Research Guided by the Theory of Care-Seeking Behavior: A Scoping Review

BACKGROUND

A particular Theory of Care-Seeking Behavior was developed to explain care-seeking behavior with psychosocial concepts, external conditions, and clinical and demographic factors. Having a careful review of studies based on this theory could guide future research on care-seeking behaviors.

OBJECTIVES

With a scoping review: describe characteristics of studies guided by a Theory of Care-Seeking Behavior, summarize support for the relationships of proposed, explanatory variables with care-seeking behaviors, and examine support for propositions in the theory.

METHOD

Searching 5 electronic databases, we sought studies that were: full-text, peer-reviewed, in English, data-based, guided by the theory, and published from January 1, 1992, to January 1, 2022.

RESULTS

Across 18 identified articles, the behaviors studied included: symptomatic screening (n = 8), asymptomatic screening (n = 7), and care-seeking behaviors for either screening or symptoms (n = 3). A total of 3328 adults participated in the studies. In 16 studies, all participants were female. In 60% to 83% of studies, researchers had reported findings that supported the relationships of explanatory concepts with care-seeking behavior. Among the 7 studies that tested the 2 propositions of theory, all 7 tests failed to support the proposition that clinical and demographic factors influence care-seeking behavior indirectly through psychosocial variables. Six tests supported the proposition that psychosocial variables influence behavior conditionally, on external conditions.

CONCLUSIONS

Relationships of these explanatory variables with care-seeking behaviors were supported, as was 1 of 2 propositions. The Theory of Care-Seeking Behavior can be applied to new clinical situations to continue to build knowledge of the theory and understanding of care-seeking behaviors.

Investigating Digital Patient-Reported Outcome Measures in Patient-Centered Diabetes Specialist Outpatient Care (DigiDiaS): Protocol for a Multimethod Prospective Observational Study

BACKGROUND

Living with type 1 diabetes is challenging, and to support self-management, repeated consultations in specialist outpatient care are often required. The emergence of new digital solutions has revolutionized how health care services can be patient centered, providing unprecedented opportunities for flexible, high-quality care. However, there is a lack of studies exploring how the use of digital patient-reported outcome measures (PROMs) for flexible specialist care affects diabetes self-management. To provide new knowledge on the relevance of using PROMs in standard care, we have designed a multimethod prospective study.

OBJECTIVE

The overall aim of this protocol is to describe our prospective multimethod observational study designed to investigate digital PROMs in a routine specialist outpatient setting for flexible patient-centered diabetes care (DigiDiaS).

METHODS

This protocol outlines the design of a multimethod prospective observational cohort study that includes data from electronic health records, self-reported questionnaires, clinical consultation field observations, and individual in-depth interviews with patients and diabetes health care personnel. All patients with type 1 diabetes at a designated outpatient clinic were invited to participate and use the digital PROM implemented in clinical care. Both users and nonusers of the digital PROM were eligible for the prospective study, allowing for a comparison of the two groups. Data were collected at baseline and after 12 months, including self-management as the primary outcome assessed using the Patient Activation Measure, along with the secondary outcomes of digital health literacy, quality of life, health economy, and clinical variables such as glycated hemoglobin.

RESULTS

The digital solution was implemented for routine clinical care in the department in November 2021, and data collection for the prospective study started in October 2022. As of September 6, 2023, 84.6% (186/220) of patients among those in the digital PROM and 15.5% (34/220) of patients among the nonusers have consented to participate. We expect the study to have enough participants by the autumn of 2023. With 1 year of follow-up, the results are expected by spring 2025.

CONCLUSIONS

In conclusion, a multimethod prospective observational cohort study can offer valuable insights into the relevance, effectiveness, and acceptability of digital tools using PROMs in diabetes specialist care. Such knowledge is crucial for achieving broad and successful implementation and use of these tools in a large diabetes outpatient clinic.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52766.

Experiences of remote consultation in UK primary care for patients with mental health conditions: A systematic review

Objectives

There has been a rapid shift from face-to-face to remote consultation across healthcare settings. 90% of patients with mental health conditions are cared for entirely in primary care. Remote consultation can present challenges and benefits for patients with mental health conditions. The aim of this systematic review was to collate and examine the evidence relating to remote consultation in UK primary care on the experiences of patients with mental health conditions.

Methods

Six major databases were searched for empirical studies published in the English language between 1 January 2010 and 21 October 2022. Studies were included where remote consultation occurred between a patient and primary care clinician. Outcomes of interest include mode of remote consultation, patient experiences and characteristics. Final included studies were assessed for quality, and results analysed with narrative synthesis.

Results

Six studies met the inclusion criteria, covering a range of mental health conditions and remote consultation modalities (telephone, video, online, email, text-based). Patients were overall satisfied with remote consultation, with particular benefit for certain mental health conditions or anxious patients. However, several studies found that face-to-face was the preferred method, with highlighted negatives to remote consultation, such as inflexibility of online formats. Acceptability of remote consultation is context specific and influenced by the purpose of the consultation and individual patient. Remote consultation may reduce anxiety in some patients, but is potentially less acceptable than face-to-face for relational appointments.

Conclusions

Acceptability of remote consultation is context dependent. There is a lack of evidence surrounding patient characteristics and access to remote consultation.

Factors influencing access to nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia: An integrative review

WHAT IS KNOWN ON THE SUBJECT

Research has shown effectiveness of nonpharmacological interventions in improving or maintaining cognition, mood, functioning, self-efficacy and quality of life for persons with mild-to-moderate dementia (PWDs). These interventions are critical during the earlier stages of dementia. However, Canadian and international literature report underutilization of and difficulty accessing the interventions.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

To our knowledge, this is the first review that explored factors influencing seniors' utilization of nonpharmacological interventions in the earlier stages of dementia. This review contributed to the discovery of unique factors such as PWDs' beliefs, fears, perceptions, and acceptability of nonpharmacological interventions and environmental influences on intervention provision. PWDs' intervention uptake may appear as a matter of personal choices related to individuals' knowledge, beliefs and perceptions. However, the analysis of the research evidence suggests that PWDs' choices are shaped by environmental factors such as formal and informal caregiver support, acceptability and accessibility of nonpharmacological interventions, dementia care workforce, community's attitudes towards dementia and funding. The complex interplay among factors highlights the importance of targeting health promotion strategies at both individuals and their environments.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The review findings feature opportunities for healthcare practitioners, including mental health nurses, in advocating for PWDs' evidence-informed decision-making and access to desired nonpharmacological treatments. Involvement of patients and families in care-planning through ongoing assessment of health and learning needs, as well as enablers and barriers to using interventions, continuing information provision, and personalized referrals to appropriate services can promote PWDs' rights to healthcare.

ABSTRACT

INTRODUCTION: Despite the significance of nonpharmacological interventions in optimal management of mild-to-moderate dementia, it remains unclear in the literature how persons with mild-to-moderate dementia (PWDs) view, understand and access nonpharmacological interventions.

AIM

The purpose of this review was to explore the extent and nature of evidence concerning factors that influence the use of nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia.

METHOD

An integrative review was undertaken following Toronto and Remington (A step-by-step guide to conducting an integrative review, 2020)'s instruction which expanded Torraco (Human Resource Development Review, 2016, 15, 404)'s and Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546)'s guidance.

RESULTS

The review of 16 studies suggests that PWDs' use of nonpharmacological interventions is shaped by a complex interplay of various personal, interpersonal, organizational, community and political influences.

DISCUSSION

The findings highlight the complex, interrelated relationships among multiple factors and subsequent limitations of behaviour-oriented health promotion strategies. To assist PWDs in making healthier choices, health promotion strategies need to direct attention to both individuals' behaviours and environmental conditions impacting the behaviours.

IMPLICATIONS FOR PRACTICE

The findings of this review can inform multidisciplinary health practitioners' (including mental health nurses) practice with seniors living with mild-to-moderate dementia. We recommend actionable ways in which they can empower patients and their families in dementia management.

Predictors of preparedness for recovery following colorectal cancer surgery: a latent class trajectory analysis

AIM

With an interest in providing knowledge for person-centred care, our overall goal is to contribute a greater understanding of diversity among patients in terms of their preparedness before and up to six months after colorectal cancer surgery. Our aim was to describe and provide a tentative explanation for differences in preparedness trajectory profiles.

MATERIAL AND METHODS

The study was explorative and used prospective longitudinal data from a previously published intervention study evaluating person-centred information and communication. The project was conducted at three hospitals in Sweden. Patient-reported outcomes measures, including the Longitudinal Preparedness for Colorectal Cancer Surgery Questionnaire, were collected before surgery, at discharge, and four to six weeks, three months, and six months after surgery. Clinical data were retrospectively obtained from patients' medical records. We used latent class growth models (LCGMs) to identify latent classes that distinguish subgroups of patients who represent different preparedness trajectory profiles. To determine the most plausible number of latent classes, we considered statistical information about model fit and clinical practice relevance. We used multivariable regression models to identify variables that explain the latent classes.

RESULTS

The sample (N = 488) comprised people with a mean age of 68 years (SD = 11) of which 44% were women. Regarding diagnoses, 60% had colon cancer and 40% rectal cancer. The LCGMs identified six latent classes with different preparedness for surgery and recovery trajectories. The latent classes were predominantly explained by differences in age, sex, physical classification based on comorbidities, treatment hospital, global health status, distress, and sense of coherence (comprehensibility and meaningfulness).

CONCLUSION

Contrary to the received view that emphasizes standardized care practices, our results point to the need for adding person-centred and tailored approaches that consider individual differences in how patients are prepared before and during the recovery period related to colorectal cancer surgery.

Anticipatory anxiety and participation in cancer screening. A systematic review

OBJECTIVES

To synthesize current evidence on the association between anticipatory anxiety, defined as apprehension-specific negative affect that may be experienced when exposed to potential threat or uncertainty, and cancer screening to better inform strategies to maximize participation rates.

METHODS

Searches related to cancer screening and anxiety were conducted in seven electronic databases (APA PsycINFO, Scopus, Web of Science, Embase, Cochrane Library, PubMed, CINAHL), with potentially eligible papers screened in Covidence. Data extraction was conducted independently by multiple authors. Barriers to cancer screening for any type of cancer and relationships tested between anticipatory anxiety and cancer screening and intention were categorized and compared according to the form and target of anxiety and cancer types.

RESULTS

A total of 74 articles (nparticipants  = 119,990) were included, reporting 103 relationships tested between anticipatory anxiety and cancer screening and 13 instances where anticipatory anxiety was reported as a barrier to screening. Anticipatory anxiety related to a possible cancer diagnosis was often associated with increased screening, while general anxiety showed no consistent relationship. Negative relationships were often found between anxiety about the screening procedure and cancer screening.

CONCLUSION

Anticipatory anxiety about a cancer diagnosis may promote screening participation, whereas a fear of the screening procedure could be a barrier. Public health messaging and primary prevention practitioners should acknowledge the appropriate risk of cancer, while engendering screening confidence and highlighting the safety and comfort of screening tests.

Strategies for Improving Nurses' Performance Regarding Cardiovascular Patient's Adherence to Treatment Regimen: Content Analysis

Background

Patient adherence to the treatment regimen is an important goal of treatment; finding appropriate strategies to improve treatment adherence is a nursing challenge. This study aimed to explore strategies to improve nurses' performance to enhance cardiovascular patients' adherence to treatment regimens.

Materials and Methods

This is a qualitative content analysis study that was performed in an educational hospital of the Urmia University of Medical Science. Data were collected through semi-structured individual and group interviews. Sixteen individual interviews were conducted with nurses, patients, and physicians. A focus group was conducted with the presence of six nurses and nursing managers. Data were analyzed by conventional content analysis using MAXQDA 2020.

Results

After analyzing the interviews, five strategies were explored; these strategies include: follow-up of the patient after discharge (systemic and organizational follow-up, educational follow-up, counseling follow-up, and motivational follow-up), sending reminders for necessary cases to the patients (risk reminders, care reminders); improving patient education methods (modern and up-to-date education, conventional and routine education), improving support services (home care services, social support, Psychological support), and optimizing the structure and processes of the hospital (making structural changes, making process changes).

Conclusions

Much needs to be done to improve patient's adherence to treatment. Nurses are at the forefront of this work. In this study, we introduced ways to improve nurses' performance in order to increase patient adherence.

Pervasive Parental Hesitancy and Resistance towards Measles Rubella Vaccination in Jordan

Measles remains a highly contagious and potentially severe infectious disease, necessitating high vaccine coverage. However, misinformation and measles vaccine hesitancy/resistance have posed significant challenges to achieving this goal. The COVID-19 pandemic further exacerbated these challenges, leading to a measles outbreak in Jordan in 2023. This study aimed to investigate the acceptance of the measles rubella (MR) vaccine among parents in Jordan and to identify its associated determinants. This cross-sectional questionnaire-based study was conducted using a previously Arabic-validated version of the Parental Attitudes towards Childhood Vaccines (PACV) survey instrument. Data collection took place in October 2023, and the final study sample comprised a total of 391 parents, with mothers representing 69.8% of the participants (n = 273). The majority of participating parents expressed either resistance (n = 169, 43.2%) or hesitancy (n = 168, 43.0%) towards MR vaccination, while only 54 participants (13.8%) expressed MR vaccine acceptance. Multivariate analysis revealed that trust in vaccine safety/efficacy, behavior, and having fewer offspring were significantly associated with MR vaccine acceptance. The current study revealed a concerning level of MR vaccine hesitancy/resistance among parents in Jordan, which could signal a public health alarm in the country. Urgent and targeted interventions are strongly recommended to address this issue, including mass campaigns aimed at building trust in the MR vaccine's safety/efficacy. Additionally, there is an urgent need for effective public health initiatives to ensure sufficient measles vaccine coverage to prevent future outbreaks of this serious disease.

Adherence to levothyroxine treatment among patients with hypothyroidism in Oman: a national cross-sectional study

OBJECTIVE

Hormone replacement therapy with levothyroxine is considered the treatment of choice for hypothyroidism; however, non-adherence is a major contributor to poor treatment outcomes. This study aimed to evaluate levels of drug adherence (DA) to levothyroxine therapy among Omani adults with hypothyroidism and to explore related sociodemographic and clinical factors.

METHODS

A national, multi-center, cross-sectional survey was carried out from August to December 2021 at 18 primary healthcare centers across all governorates of Oman. A total of 415 Omani adults were recruited. Data were collected using a pre-tested, Arabic-language questionnaire completed by trained researchers during face-to-face interviews with the participants. Level of DA was determined using the 8-item Morisky Medication Adherence Scale (MMAS-8).

RESULTS

A total of 400 Omani adults participated in the study (response rate: 96.4%). The mean age was 41.9 ± 12.4 years old (range: 18-78 years) and 90.3% were female. According to their MMAS-8 scores, 157 (39.2%), 139 (34.8%), and 104 (26.0%) participants demonstrated low, medium, and high DA, respectively. No significant correlations were observed between level of DA and any sociodemographic or clinical characteristics, including age, gender, education, duration of treatment, and family history of thyroid disease (p > 0.050).

CONCLUSIONS

Only a quarter of Omani patients with hypothyroidism reported high levels of adherence to levothyroxine treatment, likely as a result of lack of awareness of the disease and the importance of maintaining an euthyroid state. Further studies using more objective measures of DA are recommended to determine correlates of non-compliance to levothyroxine therapy among Omani patients.

Influence of side effect information on patient willingness to take medication: consequences for informed consent and medication adherence

Medication side effect information can create negative patient expectations of side effects, but such information is considered crucial to informed consent. The current study investigated the effect of informing participants of different numbers of medication side effects. Willingness to take the medication was highest for those informed of one or four compared with none or 26 side effects, and memory of side effects was also more accurate. Findings suggest that informing patients of some, but not several, side effects may optimise both medication adherence and accuracy of informed consent.

Integrating patient voices into the extraction of social determinants of health from clinical notes: ethical considerations and recommendations

Identifying patients' social needs is a first critical step to address social determinants of health (SDoH)-the conditions in which people live, learn, work, and play that affect health. Addressing SDoH can improve health outcomes, population health, and health equity. Emerging SDoH reporting requirements call for health systems to implement efficient ways to identify and act on patients' social needs. Automatic extraction of SDoH from clinical notes within the electronic health record through natural language processing offers a promising approach. However, such automated SDoH systems could have unintended consequences for patients, related to stigma, privacy, confidentiality, and mistrust. Using Floridi et al's "AI4People" framework, we describe ethical considerations for system design and implementation that call attention to patient autonomy, beneficence, nonmaleficence, justice, and explicability. Based on our engagement of clinical and community champions in health equity work at University of Washington Medicine, we offer recommendations for integrating patient voices and needs into automated SDoH systems.

Community and Health Care Provider Preferences for Bacterial Sexually Transmitted Infection Testing Interventions for Gay, Bisexual, and Other Men Who Have Sex With Men: e-Delphi Study

BACKGROUND

Canadian clinical guidelines recommend at least annual and up to quarterly bacterial sexually transmitted infection (STI) testing among sexually active gay, bisexual, and other men who have sex with men (GBM). However, testing rates are suboptimal. Innovative solutions are needed to close the gap because there is currently limited knowledge on how best to approach this issue.

OBJECTIVE

Our aim was to build consensus regarding interventions with the greatest potential for improving local STI testing services for GBM communities in Toronto, Ontario, Canada, using a web-based e-Delphi process.

METHODS

The e-Delphi method involves using a panel format to conduct successive rounds of prioritization, with feedback between rounds, to determine priorities among groups. We recruited experts separately from the community (GBM who sought or underwent STI testing in the preceding 18 months; conducted between October 2019 and November 2019) and health care providers (those who offered STI testing to GBM in the past 12 months; conducted between February 2020 and May 2020). The experts prioritized 6 to 8 potential interventions on a 7-point Likert scale ranging from definitely not a priority to definitely a priority over 3 survey rounds and ranked their top 3 interventions. Consensus was defined as ≥60% within a ±1 response point. Summaries of responses were provided in successive rounds. We reported the percentage of a priority (encompassing somewhat a priority, a priority, and definitely a priority responses) at the end of the final round of the survey.

RESULTS

Of the community experts (CEs), 84% (43/51) completed all rounds; 19% (8/43) were living with HIV; 37% (16/43) were HIV negative and on pre-exposure prophylaxis; and 42% (18/43) were HIV negative and not on pre-exposure prophylaxis. We reached consensus on 6 interventions: client reminders (41/43, 95%), express testing (38/43, 88%), routine testing (36/43, 84%), an online booking app (36/43, 84%), online-based testing (33/43, 77%), and nurse-led testing (31/43, 72%). The CEs favored convenient interventions that also maintain a relationship with their provider. Of the provider experts (PEs), 77% (37/48) completed all rounds; 59% (22/37) were physicians. Consensus was reached on the same 6 interventions (range 25/37, 68%, to 39/39, 100%) but not for provider alerts (7/37, 19%) and provider audit and feedback (6/37, 16%). Express testing, online-based testing, and nurse-led testing were prioritized by >95% (>37/39) of the PEs by the end of round 2 because of streamlined processes and decreased need to see a provider.

CONCLUSIONS

Both panels were enthusiastic about innovations that make STI testing more efficient, with express testing rating highly in both the prioritizations and top 3 rankings. However, CEs preferred convenient interventions that involved their provider, whereas PEs favored interventions that prioritized patient independence and reduced patient-provider time.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13801.

Qualitative assessment of COVID-19 vaccination acceptance among healthcare workers in Pima County

In the Spring of 2021, the COVID-19 vaccination was authorized for emergency use by the Food and Drug Administration. Healthcare workers (HCWs) are one of the most trusted sources of information for vaccination choices. However, HCWs at this time appeared to continue to have lower rates of COVID-19 vaccination uptake than expected in Arizona. The objective of this study was to examine factors that play a role in the vaccination decision-making process among Arizona HCWs. Between January and April 2021, 18 semi-structured interviews were conducted among physicians, emergency medical technicians and long-term care nurses in Pima County. The informed consent process was completed for each participant. The interview guide was informed by the Increasing Vaccination model to collect information on vaccination decision-making. A codebook was developed using an inductive approach. Coding and analysis was conducted using the software MAXQDA. Participants were primarily male (11/18, 61%) and white (11/18, 61%). Three participants identified as Hispanic. Initial themes that emerged included: mixed opinions concerning the innovations in COVID-19 vaccine development, access-related barriers, issues related to distribution inequities, concerns about misinformation and conspiracy theories, and dialogue concerning the benefits of requiring mandatory vaccination. The results gathered from this study indicate that there continues to be hesitancy among some healthcare professionals in Pima County. These results will be used to help Arizonan Health Departments promote rollout of novel vaccines more effectively through targeting relevant vaccination decision-making factors among HCWs.

Adherence Versus Compliance

Description Adherence and compliance are 2 words that are used interchangeably by medical professionals. When we come across a patient who is not taking their medication as advised, we say the patient is non-compliant when the truth is that the patient is non-adherent. Although the terms are used as if they mean the same thing, the 2 words are different in so many ways. In order to understand the difference, it is important to understand the true meaning of these words. According to the literature, "adherence is an active choice of patients to follow through with the prescribed treatment while taking responsibility for their own well-being while compliance is a passive behavior in which a patient is following a list of instructions from the doctor." Adherence is a more positive, proactive behavior, which results in a lifestyle change by the patient, and they must then follow a daily regimen such as taking his or her medications every day or doing exercise daily. Compliance is a behavior exhibited by a patient who is simply "doing as (he or she is) told" or following instructions given by the treating doctor.

Acceptability of a virtual prostate cancer survivorship care model in regional Australia: A qualitative exploratory study

OBJECTIVE

To assess the acceptability of a nurse-led prostate cancer survivorship intervention adapted for virtual delivery and tailored to post-surgical care, in a regional Australian hospital and health service.

METHODS

A qualitative exploratory study using the Theoretical Framework of Acceptability (TFA).

RESULTS

Twenty-two participants took part in a semistructured interview comprising men who had completed the program (n = 16) and health professionals/service stakeholders involved in program delivery (n = 6). Acceptability of this virtual prostate cancer survivorship care program was very high across all constructs of the TFA, from the perspectives of both program recipients and those delivering the program. The quality of care received was seen as superior to what men had experienced previously (burden, opportunity costs). The time afforded by the regularly scheduled video-consultations allowed men to come to terms with the recovery process in their own time (self-efficacy), and provided an ongoing sense of support and access to care outside the consultation (ethicality). Clinically, the program improved care co-ordination, expedited identification of survivorship care needs, and met service priorities of providing quality care close to home (burden, perceived effectiveness).

CONCLUSIONS

Findings from this study suggest virtual post-surgical care delivered via videoconferencing is highly acceptable to prostate cancer survivors in a regional setting. Future research exploring virtual program implementation at scale and long-term patient and service outcomes is warranted.

Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis

BACKGROUND

It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause.   OBJECTIVES: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients.  SEARCH METHODS: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification.

SELECTION CRITERIA

We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients' experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies.  DATA COLLECTION AND ANALYSIS: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach.  MAIN RESULTS: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes.   AUTHORS' CONCLUSIONS: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers.

End-user perceptions of sub-epidermal moisture scanning (SEMS) acceptability: A descriptive qualitative study

AIMS

To assess patients' and nurses' perceptions and experiences of subepidermal moisture scanning acceptability.

DESIGN

Descriptive, qualitative, sub-study, embedded within a pilot randomized control trial.

METHODS

Ten patients who were in the intervention arm of the pilot trial and 10 registered nurses providing care for these patients on medical-surgical units participated in individual semi-structured interviews. Data were collected from October 2021 to January 2022. Interviews were analysed using inductive qualitative content analysis, and perspectives (patient and nurse), were triangulated.

RESULTS

Four categories were found. The first category 'Subepidermal moisture scanning is acceptable as part of care' showed that patients and nurses were willing to use subepidermal moisture scanning and viewed subepidermal moisture scanning as non-burdensome. The category 'Subepidermal moisture scanning may improve pressure injury outcomes' demonstrated that although subepidermal moisture scanning was believed to prevent pressure injuries, more research evidence about its benefits was required. 'Subepidermal moisture scanning augments existing pressure injury prevention practices', the third category, highlighted that subepidermal moisture scanning aligns with current pressure injury prevention practices while making these practices more patient-centred. In the final category, 'Important considerations when making subepidermal moisture scanning routine practice', practical issues were raised relating to training, guidelines, infection control, device availability and patient modesty.

CONCLUSION

Our study demonstrates that using subepidermal moisture scanning is acceptable for patients and nurses. Building the evidence base for subepidermal moisture scanning and then addressing practical issues prior to implementation, are important next steps. Our research suggests that subepidermal moisture scanning enhances individualized and patient-centred care, persuasive reasons to continue investigating subepidermal moisture scanning.

IMPACT

For an intervention to be successfully implemented it must be both effective and acceptable, however, there is limited evidence of patients' and nurses' views of SEMS acceptability. SEM scanners are acceptable to use in practice for patients and nurses. There are many procedural aspects that need to be considered when using SEMS such as frequency of measurements. This research may have benefit for patients, as SEMS may promote a more individualized and patient-centred approach to pressure injury prevention. Further, these findings can assist researchers, providing justification to proceed with effectiveness research.

PATIENT OR PUBLIC CONTRIBUTION

A consumer advisor was involved in study design, interpretation of data and preparation of manuscript.

Consumer perceptions on privacy and confidentiality in dermatology for 3D total-body imaging

As 3D total-body photography for the early detection of melanoma is not yet widely used in clinical practice, we do not have a full understanding of patient's concerns about use, privacy and confidentiality, and if their concerns differ depending on the use-case. We conducted a virtual consumer forum to assess patients concerns about privacy and confidentiality in dermatology imaging for research, artificial intelligence development and for their own clinical care.

Patient and Health Care Professional Perspectives on Stigma in Integrated Behavioral Health: Barriers and Recommendations

PURPOSE

Stigma related to mental health is well documented and a major barrier to using mental and physical health care. Integrated behavioral health (IBH) in primary care, in which behavioral/mental health care services are located within a primary care setting, may reduce the experience of stigma. The purpose of this study was to assess the opinions of patients and health care professionals about mental illness stigma as a barrier to engagement with IBH and to gain insight into strategies to reduce stigma, encourage discussion of mental health, and increase uptake of IBH care.

METHODS

We conducted semistructured interviews with 16 patients referred to IBH in a prior year and 15 health care professionals (12 primary care physicians and 3 psychologists). Interviews were transcribed and inductively coded separately by 2 coders for common themes and subthemes under the topic headings of barriers, facilitators, and recommendations.

RESULTS

We identified 10 converging themes from interviews with patients and the health care professionals, representing important complementary perspectives, with respect to barriers, facilitators, and recommendations. Barriers included professionals, families, and the public as sources of stigma, as well as self-stigma or avoidance, or internalizing negative stereotypes. Facilitators and recommendations included normalizing discussion of mental health and mental health care-seeking action, using patient-centered and empathetic communication strategies, sharing by health care professionals of their own experiences, and tailoring the discussion of mental health to patients' preferred understanding.

CONCLUSIONS

Health care professionals can help reduce perceptions of stigma by having conversations with patients that normalize mental health discussion, use patient-centered communication, promote professional self-disclosure, and are tailored to patients' preferred understanding.

Institutional disrespect and abuse during health-care utilization in public health facilities of Tamil Nadu: A facility-based cross-sectional survey

Background

Disrespect and abuse have a negative impact on the quality of care provided in the public health facilities, thereby impacting the public health-care utilization of the patients.

Objectives

This study aims to capture the burden and determinants of disrespect and abuse faced by the patients who seek care from public health facilities in Tamil Nadu.

Methods

This study was conducted among 4917 participants at outpatient and inpatient levels in 18 public health facilities across six districts in Tamil Nadu. Institutional disrespect and abuse were reported as proportion with 95% confidence interval (CI). Logistic regression model was done to assess the determinants of institutional disrespect and abuse.

Results

Overall, the proportion of participants facing some form of institutional disrespect and abuse was 9.8% (95% CI: 9.0%-10.6%). Elderly patients (≥60 years) (adjusted odds ratio [aOR] = 2.71; 95% CI: 1.27-5.76), widowed/separated/divorced (aOR = 1.99; 95% CI: 1.11-3.57), patients with higher educational qualification (aOR = 1.82; 95% CI: 1.25-2.64), patients belonging to the richest quintile in terms of socioeconomic status (aOR = 4.96; 95% CI: 3.59-6.84), and patients having some form of chronic disease (aOR = 1.37; 95% CI: 1.07-1.75) had significantly higher odds of facing institutional disrespect and abuse.

Conclusion

Almost one in ten patients visiting secondary and tertiary care public health facilities in Tamil Nadu had faced some form of disrespect during their hospital visit/stay. The findings from our study should be taken up and further qualitative exploration to identify the reasons for such disrespectful care and corrective solutions should be suggested.

Adherence to colorectal cancer screening and healthcare resource utilization: a longitudinal analysis in Medicare beneficiaries aged 66-75 years

OBJECTIVE

In this study, we examined colorectal cancer (CRC) screening adherence in Medicare beneficiaries and associated healthcare resource utilization (HCRU) and Medicare costs.

METHODS

Using 20% Medicare random sample data, the study population included Medicare fee-for-service beneficiaries aged 66-75 years on 1 January 2009, at average risk for CRC and continuously enrolled in Medicare Part A/B from 2008 to 2018. We excluded those who had undergone colonoscopy or flexible sigmoidoscopy during 2007-2008 and assumed everyone was due for screening in 2009; screening patterns were determined for 2009-2018. Based on US Preventive Services Task Force recommendations, individuals were categorized as adherent to screening, inadequately screened or not screened. HCRU and Medicare costs were calculated as mean per patient per year (PPPY).

RESULTS

Of 895,846 eligible individuals, 13.2% were adherent to screening, 53.4% were inadequately screened, and 33.4% were not screened. Compared with those not screened, adherent or inadequately screened individuals were more likely to be female, White and have comorbidities. These individuals also used more healthcare services, generating higher Medicare costs. For example, physician visits were 14.6, 22.9 and 25.9 PPPY and total Medicare costs were $6102, $8469 and $9102 PPPY for those not screened, inadequately screened and adherent, respectively.

CONCLUSIONS

In Medicare beneficiaries at average risk, adherence to CRC screening was low, although the rate might be underestimated due to lack of early Medicare data. The link between HCRU and screening status suggests that screening initiatives independent of clinical visits may be needed to reach unscreened or inadequately screened individuals.

How to make services adolescent friendly? A cross-sectional study on awareness of adolescent friendly health clinics in Central India

Background

India's flagship program on adolescent health - Rashtriya Kishor Swasthya Karyakram (RKSK) emphasises the importance of strengthening Adolescent Friendly Health Clinics (AFHCs) under its facility-based approach for improving the health of adolescents. AFHCs are intended to provide targeted intervention in six domains - nutrition, injuries & violence (including gender-based violence), mental health, sexual & reproductive health, substance abuse and noncommunicable diseases.

Objective

The current study was conducted to assess the determinants of awareness and utilisation of AFHC services in districts with RKSK services in Madhya Pradesh.

Subjects

In total, 1605 adolescents (both males and females) within the age group of 10-19 years were included in the study.

Methods

Multistage stratified random sampling was employed to enrol participants from three districts of Madhya Pradesh, where AFHC services have been launched.

Results

The mean age of the participants was 15.07 ± 2.32 years. Only 153 (9.5%) adolescents were aware of AFHC services. On multivariate logistic regression, awareness of AFHC was seen to be associated with being aware of RKSK, being a part of the peer educator-led peer group, having had adolescent health days organised in the village and belonging from one of the financially better off districts. Utilisation rate of AFHC services was lower still - at 2.74%.

Conclusion

Both awareness and utilisation of AFHC services remain very low among adolescents. There is a pressing need to focus on awareness generation campaigns - via mass media, but more importantly, through community health workers and peer educators - in order to sensitise target beneficiaries about the available services.

Preferences and User Experiences of Wearable Devices in Epilepsy: A Systematic Review and Mixed-Methods Synthesis

BACKGROUND AND OBJECTIVES

To examine the preferences and user experiences of people with epilepsy and caregivers regarding automated wearable seizure detection devices.

METHODS

We performed a mixed-methods systematic review. We searched electronic databases for original peer-reviewed publications between January 1, 2000, and May 26, 2021. Key search terms included "epilepsy", "seizure", "wearable", and "non-invasive". We performed a descriptive and a qualitative thematic analysis of the studies included according to the technology acceptance model. Full texts of the discussion sections were further analyzed to identify word frequency and word mapping.

RESULTS

Twenty-two observational studies were identified. Collectively, they comprised responses from 3299 participants including patients with epilepsy, caregivers and healthcare workers. Sixteen studies examined user preferences, five examined user experiences, and one examined both experiences and preferences. Important preferences for wearables included improving care, cost, accuracy, and design. Patients desired real-time detection with a latency of ≤15 minutes from seizure occurrence, along with high sensitivity (≥90%) and low false-alarm rates. Device related costs were a major factor for device acceptance, where device costs of <$300 USD and a monthly subscription fee of <$20 USD were preferred. Despite being a major driver of wearable-based technologies, sudden unexpected death in epilepsy (SUDEP) was rarely discussed. Among studies evaluating user experiences, there was a greater acceptance towards wristwatches. Thematic coding analysis showed that attitudes towards device use, and perceived usefulness were reported consistently. Word mapping identified 'specificity', 'cost', and 'battery' as key single terms, and 'battery life', 'insurance coverage', 'prediction/detection quality', and the effect of devices on 'daily life' as key bigrams.

DISCUSSION

User acceptance of wearable technology for seizure detection was strongly influenced by accuracy, design, comfort, and cost. Our findings emphasise the need for standardised and validated tools to comprehensively examine preferences and user experiences of wearable devices in this population, using the themes identified in this study. Greater efforts to incorporate perspectives and user experiences in developing wearables for seizure detection, particularly in community-based settings are needed.

PROSPERO REGISTRATION

CRD42020193565.

Contact patterns and costs of multiple sclerosis in the Swedish healthcare system-A population-based quantitative study

BACKGROUND

The burden of disease for persons with multiple sclerosis (MS) and society is changing due to new treatments. Knowledge about the total need for care is necessary in relation to changing needs and new service models.

OBJECTIVE

The aim of this study was to describe the contact patterns for MS patients, calculate costs in health care, and create meaningful subgroups to analyze contact patterns.

METHODS

All patients diagnosed with MS at Ryhov Hospital were included. All contacts in the region from January 1, 2018, until September 30, 2019, were retrieved from the hospital administrative system. Data about age, sex, contacts, and diagnosis were registered. The cost was calculated using case costing, and costs for prescriptions were calculated from medical files.

RESULTS

During the 21-month period, patients (n = 305) had 9628 contacts and 7471 physical visits, with a total cost of $7,766,109. Seventeen percent of the patients accounted for 48% of the visits. The median annual cost was $7386 in the group with 10 or fewer visits, compared to $22,491 in patients with more than 50 visits.

CONCLUSION

There are considerable differences in the utilization of care and cost between patients with MS in an unselected population, meaning that the care needs to be better customized to each patient's demands.

Transforming Motivation for Exercise in a Safe and Kind Environment-A Qualitative Study of Experiences among Individuals with Type 2 Diabetes

Exercise is a cornerstone in diabetes care; however, adherence is low and sustaining physical activity remains a challenge. Patient-centered diabetes self-management education and support are recommended; however, sparse literature exists on how to design exercise interventions that improve self-management in individuals with complications of type 2 diabetes mellitus (T2D). We aimed to gain insights into needs, barriers, and motivation based on experiences with exercise participation among individuals with T2D and complications to adjust and develop new types of tailored, supervised exercise classes in specialized care at three hospitals in Denmark. In keeping with a constructivist research paradigm, a qualitative hermeneutic approach using focus group interviews was applied to explore perspectives among different participants in terms of disease severity. Seven interviews with 30 participants (aged 49–88) representing seven different exercise classes, were conducted over three years. Reflective thematic analysis was used. Four themes were generated: People like us, Getting started with exercise, Game changers, and Moving forward. An overarching theme ‘The transformation of motivation when exercising in a safe and kind environment’ links the themes together, resembling the participants’ development of physical literacy encompassing motivation, confidence, physical competence as well as an ability to value physical activity. Supportive patient-centered exercise classes promoted a transformation of motivation grounded in the development of physical literacy among participants in specialized diabetes care. However, participants were concerned with continuing to exercise on their own after the intervention, as they experienced a lack of continuous, supervised exercise opportunities in local communities.

Culturally safe interventions in primary care for the management of chronic diseases of urban Indigenous People: a scoping review

Objectives

Chronic conditions represent an important source of major health issues among Indigenous People. The same applies to those, who live off-reserve and in urban areas. However, very few healthcare services are considered culturally safe, resulting in some avoidance of the public healthcare system. Our goal was to review the literature on culturally safe practices available to urban Indigenous People who suffer from chronic diseases.

Design

We conducted a scoping review to determine what culturally safe healthcare services are currently offered for the management of chronic conditions in urban Indigenous populations, to contribute to a tailored, holistic and safe space in mainstream healthcare systems.

Eligibility criteria

Peer-reviewed original research articles had to be published by 27 October 2020, in English or French.

Information source: In October 2020, we searched five academic databases (EBSCO, PsycArticles, SocINDEX, MEDLINE and PsycINFO) and also reviewed grey literature and the websites of organisations or governments. The data were extracted and collected in an EXCEL spreadsheet. Two reviewers independently screened 326 titles and abstracts, followed by an independent evaluation of 48 full text articles. A total of 19 studies were included in this scoping review, as well as 5 websites/documents from the grey literature.

Results

In total, 19 studies were included in our analysis. We found that Elders, family and the assistance of an interpreter are crucial elements to include to make urban Indigenous feel safe when they seek healthcare services. With this scoping review, we report interventions that are successful in terms of healthcare delivery for this population. Our findings provide insight on what services should be in place in mainstream healthcare settings to create a culturally safe experience for urban Indigenous People.

Conclusions

In recent years, there appears to be a growing awareness of the need to provide culturally safe health services. This scoping review identified multiple strategies to promote cultural safety in this context, as well as barriers and facilitators to their implementation. These elements, which have been extensively documented in the literature, should be included in the chronic diseases management interventions to be developed by urban and primary care settings.

Comparing the Acceptance of Mobile Hypertension Apps for Disease Management Among Patients Versus Clinical Use Among Physicians: Cross-sectional Survey

Background

High blood pressure or hypertension is a vastly prevalent chronic condition among adults that can, if not appropriately treated, contribute to several life-threatening secondary diseases and events, such as stroke. In addition to first-line medication, self-management in daily life is crucial for tertiary prevention and can be supported by mobile health apps, including medication reminders. However, the prescription of medical apps is a relatively novel approach. There is limited information regarding the determinants of acceptance of such mobile health (mHealth) apps among patients as potential users and physicians as impending prescribers in direct comparison.

Objective

The present study aims to investigate the determinants of the acceptance of health apps (in terms of intention to use) among patients for personal use and physicians for clinical use in German-speaking countries. Moreover, we assessed patients’ preferences regarding different delivery modes for self-care service (face-to-face services, apps, etc).

Methods

Based on an extended model of the unified theory of acceptance and use of technology (UTAUT2), we performed a web-based cross-sectional survey to explore the acceptance of mHealth apps for self-management of hypertension among patients and physicians in Germany. In addition to UTAUT2 variables, we measured self-reported self-efficacy, eHealth literacy, previous experiences with health apps, perceived threat to privacy, and protection motivation as additional determinants of mHealth acceptance. Data from 163 patients and 46 physicians were analyzed using hierarchical regression and mediation analyses.

Results

As expected, a significant influence of the unified theory of acceptance and use of technology (UTAUT) predictors on intentions to use hypertension apps was confirmed, especially for performance expectancy. Intention to use was moderate in patients (mean 3.5; SD 1.1; range 1-5) and physicians (mean 3.4, SD 0.9), and did not differ between both groups. Among patients, a higher degree of self-reported self-efficacy and protection motivation contributed to an increased explained variance in acceptance with R²=0.09, whereas eHealth literacy was identified as exerting a positive influence on physicians (increased R²=0.10). Furthermore, our findings indicated mediating effects of performance expectancy on the acceptance among patients but not among physicians.

Conclusions

In summary, this study has identified performance expectancy as the most important determinant of the acceptance of mHealth apps for self-management of hypertension among patients and physicians. Concerning patients, we also identified mediating effects of performance expectancy on the relationships between effort expectancy and social influence and the acceptance of apps. Self-efficacy and protection motivation also contributed to an increase in the explained variance in app acceptance among patients, whereas eHealth literacy was a predictor in physicians. Our findings on additional determinants of the acceptance of health apps may help tailor educational material and self-management interventions to the needs and preferences of prospective users of hypertension apps in future research.

Patterns and barriers of mental health service utilization among medical students: a cross-sectional study

Background

The prevalence of mental health problems among medical students has been steadily rising. It is greater than the prevalence of mental health problems among other students, negatively impacting students, and their future careers. The study aims to estimate the prevalence of the self-reported need for mental health care, the pattern of utilization of mental health services, and the different barriers that hinder medical students from seeking professional help.

Results

This study was conducted among medical students at Mansoura University, using a structured self-reported online questionnaire to collect the need for mental health services, sociodemographic details, the pattern of utilization of mental health services, and the barriers using a Likert scale of 30 items named Barriers to Access to Care Evaluation Version 3. According to this study, 77.77% felt the need for mental health care. The independent predictors for feeling the need for mental health care were female sex and urban residence with an adjusted odds ratio of 2.7 and 1.9, respectively. Regarding mental healthcare needs, most of the barriers were instrumental and attitudinal related. Lack of information about how to access services and solve the problem by themselves was the most common barriers followed by time and financial affords.

Conclusions

It appears that Mansoura medical students are at higher risk of feeling the need for mental care. Considerable barriers to help-seeking remain prevalent, including both logistical (e.g., time) and informational (e.g., lack of knowledge about the available services).

Safety and Acceptability of a Natural Language Artificial Intelligence Assistant to Deliver Clinical Follow-up to Cataract Surgery Patients: Proposal

Background

Due to an aging population, the demand for many services is exceeding the capacity of the clinical workforce. As a result, staff are facing a crisis of burnout from being pressured to deliver high-volume workloads, driving increasing costs for providers. Artificial intelligence (AI), in the form of conversational agents, presents a possible opportunity to enable efficiency in the delivery of care.

Objective

This study aims to evaluate the effectiveness, usability, and acceptability of Dora agent: Ufonia’s autonomous voice conversational agent, an AI-enabled autonomous telemedicine call for the detection of postoperative cataract surgery patients who require further assessment. The objectives of this study are to establish Dora’s efficacy in comparison with an expert clinician, determine baseline sensitivity and specificity for the detection of true complications, evaluate patient acceptability, collect evidence for cost-effectiveness, and capture data to support further development and evaluation.

Methods

Using an implementation science construct, the interdisciplinary study will be a mixed methods phase 1 pilot establishing interobserver reliability of the system, usability, and acceptability. This will be done using the following scales and frameworks: the system usability scale; assessment of Health Information Technology Interventions in Evidence-Based Medicine Evaluation Framework; the telehealth usability questionnaire; and the Non-Adoption, Abandonment, and Challenges to the Scale-up, Spread and Suitability framework.

Results

The evaluation is expected to show that conversational technology can be used to conduct an accurate assessment and that it is acceptable to different populations with different backgrounds. In addition, the results will demonstrate how successfully the system can be delivered in organizations with different clinical pathways and how it can be integrated with their existing platforms.

Conclusions

The project’s key contributions will be evidence of the effectiveness of AI voice conversational agents and their associated usability and acceptability.

International Registered Report Identifier (IRRID)

PRR1-10.2196/27227

Feasibility, Efficacy, and Efficiency of eHealth-Supported Pediatric Asthma Care: Six-Month Quasi-Experimental Single-Arm Pretest-Posttest Study

BACKGROUND

Early detection of loss of asthma control can effectively reduce the burden of the disease. However, broad implementation in clinical practice has not been accomplished so far. We are in need of research investigating the operationalization of eHealth pediatric asthma care in practice, which can provide the most potential benefits in terms of adoption, efficiency, and effectiveness.

OBJECTIVE

The aim of this study was to investigate the technical and clinical feasibility, including an exploration of the efficacy and cost-efficiency, of an eHealth program implemented in daily clinical pediatric asthma practice.

METHODS

We designed an eHealth-supported pediatric asthma program facilitating early detection of loss of asthma control while increasing symptom awareness and self-management. In the 6-month program, asthma control was monitored by 4 health care professionals (HCPs) by using objective home measurements and the web-based Puffer app to allow timely medical anticipation and prevent treatment delay. Technical feasibility was assessed by technology use, system usability, and technology acceptance. Clinical feasibility was assessed by participation and patient-reported health and care outcomes and via a focus group with HCPs regarding their experiences of implementing eHealth in daily practice. The efficacy and cost-efficiency were explored by comparing pretest-posttest program differences in asthma outcomes (asthma control, lung function, and therapy adherence) and medical consumption.

RESULTS

Of 41 children, 35 children with moderate-to-severe asthma volunteered for participation. With regard to technical feasibility, the Puffer app scored a good usability score of 78 on the System Usability Scale and a score of 70 for technology acceptance on a scale of 1 to 100. Approximately 75% (18/24) of the children indicated that eHealth helped them to control their asthma during the program. HCPs indicated that home measurements and real time communication enabled them to make safe and substantiated medical decisions during symptom manifestations. With an average time commitment of 15 minutes by patients, eHealth care led to a 80% gross reduction (from €71,784 to €14,018, US $1=€0.85) in health care utilization, 8.6% increase (from 18.6 to 20.2, P=.40) in asthma control, 25.0% increase (from 2.8 to 3.5, P=.04) in the self-management level, and 20.4% improved (from 71.2 to 76.8, P=.02) therapy adherence.

CONCLUSIONS

eHealth asthma care seems to be technically and clinically feasible, enables safe remote care, and seems to be beneficial for pediatric asthma care in terms of health outcomes and health care utilization. Follow-up research should focus on targeted effectiveness studies with the lessons learned, while also enabling individualization of eHealth for personalized health care.

A Telehealth Initiative to Overcome Health Care Barriers for People Experiencing Homelessness

People experiencing homelessness (PEH) encounter barriers to health care, increasing their vulnerability to illness, hospitalization, and death. Telehealth can improve access to health care, but its use in PEH has been insufficiently evaluated. Needs assessment surveys completed by clients at an urban drop-in center for PEH (n = 63) showed mental (58.7%) and physical (52.4%) health challenges were common, as was emergency department (ED) use (75.9%, n = 54). Surveys collected after in-person and telehealth clinical visits showed patient satisfaction was >90% for both visit types (n = 125, 44.0% telehealth and 56.0% in person). Without access to telehealth visits, 29.1% of patients would have gone to the ED and 38.2% would not have gotten care. Providers (n = 93, 69.6% telehealth and 30.4% in person) were more likely to agree/strongly agree they made a positive impact on patients' health through telehealth (92.2%) than in person (71.4%) (p = 0.019). Telehealth is a feasible and potentially cost-effective method to increase access to health care and reduce health outcome disparities in PEH.

Independent Use of a Home-Based Telemonitoring App by Older Patients With Multimorbidity and Mild Cognitive Impairment: Qualitative Study

Background

The management of multimorbidity is complex and patients have a high burden of disease. When symptoms of dementia also appear, it becomes even more difficult for patients to cope with their everyday lives and manage their diseases. Home-based telemonitoring may support older patients with multimorbidity and mild cognitive impairment (MCI) in their regular monitoring and self-management. However, to date, there has been no investigation into whether patients with MCI are able to operate a telemonitoring app independently to manage their own diseases. This question has become even more important during the current COVID-19 pandemic to maintain high-quality medical care for this patient group.

Objective

We examined the following research questions: (1) How do patients with MCI assess the usability of the telemonitoring app? (2) How do patients with MCI assess the range of functions offered by the telemonitoring app? (3) Was there an additional benefit for the patients with MCI in using the telemonitoring app? (4) Were patients with MCI able to use the telemonitoring app independently and without restrictions? (5) To what extent does previous experience with smartphones, tablets, or computers influence the perceived ease of use of the telemonitoring app?

Methods

We performed a formative evaluation of a telemonitoring app. Therefore, we carried out a qualitative study and conducted guided interviews. All interviews were audio-recorded, transcribed verbatim, and analyzed using the Mayring method of structured content analysis.

Results

Twelve patients (8 women, 4 men) were interviewed; they had an average age of 78.7 years (SD 5.6) and an average Mini-Mental State Examination score of 24.5 (SD 1.6). The interviews lasted between 17 and 75 minutes (mean 41.8 minutes, SD 19.4). Nine patients reported that the telemonitoring app was easy to use. All respondents assessed the range of functions as good or adequate. Desired functionalities mainly included more innovative and varied educational material, better fit of the telemonitoring app for specific needs of patients with MCI, and a more individually tailored content. Ten of the 12 patients stated that the telemonitoring app had an additional benefit for them. Most frequently reported benefits included increased feeling of security, appreciation of regular monitoring of vital parameters, and increased independence due to telemonitoring. Eight patients were able to operate the app independently. Participants found the app easy to use regardless of whether they had prior experience with smartphones, tablets, or computers.

Conclusions

The majority of examined patients with MCI were capable of operating the telemonitoring app independently. Crucial components in attaining independent use were comprehensive personal support from the start of use and appropriate design features. This study provides initial evidence that patients with MCI could increasingly be considered as a relevant user group of telemonitoring apps.

Acceptability and adoption of clinical practice guidelines and treatment protocols on preeclampsia/eclampsia in the Dominican Republic

Objective

Estimate the acceptability and adoption by health care workers of clinical practice guidelines and treatment protocols for women with preeclampsia/eclampsia and identify the facilitating factors and barriers to their implementation.

Methods

A qualitative study was conducted, using semi-structured interviews and focus groups in five maternity hospitals. Interviews were compiled for analysis, and barriers and facilitators were characterized.

Results

Seventy health professionals (52 female and 18 male) participated, representing different levels of the health system. The majority of workers and managers were aware of the existence and content of clinical practice guidelines (CPGs) for preeclampsia/eclampsia, especially the participants with more time in the health service. With respect to facilitating factors, both medical and nursing staff were positive about continued development and implementation of high-quality CPGs. There was consensus that limitations exist, especially with respect to a lack of the necessary medicines, supplies, and equipment to meet and implement the established recommendations.

Discussion

The results of the study show the need to strengthen strategies that help close the gap between research and public policy. Studies suggest that research should focus on users, policymakers, and decisionmakers in the health system. The actors in the Dominican health system recognize the GRADE methodology as an appropriate instrument for the development and implementation of CPGs. Implementation barriers require systemic and comprehensive approaches.

Acceptability of dual HIV/syphilis rapid test in community- and home-based testing strategy among transgender women in Buenos Aires, Argentina

BACKGROUND

Little is known of acceptability and feasibility of dual HIV and syphilis rapid tests in community- and home-based provider-initiated strategies among transgender women (TGW), in Latin America. Objectives were (1) to assess the acceptability of this strategy and, (2) to determine the percentage of positive results of HIV and syphilis, analyze the correlates of HIV or syphilis positive results, and measure the rates of effective referral and treatment completion among TGW.

METHODS

A multidisciplinary team tested 89 TGW in Buenos Aires. An acceptability survey was administered after the HIV/syphilis Duo test was used. All confirmed cases were referred for treatment initiation.

RESULTS

We found high levels of acceptability (98.8%) of this strategy among TGW. However, only 60.7% preferred simultaneous HIV and syphilis diagnosis test. Moreover, we found 9% of positive results of HIV, 51.7% of syphilis, and 3.4% of positive results for both infections. Only not being tested before was associated with an HIV positive result, and only low level of education was associated with a positive syphilis result. Among 8 TGW who tested positive for HIV, 37.5% (n = 3) started antiretroviral therapy. Of 46 who tested positive for syphilis, only 73.9% (n = 34) were effectively referred and from 23 who started treatment, only 39.1% completed it.

CONCLUSIONS

Community- and home-based dual HIV and syphilis rapid test is a feasible and highly acceptable approach for this hard-to-reach population. Implementing similar strategies could improve screening uptake and accessibility. However, these results highlight the need to improve strategies for treatment uptake, in order to reduce morbidity and risk of onward transmission.

Shortening "the Road" to Improve Engagement with HIV Testing Resources: A Qualitative Study Among Stakeholders in Rural Uganda

In HIV-endemic areas, traditional healers are frequently used with, or instead of, biomedical resources for health care needs. Studies show healers are interested in and capable of supporting patients in the HIV care cascade. However, adults who receive care from healers have low engagement with HIV services. To achieve epidemic control, we must understand gaps between the needs of HIV-endemic communities and the potential for healers to improve HIV service uptake. This study's objective was to characterize stakeholder perspectives on barriers to HIV testing and approaches to mitigate barriers in a medically pluralistic, HIV-endemic region. This study was conducted in Mbarara District, a rural area of southwestern Uganda with high HIV prevalence. Participants included HIV clinical staff, traditional healers, and adults receiving care from healers. Fifty-six participants [N = 30 females (52%), median age 40 years (interquartile range, 32-51.5)] were recruited across three stakeholder groups for minimally structured interviews. Themes were identified using an inductive, grounded theory approach and linked together to create a framework explaining stakeholder perspectives on HIV testing. Stakeholders described the "road" to HIV testing as time-consuming, expensive, and stigmatizing. All agreed healers could mitigate barriers by delivering HIV testing at their practices. Collaborations between biomedical and traditional providers were considered essential to a successful healer-delivered HIV testing program. This work describes a novel approach to "shorten the road" to HIV testing, suggesting that traditional healer-delivered HIV testing holds promise to expand uptake of testing among communities with limited access to existing programs.

Problem recognition and treatment beliefs relate to mental health utilization among veteran primary care patients

Mental health concerns are prevalent among primary care patients, but many do not utilize services for these conditions. This study aims to conduct a comprehensive assessment of barriers and facilitators to mental health care utilization among veteran primary care patients with common mental health concerns. We hypothesized that beliefs and knowledge about mental illness and mental health care would be more strongly associated with recent mental health care utilization than stigma, help-seeking behaviors, or logistical barriers. Veterans (n = 116) enrolled in primary care with current symptoms of depression (58%), posttraumatic stress disorder (37%), and/or hazardous alcohol use (50%) who either recently used mental health services (47%) or had no recent mental health treatment utilization (53%) completed a telephone-based screening, medical records review, and mail survey of 10 measures of barriers and facilitators to mental health treatment utilization. Recognition of problems as a cause for concern, odds ratio = 5.95, 95% confidence interval [2.36, 15.01], and beliefs about psychotherapy, odds ratio = 2.53, 95% confidence interval [1.39, 4.60], emerged as stronger correlates of recent mental health care utilization than stigma, self-efficacy, and external barriers to treatment. Results suggest the use of specific theories, measures, and interventions that focus on patient recognition of problems and beliefs about treatment over those that focus on other treatment barriers and facilitators. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A cross-sectional study of socioeconomic status and treatment interruption among Japanese workers during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic has caused interruptions to chronic disease and non-emergency treatment. The purpose of this study is to examine which socioeconomic status groups are most at risk of treatment interruption among Japanese workers.

METHODS

This cross-sectional internet monitor study was conducted among Japanese workers on December 22-26, 2020. Out of a total of 33 302 participants in the survey, 9510 (5392 males and 4118 females) who responded that they required regular treatment or hospital visits were included in the analysis. A multilevel logistic model nested in the prefecture of residence was used to estimate the odds ratio (OR) for treatment disruption. We examined separate multivariate models for socioeconomic factors, health factors, and lifestyle factors.

RESULTS

During a period of rapid COVID-19 infection, about 11% of Japanese workers who required regular treatment experienced interruptions to their treatment. The OR of treatment interruption associated with not being married compared with being married was 1.44 (95%CI: 1.17-1.76); manual labor work compared with desk work was 1.30 (95%CI: 1.11-1.52); loss of employment when the COVID-19 pandemic started and continued unemployment compared with being employed over the entire pandemic period was 1.62 (95%CI: 1.13-2.31) and 2.57 (95%CI: 1.63-4.07), respectively; and feeling financially unstable was 2.92 (95%CI: 2.25-3.80).

CONCLUSION

Treatment interruption is a new health inequality brought about by COVID-19 with possible medium- and long-term effects, including excess mortality, morbidity, and productivity loss due to increased presenteeism. Efforts are needed to reduce treatment interruptions among workers who require regular treatment.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs

BACKGROUND

The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.

OBJECTIVE

The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.

DESIGN

Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.

PARTICIPANTS

We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.

APPROACH

Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.

KEY RESULTS

Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.

CONCLUSIONS

Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

[Acceptability and adoption of clinical practice guidelines and treatment protocols on preeclampsia/eclampsia in the Dominican RepublicAceitabilidade e adoção de diretrizes de prática clínica e protocolos de atenção para pré-eclâmpsia e eclâmpsia na República Dominicana]

Objetivo.

Estimar la aceptabilidad y adopción de las guías de prática clínica (GPC) y protocolos de atención a la mujer con preeclampsia-eclampsia por parte del personal prestador de los servicios de salud, e identificar los factores facilitadores y las barreras para su implementación.

Métodos.

Se desarrolló un estudio cualitativo por medio de entrevistas semiestructuradas y grupos focales en cinco maternidades. Se recopilaron las entrevistas para su análisis y se caracterizaron las barreras y facilitadores.

Resultados.

Participaron 70 profesionales de la salud (52 de sexo femenino y 18 de sexo masculino) que se desempeñan en distintos niveles del sistema de salud, participaron. La mayoría de los prestadores y gerentes conocen la existencia de las GPC de eclampsia-preeclampsia y su contenido, sobre todo los participantes con más tiempo en el servicio. Para los facilitadores, se estableció una valoración positiva entre el personal médico y de enfermería ante el proceso de continuar con la elaboración e implementación de GPC de alta calidad. Hubo consenso en cuanto a la existencia de limitaciones, sobre todo, por la falta de medicamentos, insumos y equipos requeridos, para cumplir y aplicar las recomendaciones formuladas.

Discusión.

Los resultados del estudio exponen la necesidad de fortalecer estrategias que ayuden a cerrar la brecha entre la investigación y la política pública. Estudios fundamentan la investigación en priorizar la atención a los usuarios, y los encargados de formular políticas y los tomadores de decisiones en el sistema de salud. Los actores del sistema de salud dominicano reconocen la metodología GRADE como un instrumento apropiado para la formulación e implementación de GPC. Las barreras de implementación requieren de abordajes sistémicos e integrales.

Fear-Based Barriers to Care in the COVID-19 Pandemic

Description COVID-19 has made patients afraid to engage with providers in-person to manage acute, chronic and preventive non-COVID-related health care needs. As health care providers, we must continue to do everything within our power to address our patients' fear of our infrastructure and the increasing barriers they are experiencing to accessing the care that they need.

Acceptance Study on the Usage of Health-Enabling Technologies in Therapy and Diagnostics for People with Mental Disorders

Mental disorders are widespread among the world's population and place a high burden on both the people affected and the economy. In this area of health care and prevention major deficits can be found. Health-enabling technologies are being developed in order to provide support in the therapy and diagnostics of mental disorders. However, it is not clear whether patients are open to these technologies and what they expect from a suitable usage. The main goal of this study is to find out what opinions, hopes and fears mentally ill persons have towards a supporting treatment with health-enabling technologies. Personal interviews were conducted with psychiatric patients for that purpose. The evaluation of the interview data revealed a predominantly positive mindset of the participants. In addition to the general question according to the acceptance, requirements and expectations for the use of health-enabling technologies were acquired. In this context the concern of an invasion of privacy was exposed as a major barrier.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Patients and Professionals' Acceptability Study

Background

Integrated care (IC) can promote health and social care efficiency through prioritization of preventive patient-centered models and defragmentation of care and collaboration across health tiers, and mobile health (mHealth) can be the cornerstone allowing for the adoption of IC.

Objective

This study aims to assess the acceptability, usability, and satisfaction of an mHealth-enabled IC model for complex chronic patients in both patients and health professionals.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, 2-arm, parallel, hybrid effectiveness-implementation trial was conducted from July 2018 to August 2019 in a rural region of Catalonia, Spain. Home-dwelling patients 55 years and older with chronic conditions and a history of hospitalizations for chronic obstructive pulmonary disease or heart failure (use case [UC] 1), or a scheduled major elective hip or knee arthroplasty (UC2) were recruited. During the 3 months, patients experienced an mHealth-enabled IC model, including a self-management app for patients, a set of integrated sensors, and a web-based platform connecting professionals from different settings or usual care. The Person-Centered Coordinated Care Experience Questionnaire (P3CEQ) and the Nijmegen Continuity Questionnaire (NCQ) assessed person-centeredness and continuity of care. Acceptability was assessed for IC arm patients and staff with the Net Promoter Score (NPS) and the System Usability Scale (SUS).

Results

The analyses included 77 IC patients, 58 controls who completed the follow-up, and 30 health care professionals. The mean age was 78 (SD 9) years in both study arms. Perception of patient-centeredness was similarly high in both arms (usual care: mean P3CEQ score 16.1, SD 3.3; IC: mean P3CEQ score 16.3, SD 2.4). IC patients reported better continuity of care than controls (usual care: mean NCQ score 3.7, SD 0.9; IC: mean NCQ score 4.0, SD 1; P=.04). The scores for patient acceptability (UC1: NPS +67%; UC2: NPS +45%) and usability (UC1: mean SUS score 79, SD 14; UC2: mean SUS score 68, SD 24) were outstanding. Professionals’ acceptability was low (UC1: NPS −25%; UC2: NPS −35%), whereas usability was average (UC1: mean SUS score 63, SD 20; UC2: mean SUS score 62, SD 19). The actual use of technology was high; 77% (58/75) of patients reported physical activity for at least 60 days, and the ratio of times reported over times prescribed for other sensors ranged from 37% for oxygen saturation to 67% for weight.

Conclusions

The mHealth-enabled IC model showed outstanding results from the patients’ perspective in 2 different UCs but lacked maturity and integration with legacy systems to be fully accepted by professionals. This paper provides useful lessons learned through the development and assessment process and may be of use to organizations willing to develop or implement mHealth-enabled IC for older adults.

Patient satisfaction with dental treatment at a university dental clinic: A qualitative analysis

PURPOSE/OBJECTIVES

The aim for this study was to identify important factors influencing patient satisfaction in a university dental clinic, through qualitative analysis.

METHODS

From June 1, 2014 to January 30, 2018, 7827 patient satisfaction surveys were collected. A thematic analysis was conducted on the 10,956 patient responses to 3 open-ended questions. A thematic coding dictionary was inductively developed using thematic analysis managed with MAXQDA 2018 Standard, a qualitative data management software program.

RESULTS

The thematic dictionary included 12 categories, developed from 48 working codes, and enabled the patient annotations to be grouped and sorted based on common themes to highlight significant aspects of the patient experience. Four notable themes that emerged from patient comments include: (1) satisfaction with the emotional care felt during their appointments; (2) satisfaction with skills and treatment provided and the connections made with various personnel; (3) the importance of establishing and maintaining patient expectations throughout their care; and (4) the high value patients place on clear communication with the patient, as well as the communication between departments, dental student and faculty, providers, and front desk.

CONCLUSION

The results of this study highlight 12 key themes related to the patient experience at the College of Dentistry from the patients' perspective. These data provide insight into aspects of the dental experience that have a large effect on patient satisfaction. With this knowledge, steps can be taken to enhance the patient experience and, therefore, help dental schools move further in the direction of person-centered care.

Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy

Background

Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries’ rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high.

Objective

We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia).

Methods

We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization.

Results

Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants.

Conclusions

While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally.

How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation

Vaccine hesitancy occurs throughout the world and can result in poor vaccine uptake and vaccine-preventable disease-outbreaks. Vaccine hesitancy dates back to the days of Edward Jenner and the smallpox vaccine. It persists despite the preponderance of evidence supporting vaccine safety and effectiveness. Studies show even among parents of well-vaccinated children that 15–35% of those parents are vaccine-hesitant. Studies have failed to show the efficacy of educational interventions, and, indeed, a number of studies of educational interventions show a contrarian effect leaving the vaccine-hesitant more entrenched in their views. Still dozens of studies support health care provider recommendation as a major factor in achieving high rates of vaccine uptake. Furthermore, studies find those recommendations perceived as stronger are more effective than those perceived as weaker. What makes for a stronger recommendation? Several observational studies indicate that presumptive, announcement language as contrasted with participatory, conversational language makes for a stronger more effective recommendation. Several trials now demonstrate that health care providers and practices can implement this language and obtain higher vaccination uptake. The authors recommend the practice be adopted as a routine practice in the clinical setting for all vaccinations

Supporting holistic care for patients with tuberculosis in a remote Indigenous community: a case report

CONTEXT

Tuberculosis (TB) is a serious infectious disease with high rates of morbidity and mortality if left untreated. In Australia, TB has been virtually eradicated in non-Indigenous Australian-born populations but in remote Aboriginal and/or Torres Strait Islander communities TB presents a rare but significant public health issue. Remote health services are most likely to encounter patients with suspected and confirmed TB diagnosis but may be unprepared for supporting someone with this disease and the complexities of balancing public health risk with patient autonomy.

ISSUE

This case study will outline the process for diagnosis and treatment of a TB patient in a remote Cape York community. This case involved significant delay in diagnosis and required several strategies to achieve successful disease eradication. The process of treatment, however, had a significant effect on the patient's physical health, and social and emotional wellbeing.

LESSONS LEARNED

This case highlights the importance of early collaboration between medical, nursing, Indigenous health worker and allied health services and the importance of technology such as electronic information records to support opportunistic access to diagnostic services and treatment. The enactment of the TB protocol should include discussions about the consequences of any restrictions of movement, employment or social/community roles. Identifying alternative opportunities to engage in meaningful roles may reduce the impact the disease has on a patient's quality of life.

Adherence and acceptance of a home-based telemonitoring application used by multi-morbid patients aged 65 years and older

Introduction

Currently, there are only a small number of comprehensive study results on adherence and acceptance of telemonitoring applications (TMAs) regarding multi-morbid older patients. The ATMoSPHAERE study aimed to develop an information and communication platform for an intersectoral networking of, for example, general practitioners, therapists, social services and the multi-morbid older patient.

Methods

The study presented was designed as a longitudinal bicentric intervention study which focused on multi-morbid patients aged ≥65 years using home-based telemedical measurement and input devices. The development and testing of this TMA aimed to optimise patients’ health care through intersectoral networking of all treating actors. Quantitative methods of data collection and analysis were used.

Results

Patients who completed the study were significantly younger than drop-outs and non-participants. The mental health of study patients significantly improved between the beginning and end of TMA use. The main reason for non-participation in the study was the high time expenditure when participating in the study. No perceived (information) benefits for health and insufficient content variety were the main reasons for drop-out. Appropriateness and handling of TMAs must be aligned with the needs of the heterogeneous user group of multi-morbid patients in order to increase acceptance and the added value of TMAs. Telemonitoring hardware should be oriented on functional capabilities of the older target group. Telemonitoring software content requires an individual, disease-specific approach for patients. The TMA should be unobtrusively integrated into usual daily life and be used to an appropriate extent according to the underlying disease in order to avoid stressing patients. With regard to adherence concerning TMAs, it is crucial to provide a contact person who is always available for patients having problems handling TMAs. Health concerns and questions can thus be addressed early, providing a feeling of safety in the care process.

Discussion

User acceptance of TMAs is an essential indicator and driver for use and for future implementation efforts in health care. In order to achieve maximum user centricity in development processes, patients must be involved as experts, co-designers and future users, considering their needs and perceptions.

Risk Stratification and Factors Associated with Abandonment of Tuberculosis Treatment in a Secondary Referral Unit

PURPOSE

To study the factors associated with the risk of discontinuing active tuberculosis treatment among patients in an outpatient referral unit and to analyze the association between patients' abandonment risk score and their odds of discontinuing the treatment.

PATIENTS AND METHODS

In this cohort study, tuberculosis patients were prospectively followed up from June 2012 through July 2019 at a secondary tuberculosis referral unit in Mato Grosso do Sul, Brazil. At initial consultation, patients were interviewed using a standardized questionnaire and were assigned a score for the risk of treatment abandonment by the nurse. Univariate and multivariate analyses were performed using logistic regression.

RESULTS

One hundred and forty-eight patients were included in the study, of which 65.0% (96/148) were male. Their mean age was 43.3 ± 14.8 years (range: 18-89 years). Smoking, drug use, repeated admissions, and a high abandonment risk score were the variables associated with the highest risk of discontinuing the treatment. The rate of tuberculosis and human immunodeficiency virus coinfection was 37.2%. The overall rate of global treatment abandonment was 10.8% (95% confidence interval [CI]: 6.1-16.2). Upon stratification of patients that abandoned by the risk score, 22.9% (8/35) of the ones that abandoned had a high risk, 10.9% (6/55) had an intermediate risk, and 3.5% (2/58) had a low risk of treatment abandonment. In multivariate analysis, the factors associated with abandoning the treatment were smoking [adjusted odds ratio (aOR) = 4.91 (95% CI: 1.08, 22.32)] and undergoing retreatment (aOR) = 3.66 (95% CI: 1.04, 12 88).

CONCLUSION

Smoking and undergoing retreatment were independent risk factors for tuberculosis treatment abandonment in this center. Risk stratification can help prioritize the strengthening of treatment adherence among patients at higher risk of abandoning treatment in referral units.

A Pilot Study to Evaluate the Acceptability of Using a Smart Pillbox to Enhance Medication Adherence Among Primary Care Patients

Smart pillboxes that remind patients to take medication may help avoid unintended non-adherence to medication regimens. To better understand the implementation potential of smart pillboxes among patients with chronic diseases, this study aimed to explore patients’ acceptability to use such devices and its associated factors. Five-hundred primary care patients aged 40 years or older were randomly recruited from a government-funded primary care clinic in Hong Kong. Patients were asked (i) if they needed to take medication daily, (ii) how many daily oral medications they needed to take on average, (iii) if they had ever missed a dose by accident, and (iv) if they were willing to use a smart pillbox for free to remind them to take medication. Out of the 344 participants included in the analysis who needed to take daily oral medication, 49.1% reported having previously missed a dose by accident, and 70.6% were willing to use a smart pillbox for free. A multiple logistic regression model found that male patients (adjusted odds ratio (aOR): 0.59) and patients with hypertension (aOR: 0.56) were less likely to have previously missed a dose by accident. Patients who needed to take a greater number of daily medications (aOR: 1.16), who had previously missed a dose by accident (aOR: 2.44), with heart disease (aOR: 3.67) and with a high monthly income (aOR: 2.30) were more willing to use a smart pillbox, while older patients (aOR: 0.95) were less willing to do so. Primary care patients who reported missing a dose by accident were 2.4 times as likely to want to use a smart pillbox while those with heart disease were almost 4 times as likely to want to use a smart pillbox. Further studies such as those evaluating the willingness to pay for smart pillboxes and randomised control trials to evaluate the effectiveness of smart pillboxes in enhancing medication adherence should be conducted to provide more evidence about the implementation potential of such devices.