Self-Care Activities (SDSCA) measure. Diabetes duration (model 1), treatment and complications (model 2), and distress, as assessed by the Problem Areas In Diabetes (PAID) scale (model 3), were stepwise included. Sociodemographic characteristics were added to all models to account for confounding. Results Patients with a longer history of diabetes were less physically active, but monitored their blood glucose levels more frequently than more recently diagnosed patients. These relationships were mediated by the presence of complications and the use of insulin, with lower levels of physical activity being found among patients with macrovascular complications and higher frequencies of glucose monitoring among patients on insulin. All predictors together explained maximally 5% of the variance in self-care, except for glucose monitoring (37%) and smoking (11%). Conclusion Type 2 diabetes patients' self-care activity changes over the course of illness. To provide tailored self-management support, diabetes care providers should take into account patients' phase of illness, including their treatment and complications, as well as their personal characteristics and distress level.
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Affiliation(s)
- Anne van Puffelen
- NIVEL (the Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands
| | - Marise Kasteleyn
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, the Netherlands
| | - Lianne de Vries
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VUmc, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - Mieke Rijken
- NIVEL (the Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands
- Department of Health and Social Management, University of Eastern Finland, PO Box 1627, FI-70211 Kuopio, Finland
| | - Monique Heijmans
- NIVEL (the Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands
| | - Giel Nijpels
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VUmc, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
| | - François Schellevis
- NIVEL (the Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN Utrecht, the Netherlands
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VUmc, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands
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Alwashmi MF, Fitzpatrick B, Davis E, Gamble JM, Farrell J, Hawboldt J. Perceptions of Health Care Providers Regarding a Mobile Health Intervention to Manage Chronic Obstructive Pulmonary Disease: Qualitative Study. JMIR Mhealth Uhealth 2019; 7:e13950. [PMID: 31199330 PMCID: PMC6592475 DOI: 10.2196/13950] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/12/2019] [Accepted: 05/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Using a mobile health (mHealth) intervention, consisting of a smartphone and compatible medical device, has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes while mitigating health care costs. Objective The aim of this study was to explore the potential facilitators and barriers among health care providers (HCPs) regarding the use of mHealth interventions for COPD management. Methods This was a qualitative study. Semistructured individual interviews were conducted with HCPs, including nurses, pharmacists, and physicians who work directly with patients with COPD. A flexible prompts guide was used to facilitate discussions. Interview topics included the following: demographics, mHealth usage, perceptions toward challenges of mHealth adoption, factors facilitating mHealth adoption, and preferences regarding features of the mHealth intervention for COPD management. Interviews were conversational in nature, and items were not asked verbatim or in the order presented. The interviews were transcribed verbatim and compared against the digital recordings to ensure the accuracy of the content. After creating a codebook for analysis, 2 researchers independently coded the remaining interview data using pattern coding. They discussed commonalities and differences in coding until a consensus was reached. Results A total of 30 nurses, physicians, and pharmacists participated. The main facilitators to mHealth adoption are possible health benefits for patients, ease of use, educating patients and their HCPs, credibility, and reducing cost to the health care system. Alternatively, the barriers to adoption are technical issues, privacy and confidentiality issues, lack of awareness, potential limited uptake from the elderly, potential limited connection between patients and HCPs, and finances. Conclusions It is important to understand the perceptions of HCPs regarding the adoption of innovative mHealth interventions for COPD management. This study identifies some potential facilitators and barriers that may inform the successful development and implementation of mHealth interventions for COPD management.
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Affiliation(s)
| | | | - Erin Davis
- Memorial University of Newfoundland, St John's, NL, Canada
| | - John-Michael Gamble
- School of Pharmacy, Faculty of Science, University of Waterloo, Waterloo, ON, Canada
| | - Jamie Farrell
- Memorial University of Newfoundland, St John's, NL, Canada
| | - John Hawboldt
- Memorial University of Newfoundland, St John's, NL, Canada
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Alwashmi MF, Hawboldt J, Davis E, Fetters MD. The Iterative Convergent Design for Mobile Health Usability Testing: Mixed Methods Approach. JMIR Mhealth Uhealth 2019; 7:e11656. [PMID: 31025951 PMCID: PMC6658163 DOI: 10.2196/11656] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/05/2018] [Accepted: 03/24/2019] [Indexed: 01/12/2023] Open
Abstract
Although patients express an interest in using mobile health (mHealth) interventions to manage their health and chronic conditions, many current mHealth interventions are difficult to use. Usability testing is critical for the success of novel mHealth interventions. Researchers recognize the utility of using qualitative and quantitative approaches for usability testing, but many mHealth researchers lack the awareness of integration approaches from advances in mixed methods research that can add value to mHealth technology. As efficient usability testing proceeds iteratively, we introduce a novel mixed methods design developed specifically for mHealth researchers. The iterative convergent mixed methods design involves simultaneous qualitative and quantitative data collection and analysis that continues cyclically through multiple rounds of mixed methods data collection and analysis until the mHealth technology under evaluation is found to work to the satisfaction of the researcher. In cyclical iterations, early development is more qualitatively driven but progressively becomes more quantitatively driven. Using this design, mHealth researchers can leverage mixed methods integration procedures in the research question, data collection, data analysis, interpretation, and dissemination dimensions. This study demonstrates how the iterative convergent mixed methods design provides a novel framework for generating unique insights into multifaceted phenomena impacting mHealth usability. Understanding these practices can help developers and researchers leverage the strengths of an integrated mixed methods design.
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Affiliation(s)
| | | | - Erin Davis
- Memorial University, St John's, NL, Canada
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
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Langford AT, Wang B, Orzeck-Byrnes NA, Aidasani SR, Hu L, Applegate M, Moloney DN, Sevick MA, Rogers ES, Levy NK. Sociodemographic and clinical correlates of key outcomes from a Mobile Insulin Titration Intervention (MITI) for medically underserved patients. PATIENT EDUCATION AND COUNSELING 2019; 102:520-527. [PMID: 30293934 DOI: 10.1016/j.pec.2018.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/14/2018] [Accepted: 09/15/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Insulin titration is typically done face-to-face with a clinician; however, this can be a burden for patients due to logistical issues associated with in-person clinical care. The Mobile Insulin Titration Intervention (MITI) used basic cell phone technology including text messages and phone calls to help patients with diabetes find their optimal basal insulin dose (OID). OBJECTIVE To evaluate sociodemographic and clinical correlates of reaching OID, text message response rate, and days needed to reach OID. METHODS Primary care providers referred patients to MITI and nurses delivered the program. Three multivariable regression models quantified relationships between various correlates and primary outcomes. RESULTS The sample included 113 patients from 2 ambulatory clinics, with a mean age of 50 years (SD = 10), 45% female, 79% Hispanic, 43% unemployed, and 46% uninsured. In regression models, baseline fasting blood glucose (FBG) was negatively associated with odds of reaching OID and 100% text responses, and positively associated with days to reach OID, p < .05). CONCLUSIONS Patients with higher baseline FBG levels were less successful across outcomes and may need additional supports in future mHealth diabetes programs. PRACTICAL IMPLICATIONS Basic cell phone technology can be used to adjust patients' insulin remotely, thereby reducing logistical barriers to care.
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Affiliation(s)
| | - Binhuan Wang
- NYU School of Medicine, Department of Population Health, USA
| | | | | | - Lu Hu
- NYU School of Medicine, Department of Population Health, USA
| | | | | | - Mary Ann Sevick
- NYU School of Medicine, Department of Population Health, USA
| | - Erin S Rogers
- NYU School of Medicine, Department of Population Health, USA
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Hovadick ACDA, Reis IA, Torres HC. Short Message Service (SMS) e promoção do autocuidado em DM2: revisão integrativa. ACTA PAUL ENFERM 2019. [DOI: 10.1590/1982-0194201900029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivo: Sintetizar e analisar as evidências disponíveis na literatura científica sobre os efeitos do uso de Short Message Service (SMS) na promoção do autocuidado em diabetes mellitus tipo 2. Métodos: Foi desenvolvida uma revisão integrativa da literatura, no período de 2007 a 2017, utilizando para a busca dos estudos as seguintes bases de dados: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Scopus, Web of Science, Base de dados de enfermagem, Campus Virtual de Saúde Pública, Coleção Nacional das Fontes de Informação do Sistema Único de Saúde, Coordenadoria Regional de Saúde Sul, Índice Bibliográfico Español en Ciencias de la Salud (iBECS), Literatura Latino-Americana e do Caribe em Ciências da Saúde e PubMed. Para isso, utilizou-se descritores como: mensagem de texto, autocuidado, educação em saúde, promoção em saúde e diabetes mellitus, bem como os respectivos descritores em inglês e espanhol, e os Medical Subject Headings associados. Foi identificada uma amostra inicial de 739 artigos, dos quais 23 foram classificados como elegíveis para compor a amostra final. Resultados: Em geral, os trabalhos reportaram resultados positivos. Dentre estes, destacam-se: melhora significativa dos níveis de hemoglobina glicada, maior adesão aos medicamentos, melhora das práticas de autocuidado, aumento do conhecimento acerca do diabetes e melhor cuidado com os pés. Conclusão: Evidências científicas na literatura mostram que o uso de SMS como estratégia metodológica pode favorecer a melhora das práticas de autocuidado em diabetes tipo 2.
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Grutzmacher SK, Munger AL, Speirs KE, Vafai Y, Hilberg E, Braunscheidel Duru E, Worthington L, Lachenmayr L. Predicting Attrition in a Text-Based Nutrition Education Program: Survival Analysis of Text2BHealthy. JMIR Mhealth Uhealth 2019; 7:e9967. [PMID: 30664489 PMCID: PMC6360389 DOI: 10.2196/mhealth.9967] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 10/16/2018] [Accepted: 10/17/2018] [Indexed: 11/16/2022] Open
Abstract
Background Text-based programs have been shown to effectively address a wide variety of health issues. Although little research examines short message service (SMS) text messaging program characteristics that predict participant retention and attrition, features of SMS text message programs, such as program duration and intensity, message content, and the participants’ context, may have an impact. The impact of stop messages—messages with instructions for how to drop out of an SMS text message program—may be particularly important to investigate. Objective The aim of this study was to describe attrition from Text2BHealthy, a text-based nutrition and physical activity promotion program for parents of low-income elementary school children, and to determine the impact of message content and number of stop messages received on attrition. Methods Using data from 972 parents enrolled in Text2BHealthy, we created Kaplan-Meier curves to estimate differences in program duration for different SMS text message types, including nutrition, physical activity, stop, and other messages. Covariates, including rurality and number of stop messages received, were included. Results Retention rates by school ranged from 74% (60/81) to 95.0% (132/139), with an average retention rate of 85.7% (833/972) across all schools. Program duration ranged from 7 to 282 days, with a median program duration of 233 days and an average program duration of 211.7 days. Among those who dropped out, program duration ranged from 7 to 247 days, with a median program duration of 102.5 days. Receiving a stop message increased the probability of attrition compared with receiving messages about nutrition, physical activity, or other topics (hazard ratio=51.5, 95% CI 32.46-81.7; P<.001). Furthermore, each additional stop message received increased the probability of attrition (hazard ratio=10.36, 95% CI 6.14-17.46; P<.001). The degree of rurality also had a significant effect on the probability of attrition, with metropolitan county participants more likely to drop out of the program than rural county participants. The interaction between SMS text message type and total number of stop messages received had a significant effect on attrition, with the effect of the number of stop messages received dependent on the SMS text message type. Conclusions This study demonstrates the potential of SMS text message programs to retain participants over time. Furthermore, this study suggests that the probability of attrition increases substantially when participants receive messages with instructions for dropping out of the program. Program planners should carefully consider the impact of stop messages and other program content and characteristics on program retention. Additional research is needed to identify participant, programmatic, and contextual predictors of program duration and to explicate the relationship between program duration and program efficacy.
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Affiliation(s)
- Stephanie K Grutzmacher
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
| | - Ashley L Munger
- Department of Child and Family Studies, California State University, Los Angeles, Los Angeles, CA, United States
| | - Katherine E Speirs
- Department of Family Studies and Human Development, Norton School of Family and Consumer Sciences, University of Arizona, Tucson, AZ, United States
| | - Yassaman Vafai
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, United States
| | - Evan Hilberg
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
| | - Erin Braunscheidel Duru
- Maryland Food Supplement Nutrition Education, University of Maryland, College Park, Columbia, MD, United States
| | - Laryessa Worthington
- Maryland Food Supplement Nutrition Education, University of Maryland, College Park, Columbia, MD, United States
| | - Lisa Lachenmayr
- Maryland Food Supplement Nutrition Education, University of Maryland, College Park, Columbia, MD, United States
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Ersotelos NT, Margioris AN, Zhang X, Dong F. Review of mobile applications for optimizing the follow-up care of patients with diabetes. Hormones (Athens) 2018; 17:541-550. [PMID: 30317460 PMCID: PMC6294816 DOI: 10.1007/s42000-018-0062-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/28/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several smartphone applications aim at facilitating communication between patients and healthcare providers. In this review, we evaluate and compare the most promising applications in the field of diabetes mellitus (DM) and obesity. Most applications monitor body weight, fasting or postprandial blood glucose, glycosylated hemoglobin (Hgb) A1c (HgbA1c), and units and types of insulin used. METHODS Nine clinically tested applications and two Web platforms were grouped into three categories that were evaluated and compared. Group 1 included seven applications focusing mainly on monitoring DM, fitness and weight, blood glucose levels, and HbA1c. Group 2 included two applications that focus on insulin dosage calculators and glucose self-monitoring tests. Group 3 included two web-platforms that interact with patients via SMS (short message service) messaging. RESULTS A common feature of the applications examined was the limited number of clinical parameters tested, the small number of subjects taking part in the evaluation, and the fact that the controls were not randomized. Furthermore, the interfaces of the applications varied and were not standardized. Finally, another common characteristic across applications was the lack of standardization of the interface and the overall structure due to language barriers, the devices usually having been designed around a specific language. Lastly, most applications lacked a critical mass of evaluators and were thus not worthy of being considered of serious clinical relevance. CONCLUSIONS The current smartphone applications for DM are characterized by a limited number of participants, a small number of parameters, and a lack of standardization.
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Affiliation(s)
- Nikolaos Th Ersotelos
- School of Computer Science and Technology, University of Bedfordshire, University Square, Luton, Bedfordshire, LU1 3JU, UK.
| | - Andrew N Margioris
- Department of Clinical Chemistry, Medical School, University of Crete, 71110, Heraklion, Crete, Greece
| | - Xu Zhang
- School of Computer Science and Technology, University of Bedfordshire, University Square, Luton, Bedfordshire, LU1 3JU, UK
| | - Feng Dong
- School of Computer Science and Technology, University of Bedfordshire, University Square, Luton, Bedfordshire, LU1 3JU, UK
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Beyond the reminder: The next steps in pharmacist-driven, mHealth patient engagement. J Am Pharm Assoc (2003) 2018; 59:S21-S24. [PMID: 30448025 DOI: 10.1016/j.japh.2018.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 08/21/2018] [Accepted: 10/03/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe opportunities for pharmacists to use mobile messaging and real-time monitoring to engage with patients taking long-term medications. SUMMARY The proliferation of mobile phone use across the United States has been met with increased application of these devices by the medical community. However, beyond simple text messages and app-based functions, use of these devices by pharmacies and pharmacists has not been leveraged to improve patient outcomes, such as medication adherence. Resources now exist that can facilitate more advanced mobile communication between patients and pharmacists, which can be managed and informed by data available in most pharmacies. Such tailored messaging can be personalized further by being reactive to patient behavior using real-time medication use monitoring tools, facilitating low-cost, high-reach interventions for patients in need of ongoing guidance. CONCLUSION Mechanisms now exist for pharmacies to engage patients more proactively with their prescribed therapy using mobile communication and devices. By facilitating such engagement, pharmacists can remain connected with patients throughout their care, better interpret their needs, navigate adherence-related issues, and more holistically counsel patients based on observed behaviors. Community pharmacy leadership should pursue the use of these advanced mobile messaging techniques as another tool in their arsenal to improve patient outcomes.
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Ploderer B, Brown R, Seng LSD, Lazzarini PA, van Netten JJ. Promoting Self-Care of Diabetic Foot Ulcers Through a Mobile Phone App: User-Centered Design and Evaluation. JMIR Diabetes 2018; 3:e10105. [PMID: 30305266 PMCID: PMC6238831 DOI: 10.2196/10105] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/21/2018] [Accepted: 07/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background Without effective self-care, people with diabetic foot ulcers (DFUs) are at risk of prolonged healing times, hospitalization, amputation, and reduced quality of life. Despite these consequences, adherence to DFU self-care remains low. New strategies are needed to engage people in the self-care of their DFUs. Objective This study aimed to evaluate the usability and potential usefulness of a new mobile phone app to engage people with DFUs in self-care. Methods We developed a new mobile phone app, MyFootCare, to engage people with DFUs through goals, progress monitoring, and reminders in self-care. Key features included novel visual analytics that automatically extract and monitor DFU size information from mobile phone photos of the foot. A functional prototype of MyFootCare was created and evaluated through a user-centered design process with 11 participants with DFUs. Data were collected through semistructured interviews discussing existing self-care practices and observations of MyFootCare with participants. Data were analyzed qualitatively through thematic analysis. Results Key themes were as follows: (1) participants already used mobile phone photos to monitor their DFU progress; (2) participants had limited experience with using mobile phone apps; (3) participants desired the objective DFU size data provided by the tracking feature of MyFootCare to monitor their DFU progress; (4) participants were ambivalent about the MyFootCare goal image and diary features, commenting that these features were useful but also that it was unlikely that they would use them; and (5) participants desired to share their MyFootCare data with their clinicians to demonstrate engagement in self-care and to reflect on their progress. Conclusions MyFootCare shows promising features to engage people in DFU self-care. Most notably, ulcer size data are useful to monitor progress and engage people. However, more work is needed to improve the usability and accuracy of MyFootCare, that is, by refining the process of taking and analyzing photos of DFUs and removing unnecessary features. These findings open the door for further work to develop a system that is easy to use and functions in everyday life conditions and to test it with people with DFUs and their carers.
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Affiliation(s)
- Bernd Ploderer
- School of Electrical Engineering and Computer Science, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ross Brown
- School of Electrical Engineering and Computer Science, Queensland University of Technology, Brisbane, QLD, Australia
| | - Leonard Si Da Seng
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Peter A Lazzarini
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Jaap J van Netten
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.,Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam, Netherlands
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McElfish PA, Balli ML, Hudson JS, Long CR, Hudson T, Wilmoth R, Rowland B, Warmack TS, Purvis RS, Schulz T, Riklon S, Holland A, Dickey T. Identifying and Understanding Barriers and Facilitators to Medication Adherence Among Marshallese Adults in Arkansas. J Pharm Technol 2018; 34:204-215. [PMID: 34860999 DOI: 10.1177/8755122518786262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Significant health disparities are present in Marshallese adults residing in the United States, most notably a high incidence of type 2 diabetes and other chronic conditions. There is limited research on medication adherence in the Marshallese population. Objective: This study explored perceptions of and experiences with medication adherence among Marshallese adults residing in Arkansas, with the aim of identifying and better understanding barriers and facilitators to medication adherence. Methods: Eligible participants were Marshallese adults taking at least one medication for a chronic health condition. Each participant completed a brief survey and semistructured interview conducted in Marshallese by a bilingual Marshallese staff member. Interviews were recorded, transcribed, and translated from Marshallese to English. Qualitative data were coded for a priori and emergent themes. Results: A total of 40 participants were included in the study. The most common contributing factor for nonadherence was forgetting to take medication (82%). A majority of participants (70%) reported difficulty paying for medicine, 45% reported at least one form of cost-related nonadherence, and 40% engaged in more than one cost-related nonadherence practice. Family support and medication pill boxes were identified as facilitators for medication adherence. The majority of the participants (76.9%) stated that they understood the role of a pharmacist. Participants consistently desired more education on their medications from pharmacy providers. Conclusion: This is the first study to explore barriers and facilitators to medication adherence among Marshallese patients. The findings can be used to develop methods to improve medication adherence among Marshallese.
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Affiliation(s)
- Pearl A McElfish
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Michelle L Balli
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Jonell S Hudson
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Christopher R Long
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Teresa Hudson
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Ralph Wilmoth
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Brett Rowland
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - T Scott Warmack
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Rachel S Purvis
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Thomas Schulz
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Sheldon Riklon
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Angel Holland
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
| | - Tiffany Dickey
- University of Arkansas for Medical Sciences Northwest, Fayetteville, AR, USA
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Nelson LA, Wallston KA, Kripalani S, LeStourgeon LM, Williamson SE, Mayberry LS. Assessing barriers to diabetes medication adherence using the Information-Motivation-Behavioral skills model. Diabetes Res Clin Pract 2018; 142:374-384. [PMID: 29879495 PMCID: PMC6083841 DOI: 10.1016/j.diabres.2018.05.046] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/29/2018] [Accepted: 05/24/2018] [Indexed: 11/20/2022]
Abstract
AIMS Medication nonadherence is a prevalent and costly problem among patients with type 2 diabetes. Applications of theory can inform and improve adherence promotion interventions. We used a new assessment based on the Information-Motivation-Behavioral skills (IMB) model of adherence to assess patient-reported barriers and test the theoretical model. METHODS Participants (N = 237) completed a card sorting task to identify barriers to adherence, a survey, and a hemoglobin A1c (HbA1c) test. We identified the most commonly reported adherence barriers and examined associations between patient characteristics and barriers mapped onto each of the IMB constructs. We used structural equation modeling to test the IMB model and determine if barriers as reported on this measure predict patients' self-reported diabetes medication adherence and, in turn, HbA1c levels. RESULTS The most frequently reported barriers were forgetting doses, thinking brand name medicine works better than generic medicine, not seeing immediate benefit, and feeling burned out with taking diabetes medicine. Younger age and lower health literacy were associated with higher barrier scores for all IMB model constructs. Information and social motivation barriers affected adherence via behavioral skills barriers (indirect effects -0.19, CI [-0.33, -0.09] and -0.24, CI [-0.37, -0.14], respectively). The IMB barrier constructs explained 44% of the variance in diabetes medication adherence which, in turn, was significantly associated with and explained 8% of the variance in HbA1c (both p < .001). CONCLUSIONS Results suggest this assessment task can identify patient-specific barriers to diabetes medication adherence. Interventions targeting patient-specific barriers using this assessment could improve adherence and HbA1c.
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Affiliation(s)
- Lyndsay A Nelson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth A Wallston
- School of Nursing, Vanderbilt University, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren M LeStourgeon
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sarah E Williamson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lindsay S Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA.
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Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I, Greenhalgh T. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06210] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundThere is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.Objective(s)To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.DesignMultilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).SettingThree contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.Data collection and analysisMacro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.ResultsPolicy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.ConclusionsVirtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.LimitationsThe focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.Future researchFurther studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Nelson LA, Wallston KA, Kripalani S, Greevy RA, Elasy TA, Bergner EM, Gentry CK, Mayberry LS. Mobile Phone Support for Diabetes Self-Care Among Diverse Adults: Protocol for a Three-Arm Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e92. [PMID: 29636319 PMCID: PMC5915673 DOI: 10.2196/resprot.9443] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/19/2018] [Accepted: 02/08/2018] [Indexed: 01/03/2023] Open
Abstract
Background Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status and are racial/ethnic minorities disproportionately experience barriers to adherence and poor outcomes. Basic phone technology (text messages and phone calls) provides a practical medium for delivering content to address patients’ barriers to adherence; however, trials are needed to explore long-term and sustainable effects of mobile phone interventions among diverse patients. Objective The aim of this study is to evaluate the effects of mobile phone–based diabetes support interventions on self-care and hemoglobin A1c (HbA1c) among adults with T2D using a 3-arm, 15-month randomized controlled trial with a Type 1 hybrid effectiveness-implementation approach. The intervention arms are (1) Rapid Encouragement/Education And Communications for Health (REACH) and (2) REACH + Family-focused Add-on for Motivating Self-care (FAMS). Methods We recruited primary care patients with T2D (N=512) from Federally Qualified Health Centers and an academic medical center, prioritizing recruitment of publicly insured and minority patients from the latter. Eligible patients were prescribed daily diabetes medication and owned a cell phone with text messaging capability. We excluded patients whose most recent HbA1c result within 12 months was <6.8% to support detection of intervention effects on HbA1c. Participants were randomly assigned to REACH only, REACH + FAMS, or the control condition. REACH provides text messages tailored to address patient-specific barriers to medication adherence based on the Information-Motivation-Behavioral skills model, whereas FAMS provides monthly phone coaching with related text message content focused on family and friend barriers to diet and exercise adherence. We collect HbA1c and self-reported survey data at baseline and at 3, 6, and 12 months, and again at 15 months to assess sustained changes. We will use generalized estimating equation models to test the effects of REACH (either intervention arm) on HbA1c relative to the control group, the potential additive effects of FAMS, and effects of either intervention on adherence to self-care behaviors and diabetes self-efficacy. Results The trial is ongoing; recruitment closed December 2017. We plan to perform analyses on 6-month outcomes for FAMS in July 2018, and project to have 15-month data for REACH analyses in April 2019. Conclusions Our study will be one of the first to evaluate a long-term, theory-based text messaging intervention to promote self-care adherence among racially/ethnically and socioeconomically diverse adults with T2D. Moreover, our study will assess the feasibility of a family-focused intervention delivered via mobile phones and compare the effects of text messaging alone versus text messaging plus phone coaching. Findings will advance our understanding of how interventions delivered by phone can benefit diverse patients with chronic conditions. Trial Registration ClinicalTrials.gov NCT02409329; https://clinicaltrials.gov/ct2/show/NCT02409329 (Archived by WebCite at http://www.webcitation.org/6yHkg9SSl); NCT02481596; https://clinicaltrials.gov/ct2/show/NCT02481596 (Archived by WebCite at http://www.webcitation.org/6yHkj9XD4)
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Affiliation(s)
- Lyndsay A Nelson
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kenneth A Wallston
- Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,School of Nursing, Vanderbilt University, Nashville, TN, United States.,Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Tom A Elasy
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Erin M Bergner
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Chad K Gentry
- Department of Pharmacy, College of Pharmacy and Health Sciences, Lipscomb University, Nashville, TN, United States
| | - Lindsay S Mayberry
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Hincapie AL, Gupta V, Brown SA, Metzger AH. Exploring Perceived Barriers to Medication Adherence and the Use of Mobile Technology in Underserved Patients With Chronic Conditions. J Pharm Pract 2017; 32:147-153. [PMID: 29212410 DOI: 10.1177/0897190017744953] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Evidence suggests that the prevalence of medication nonadherence is greater in medically underserved, low-income communities. There is paucity of qualitative data examining the potential use of mobile health (mHealth) in underserved patients. This study aimed to explore barriers to medication adherence and identify opportunities and challenges for the potential use of mHealth adherence interventions in an underserved population. METHODS A qualitative cross-sectional focus group was conducted. Focus groups were conducted with underserved patients recruited at a federally qualified health center. The Health Belief Model was used as theoretical framework to develop the focus group guide. Audio-recorded data were transcribed and thematically analyzed to identify common themes across the data set. RESULTS Seventeen patients participated in 4 focus groups. Findings were organized by the following themes: (1) perceived barriers to medication adherence, (2) everyday practices used to improve medication adherence, and (3) perceived benefits and barriers to technology use. Use of text messages seemed beneficial; however, not carrying a phone always was a significant barrier for patients. Some patients expressed willingness to try smartphone applications but stated that they would not be able to afford them. Changes in daily routine and complexity of medication regimens were seen as barriers to medication adherence. CONCLUSIONS Findings underscore the importance of considering diverse experiences when engaging patients in mHealth for medication adherence. Providing patient-centered approaches to assist patients construct their individualized medication adherence strategies may lead to better outcomes.
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Affiliation(s)
- Ana L Hincapie
- 1 James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Vasudha Gupta
- 2 College of Pharmacy, Roseman University of Health Sciences, Henderson, NV, USA
| | | | - Anne H Metzger
- 1 James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
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Bergner EM, Nelson LA, Rothman RL, Mayberry L. Text Messaging May Engage and Benefit Adults with Type 2 Diabetes Regardless of Health Literacy Status. Health Lit Res Pract 2017; 1:e192-e202. [PMID: 29214241 PMCID: PMC5714586 DOI: 10.3928/24748307-20170906-01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Technology-delivered interventions have the potential to improve diabetes self-care and glycemic control among adults with type 2 diabetes (T2D). However, patients who do not engage with interventions may not reap benefits, and there is little evidence on how engagement with mobile health interventions varies by health literacy status. Objective: This study explored how patients with limited health literacy engaged with and experienced Rapid Education/Encouragement and Communications for Health (REACH), a text messaging intervention designed to support the self-care adherence of disadvantaged patients with T2D. We recruited adults with T2D from federally qualified health centers and used mixed methods to examine (1) associations between users' health literacy status and their prior mobile phone use and their engagement with REACH and (2) similarities and differences in users' self-reported benefits by health literacy status. Methods: Participants (N = 55) completed a survey, including measures of health literacy and prior mobile phone use. For 2 weeks, participants experienced REACH, which included daily text messages promoting self-care and asking about medication adherence, and weekly text messages providing medication adherence feedback. After 2 weeks, participants completed a semi-structured telephone interview about their experiences. Key Results: Participants with limited health literacy were less likely to have used cell phones to access the Internet (48% vs. 90%, p = .001) or email (36% vs. 87%, p < .001), but equally as likely to have used text messaging and to respond to REACH text messages (p = .12 and p = .40, respectively) compared to participants with adequate health literacy. Participants responded to 93% of text messages on average and reported benefits of the intervention, including reminders and accountability, convenience and accessibility, and information and motivation. Participants with limited health literacy described a unique benefit of receiving social support from the intervention. Conclusions: Text messaging interventions may engage and benefit patients with T2D, regardless of health literacy status. Text messaging may have the potential to reduce T2D health disparities related to limited health literacy. [Health Literacy Research and Practice. 2017;1(4):e192–e202.] Plain Language Summary: Limited health literacy is associated with less engagement with health information technology, but there is little evidence on how engagement with text messaging interventions varies by health literacy status. This intervention engaged and benefited adults with type 2 diabetes in safety-net clinics, regardless of health literacy status. Participants with limited health literacy described a unique intervention benefit of social support.
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Affiliation(s)
- Erin M Bergner
- Senior Research Specialist, Center for Health Behavior and Health Education, Vanderbilt University Medical Center
| | - Lyndsay A Nelson
- Research Assistant Professor, Center for Health Behavior and Health Education, Vanderbilt University Medical Center
| | - Russell L Rothman
- Professor of Medicine, and the Director, Center for Health Services Research, Vanderbilt University Medical Center
| | - Lindsay Mayberry
- Assistant Professor, Department of Medicine, Center for Health Behavior and Health Education, Vanderbilt University Medical Center
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45
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Gimbel R, Shi L, Williams JE, Dye CJ, Chen L, Crawford P, Shry EA, Griffin SF, Jones KO, Sherrill WW, Truong K, Little JR, Edwards KW, Hing M, Moss JB. Enhancing mHealth Technology in the Patient-Centered Medical Home Environment to Activate Patients With Type 2 Diabetes: A Multisite Feasibility Study Protocol. JMIR Res Protoc 2017; 6:e38. [PMID: 28264792 PMCID: PMC5359418 DOI: 10.2196/resprot.6993] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/16/2017] [Accepted: 02/12/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow. OBJECTIVE We aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities. METHODS This is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics. RESULTS We have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016. CONCLUSIONS The study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting. TRIAL REGISTRATION ClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei).
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Affiliation(s)
- Ronald Gimbel
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Joel E Williams
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Cheryl J Dye
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Liwei Chen
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Paul Crawford
- Nellis Family Medicine Residency Program, Mike O'Callaghan Federal Hospital, Las Vegas, NV, United States
| | - Eric A Shry
- Madigan Army Medical Center, Tacoma, WA, United States
| | - Sarah F Griffin
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Karyn O Jones
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Windsor W Sherrill
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Khoa Truong
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Jeanette R Little
- MHIC Laboratory Lead, Telemedicine & Advanced Technology Research Center, U.S. Army Medical Research & Materials Command, Fort Gordon, GA, United States
| | - Karen W Edwards
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Marie Hing
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Jennie B Moss
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
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Mayberry LS, Berg CA, Harper KJ, Osborn CY. The Design, Usability, and Feasibility of a Family-Focused Diabetes Self-Care Support mHealth Intervention for Diverse, Low-Income Adults with Type 2 Diabetes. J Diabetes Res 2016; 2016:7586385. [PMID: 27891524 PMCID: PMC5116505 DOI: 10.1155/2016/7586385] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/04/2016] [Indexed: 11/17/2022] Open
Abstract
Family members' helpful and harmful actions affect adherence to self-care and glycemic control among adults with type 2 diabetes (T2D) and low socioeconomic status. Few family interventions for adults with T2D address harmful actions or use text messages to reach family members. Through user-centered design and iterative usability/feasibility testing, we developed a mHealth intervention for disadvantaged adults with T2D called FAMS. FAMS delivers phone coaching to set self-care goals and improve patient participant's (PP) ability to identify and address family actions that support/impede self-care. PPs receive text message support and can choose to invite a support person (SP) to receive text messages. We recruited 19 adults with T2D from three Federally Qualified Health Centers to use FAMS for two weeks and complete a feedback interview. Coach-reported data captured coaching success, technical data captured user engagement, and PP/SP interviews captured the FAMS experience. PPs were predominantly African American, 83% had incomes <$35,000, and 26% were married. Most SPs (n = 7) were spouses/partners or adult children. PPs reported FAMS increased self-care and both PPs and SPs reported FAMS improved support for and communication about diabetes. FAMS is usable and feasible and appears to help patients manage self-care support, although some PPs may not have a SP.
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Affiliation(s)
- Lindsay Satterwhite Mayberry
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
- *Lindsay Satterwhite Mayberry:
| | - Cynthia A. Berg
- Department of Psychology, University of Utah, Salt Lake City, UT, USA
| | - Kryseana J. Harper
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chandra Y. Osborn
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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