The ethical challenges of personalized digital health

Participatory methods in designing digital health interventions for informal caregivers of people with dementia. A systematic review

Aims

The growing use of technology in healthcare has contributed to the development of digital interventions for informal caregivers of people living with dementia. However, the marked heterogeneity of interventions poses challenges in evaluating their effectiveness. We conducted a review to delineate the distinctive features and development of the interventions, with focus on participatory methods.

Methods

We searched the following databases: Cochrane; Cinahl; Pubmed; Psychinfo; Scopus; Web of Knowledge, and IEEE, and screened and selected studies based on titles, abstracts and full texts. We used standardized procedure to abstract and synthetize relevant data of primary studies, and the Mixed Methods Appraisal Tool to assess their quality.

Results

Of 3136 records, 20 studies met the inclusion criteria. Most of the studies were web-based interventions, with multiple components and interactive features. The design and development of eight interventions employed participatory methods with large variations in the underlying framework and application.

Conclusions

This review sheds light on the design and development of digital interventions for dementia caregivers. The limited and heterogeneous use of participatory methods, along with inadequate reporting, hinders a clear understanding of intervention efficacy and implementation. Formal standardization of participatory action research methods is necessary to improve the design, development, and evaluation of digital interventions for caregivers of people with dementia.

Digital Transformation in Patient Organizations: Interview and Focus Group Study

BACKGROUND

Patient organizations (POs) are an integral part of the health care landscape, serving as advocates and support systems for patients and their families. As the digitalization of health care accelerates, POs are challenged to adapt their diverse roles to digital formats. However, the extent and form of POs' digital adaptation and the challenges POs encounter in their digital transformation remain unexplored.

OBJECTIVE

This study aims to investigate the digital transformation processes within POs. We examined the types of digital activities and processes implemented, people involved in respective tasks, challenges encountered, and attitudes toward the digitalization of POs.

METHODS

The study was carried out by the multicenter interdisciplinary research network Pandora. We adopted a qualitative exploratory approach by conducting 37 semistructured interviews and 2 focus groups with representatives and members of POs in Germany. Results were obtained using a deductive-inductive approach based on a qualitative content analysis. Methods and results were reported in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.

RESULTS

POs primarily apply basic digital tools to engage in communication, health education, and information dissemination. Some also develop specific mobile apps and collect health data through patient registries. Volunteers cover a considerable part of the workload. Sometimes, POs collaborate with external partners, such as health professionals or other nonprofit organizations. Furthermore, many (13/46, 28%) interviewees referred to the importance of involving members in digitalization efforts to better meet their needs. However, they described the actual practices used to involve members in, for example, developing digital services as limited, passive, or implicit. When evaluating digital transformation processes, representatives and members of POs expressed generally positive attitudes and acknowledged their potential to improve the accessibility of support services, management efficiency, and outreach. Still, resource constraints; the complexity of digital initiatives; and accessibility issues for certain demographic groups, especially older persons, were frequently mentioned as challenges. Several (15/46, 33%) interviewees highlighted POs' increasing responsibility to support their members' digital competencies and digital health literacy.

CONCLUSIONS

POs are actively involved in the digital transformation of health services. To navigate challenges and further shape and sustain digital activities and processes, POs may benefit from governance frameworks, that is, a clear plan outlining with whom, how, and with what objectives digital projects are being realized. Support from public, scientific, and policy institutions to enhance the process through training, mentorship, and fostering collaborative networks seems warranted.

Development of a digital risk-prediction tool based on family health history for the general population: legal and ethical implications

Cardiovascular diseases, both inherited and familial, indicate a risk of early and preventable cardiovascular events for relatives of affected individuals. A digital risk-prediction tool that enables general population individuals to evaluate their cardiovascular risk based on family health history could be a responsible approach to facilitate early detection and improve public health, but development and use of such a tool is not without legal and ethical requirements. At the start of tool development, experts addressed potential legal and ethical implications. Especially European Union (EU) regulations could present potential obstacles for the tool's development, broader availability and general use. A first example is that the EU General Data Protection Regulation does not allow the tool to collect health data about relatives without their consent; the alternative is data anonymisation. This requirement has major consequences for the tool's usefulness and raises ethical concerns about who 'the owner' is of family data. A second example is related to the EU's Medical Device Regulation: if software generates health risks or provides medical advice, it requires a CE mark from a 'notified body', an extensive and costly procedure. In this article, we describe these implications in more detail and discuss possible solutions. To conclude, alongside national law, European law can impact on the development of digital tools that collect family health data to provide information on health risks. We recommend including experts in law and ethics in developmental stages of such tools which are likely to become more frequent in routine public care.

A qualitative exploration of participants' perspectives and experiences of novel digital health infrastructure to enhance patient care in remote communities within the Home Health Project

The Home Health Project, set on Clare Island, five kilometres off the Irish Atlantic coast, is a pilot exploration of ways in which various forms of technology can be utilised to improve healthcare for individuals living in isolated communities. The integration of digital health technologies presents enormous potential to revolutionise the accessibility of healthcare systems for those living in remote communities, allowing patient care to function outside of traditional healthcare settings. This study aims to explore the personal experiences and perspectives of participants who are using digital technologies in the delivery of their healthcare as part of the Home Health Project. Individual semi-structured interviews were conducted with nine members of the Clare Island community participating in the Home Health Project. Interviews took place in-person, in June 2023. Interviews were audio-recorded and transcribed verbatim. The data were analysed inductively using reflexive thematic analysis. To identify determinants of engagement with the Home Health Project, the data was then deductively coded to the Theoretical Domains Framework (TDF) and organised into themes. Seven of the possible 14 TDF domains were supported by the interview data as influences on engagement with the Project: Knowledge, Beliefs about capabilities, Optimism, Intentions, Environmental context and resources, Social influences and Emotion. Overall, participants evaluated the Home Health Project as being of high quality which contributed to self-reported increases in health literacy, autonomy, and feeling well supported in having their health concerns addressed. There was some apprehension related to data protection, coupled with a desire for extended training to address aspects of digital illiteracy. Future iterations can capitalise on the findings of this study by refining the technologies to reflect tailored health information, personalised to the individual user.

A Chatbot (Juno) Prototype to Deploy a Behavioral Activation Intervention to Pregnant Women: Qualitative Evaluation Using a Multiple Case Study

BACKGROUND

Despite the increasing focus on perinatal care, preventive digital interventions are still scarce. Furthermore, the literature suggests that the design and development of these interventions are mainly conducted through a top-down approach that limitedly accounts for direct end user perspectives.

OBJECTIVE

Building from a previous co-design study, this study aimed to qualitatively evaluate pregnant women's experiences with a chatbot (Juno) prototype designed to deploy a preventive behavioral activation intervention.

METHODS

Using a multiple-case study design, the research aims to uncover similarities and differences in participants' perceptions of the chatbot while also exploring women's desires for improvement and technological advancements in chatbot-based interventions in perinatal mental health. Five pregnant women interacted weekly with the chatbot, operationalized in Telegram, following a 6-week intervention. Self-report questionnaires were administered at baseline and postintervention time points. About 10-14 days after concluding interactions with Juno, women participated in a semistructured interview focused on (1) their personal experience with Juno, (2) user experience and user engagement, and (3) their opinions on future technological advancements. Interview transcripts, comprising 15 questions, were qualitatively evaluated and compared. Finally, a text-mining analysis of transcripts was performed.

RESULTS

Similarities and differences have emerged regarding women's experiences with Juno, appreciating its esthetic but highlighting technical issues and desiring clearer guidance. They found the content useful and pertinent to pregnancy but differed on when they deemed it most helpful. Women expressed interest in receiving increasingly personalized responses and in future integration with existing health care systems for better support. Accordingly, they generally viewed Juno as an effective momentary support but emphasized the need for human interaction in mental health care, particularly if increasingly personalized. Further concerns included overreliance on chatbots when seeking psychological support and the importance of clearly educating users on the chatbot's limitations.

CONCLUSIONS

Overall, the results highlighted both the positive aspects and the shortcomings of the chatbot-based intervention, providing insight into its refinement and future developments. However, women stressed the need to balance technological support with human interactions, particularly when the intervention involves beyond preventive mental health context, to favor a greater and more reliable monitoring.

Evaluating Information Technology-enabled Precision Prevention Initiatives in Health and Care

Information technology-enabled precision prevention is a relatively new approach designed to improve population health. It forms an organic development linking principles of optimizing added value from health-related information technology and data systems with clinical aspirations to add longer-term problem prevention to immediate illness treatment. It includes drawing on information technology to identify persons at risk for developing certain conditions and then developing targeted behavioral and psychosocial approaches to modifying the behaviors of individuals or specific groups. We here discuss evaluation challenges associated with information technology-enabled precision prevention approaches to facilitate the development of an empirical evidence base. Challenges associated with measuring the impact of information technology-enabled precision prevention initiatives include considerations surrounding the relevance and fit of external data sources, the accuracy of prediction models, establishing added benefits of preventative activities, measuring pre-post outcomes at individual and population levels, and considerations surrounding cost-benefit analysis. Challenges associated with assessing processes of information technology-enabled precision prevention initiatives include the quality of data used to create underlying data models, exploring processes not necessarily related to each other, evolving social and environmental determinants of health and individual circumstances, the evolving nature of needs and interventions over time, and ethical considerations. If these challenges are attended to in evaluation activities, this will help to ensure that information technology-enabled approaches to precision prevention will have a positive impact on individual and population health.

Determining the feasibility of a codesigned and personalised intervention (Veg4Me) to improve vegetable intake in young adults living in rural Australian communities: protocol for a randomised controlled trial

INTRODUCTION

Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control).

METHODS AND ANALYSIS

A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18-35 years; eat<5 serves of vegetables/day; have an internet connected mobile device/computer) living in Loddon Campaspe or Colac Otway Shire in Victoria, Australia, will be randomised to receive 12 weeks of personalised (intervention) or non-personalised (control) support to increase vegetable intake via a free web application (app; Veg4Me). The primary outcome is feasibility (recruitment, participation and retention rates). Secondary outcomes are user engagement, usability and experience, as well as vegetable intake, eating habits and digital health equity. Process evaluation will be conducted in a subsample of participants using semistructured interviews. Descriptive statistics will be presented for the personalised and non-personalised groups at baseline and 12 weeks. Generalised linear models will be used to evaluate group differences in outcomes. Interviews will be transcribed and analysed thematically.

ETHICS AND DISSEMINATION

All procedures involving human subjects were approved by Deakin University's Human Ethics Advisory Group-Health (HEAG-H 06_2023) on 6 March 2023. Dissemination events will be held in the City of Greater Bendigo and the Colac Otway Shire. Summaries of the results will be disseminated to participants via email. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry, ACTRN12623000179639p, prospectively registered on 21 February 2023, according to the World Health Organizational Trial Registration Data Set. Universal Trial Number U1111-1284-9027.