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Category: Cutting Edge Literature

Stop the Divide: Facilitators and Barriers to Uptake of Digital Health Interventions Among Socially Disadvantaged Populations

Price-Haywood EG, Arnold C, Harden-Barrios J, Davis T. Stop the Divide: Facilitators and Barriers to Uptake of Digital Health Interventions Among Socially Disadvantaged Populations. Ochsner J. Spring 2023;23(1):34-42. doi:10.31486/toj.22.0101

This qualitative study provided facilitators and barriers to implementing a new electronic patient portal (MyChart) in predominantly Black/African American and/or Medicaid-/Medicare-insured populations. MyChart is a portal accessible by mobile phone or computer with internet service. The program launched in Louisiana in 2020 and includes a digital medicine program that provides access to health coaches, clinical pharmacists, data from remote monitoring equipment, and appointment scheduling tools. For this study, 40 patients and 30 providers were surveyed about their experiences using the digital medicine platform. Participants described their access experience, attitudes, satisfaction, and challenges using health technology. Most patients were middle-aged, female, Black/African Americans who lived in urban areas and were insured by Medicaid. Most providers were young White male physicians who served predominantly Medicare/Medicaid-insured populations. Patients liked the consolidation of their health information, ease of appointment scheduling, medication refill requests, and medical advice messaging. As the mobile phone was the preferred access method, it is notable that most patients accessed these things successfully from their phones. Practitioners felt the largest barrier to implementation was the requirement to respond to too many messages, producing workload inefficiencies. While patients liked not traveling to clinics for visits, telemedicine visits were difficult on mobile phones. A lack of high-speed broadband access prevented some patients from engaging in telemedicine visits. Practitioners had concerns about video quality, safety when visits occurred in public spaces, like a car or workplace, and workflow issues around wait times. Most participants had positive views of using technology to help manage health. It remains critical to provide resources, like high-speed broadband access and digital navigators to push the digital health field forward in a sustainable way for patients and providers.

Implementation of a Youth Violence Prevention Programme in Primary Care

Roche JS, Philyaw-Kotov ML, Sigel E, et al. Implementation of a youth violence prevention programme in primary care. Inj Prev. Jun 2022;28(3):231-237. doi:10.1136/injuryprev-2021-044293

This study provides data from a pilot effectiveness-implementation trial of a violence prevention program for teenagers (SafERteens). SafERteens is a single-session violence prevention intervention conducted in the emergency department. Phase 1 of this study gathered feedback from medical providers, social workers, and administrators to identify key barriers and facilitators. This information was used to tailor training and implementation of a primary care version of SafERteens. In phase 2, clinic staff were trained, and the sample was recruited. In phase 3, maintenance aims were examined. In phase 1, the need for a single-session violence prevention intervention was affirmed by clinic staff. Feedback was used to adapt the toolkit and to determine appropriate staff to assist with screening tasks. Staff outside of the clinic were needed to administer screening and intervention implementation. In phase 2, training was administered, and follow-up calls were initiated weekly to workshop barriers to site-specific program delivery. In phase 3, reach, effectiveness, adoption, implementation, and maintenance were assessed. Most (86.6%) participants felt that SafERteens was useful, and said they would recommend the session to a peer. All sites that received a training session delivered the intervention using the altered web package. Intervention fidelity scores were high, with MI competence (measured by MITI-4) mean global ratings = 4.03. Staff indicated a desire to continue delivery of SafERteens at both local and university-associated youth clinics. Reductions in substance use consequences and non-partner severe aggression were maintained three months post single session.


Crossing the Digital Divide: A Content Analysis of Mainstream Australian Mental Health Websites for Languages Other Than English

Murray KE, Musumeci CJ, Cassidy E. Crossing the digital divide: A content analysis of mainstream Australian mental health websites for languages other than English. Health Soc Care Community 2022;30(6):e4831-e4839. doi:10.1111/hsc.13890

Online mental health services are an effective way to provide support while individuals wait for access to face-to-face therapeutic care. As the wait time for access to face-to-face mental health care increases, so too does the use of government-sponsored digital mental health platforms. The Australian government funds mental health websites to promote access to these online services. This article assessed the accessibility of these websites for non-English speaking/literate users. Of the thirty-three websites that provided access to mental health tools and educational materials, only four had translation options available. While non-English translation was available on four websites, only two displayed the translation option directly on the homepage. A search was required to access translation options on the other two websites. The authors also assessed websites for inclusion of content tailored to culturally and linguistically diverse (CALD) communities. A total of 1100 unique content subsections were found across the 33 websites. Eight subsections were specific to CALD communities and only 9 websites even mentioned CALD communities in relation to mental health. Overall, the authors suggest that digital mental health tools should strive to be more inclusive of language barriers in Australian populations.

An Emerging Framework for Digital Mental Health Design with Indigenous Young People: A Scoping Review of The Involvement of Indigenous Young People in The Design and Evaluation of Digital Mental Health Interventions

Povey J, Raphiphatthana B, Torok M, et al. An emerging framework for digital mental health design with Indigenous young people: a scoping review of the involvement of Indigenous young people in the design and evaluation of digital mental health interventions. Syst Rev 2023;12(1):108. doi:10.1186/s13643-023-02262-w

This scoping review provides an overview of the current literature on digital mental health interventions tailored for Indigenous young people. All analyzed research was conducted in the United States (n = 8), New Zealand (n = 6), Australia (n = 7), or Canada (n = 3). Primarily, studies were formative, design, and feasibility designs that used qualitative methods (58%). Pilot or efficacy studies using quantitative methods were less common (41%). To assess best practice processes all studies were scored using The Aboriginal and Torres Strait Islander QAT. These scores were used to develop an emerging framework for developing digital mental health resources with Indigenous young people. The first of the four principles of the framework is Indigenous governance. Including Indigenous leadership in all aspects of study design and developing interventions based on needs specifically identified by the community promoted engagement, better-tailored study processes, and improved overall project success. Engaging Indigenous youth through the iterative process of design, development, and review of informed adaptations to protocols increased recruitment, data quality, and acceptability. Studies using capacity-strengthening activities displayed higher engagement and more successful partnerships between researchers and Indigenous youth. It is important to note that agreements to protect existing or created Ingenious knowledges were rarely reported and are recommended for future research. While all studies reported initial benefits to the Indigenous communities, long-term sustainable changes were rarely reported. Future research developing digital mental health interventions tailored for Indigenous young people should include governance, tailor engagement strategies, foster partnerships, and plan for sustainable knowledge translation.


Digital Health Interventions for All? Examining Inclusivity Across All Stages of The Digital Health Intervention Research Process

Krukowski RA, Ross KM, Western MJ, et al. Digital health interventions for all? Examining inclusivity across all stages of the digital health intervention research process. Trials. 2024;25(1):98. doi:10.1186/s13063-024-07937-w

This article provides a commentary on the barriers and potential solutions for appropriately conducting digital health research in diverse populations. The article reiterates the importance of increasing diversity across all phases of research to prevent digital interventions from widening, rather than bridging existing health disparities. To have research that accurately represents the population, diverse samples need to be recruited. Some potential barriers at the recruitment stage are trust concerns and a lack of awareness of the recruitment effort. The authors suggest broadening recruitment strategies and making specific strategies to inform multiple communities about the purpose of the research. During the initial enrollment process, lack of internet access, proper technology, and lengthy screening processes prevent individuals from enrolling in digital health studies. Those who do make it through recruitment face extensive time commitments that interfere with daily life, an inability to maintain the response requirements outlined in the study design, or difficulty understanding the content provided by the intervention. To reduce these barriers the authors suggested using more flexible protocols, getting end-user feedback on content, and focusing on strategies to increase user engagement e.g. quizzes. Once the data is collected, it is important to note that effectiveness measures are infrequently tailored to culturally diverse populations and provide inadequate support. The authors suggest that new definitions of effectiveness should include measures of inclusivity. This would require testing new digital health interventions in populations that more accurately represent the end users of the intervention. Finally, the authors acknowledge the insufficient incentives, human connection, and time for most working adults to engage in digital health research. They suggest testing retention strategies with diverse subgroups and providing updated recommendations for future research.


Mobile Health Intervention in Patients with Type 2 Diabetes: A Randomized Clinical Trial

Gerber BS, Biggers A, Tilton JJ, et al. Mobile Health Intervention in Patients With Type 2 Diabetes: A Randomized Clinical Trial. JAMA Netw Open 2023;6(9):e2333629. doi:10.1001/jamanetworkopen.2023.33629

This randomized clinical trial addressed whether mobile health (mHealth) tools could help improve blood glucose levels in African American and Latinx individuals with type 2 diabetes. Continued research has shown that African American and Latinx populations with type 2 diabetes have higher hemoglobin A1c (HbA1c) levels than non-Latinx white populations. Here the authors explored whether mHealth tools facilitating pharmacist and health coaching activities could bridge these existing racial and ethnic disparities. Two hundred and twenty-one African American and Latinx adults participated in this two-year trial. Participants were randomized to receive the intervention in year one or year two (waitlist control). During the intervention pharmacists liaised with participants’ primary healthcare providers to determine therapeutic goals, discussed patient experiences with health coaches, monitored medications, reviewed participants’ logs of glucose and blood pressure, and provided one-on-one education to patients via the telehealth platform VSee. Participant meetings ranged from 30 minutes to one hour, occurring every 2-3 months. From the initial 221 enrolled in the trial, 187 completed the intervention and follow-up visit. During the first twelve months, participants’ HbA1c levels in the intervention group showed improvement compared to the waitlist group (p = 0.005). The waitlist group also showed the benefits of the intervention, displaying a change in HbA1c when receiving the intervention compared to the first 12 months (p = 0.002). Despite no longer receiving the intervention in the ladder 12 months, participants who received the intervention in the first 12 months continued to maintain lower HbA1c compared to baseline through 24 months. This study provides support for the utility of a virtual integrative team for managing type 2 diabetes in African American and Latinx populations.


Efficacy of the Mindfulness Meditation Mobile App “Calm” to Reduce Stress Among College Students: Randomized Controlled Trial

Huberty J, Green J, Glissmann C, Larkey L, Puzia M, Lee C. Efficacy of the Mindfulness Meditation Mobile App “Calm” to Reduce Stress Among College Students: Randomized Controlled Trial. JMIR Mhealth Uhealth 2019;7(6):e14273 doi:10.2196/14273

This study examined the sustained stress reduction, mindfulness, and self-compassion in a sample of college students following an 8-week trial of the “Calm” app. Most college students (75%) report elevated stress during the semester, resulting in higher stress levels in this population compared to other age groups. Elevated stress has been associated with a greater likelihood of suicide attempts, which are the second leading cause of death in teens and young adults (ages 15-24). Mindfulness interventions have been offered on college campuses in an effort to reduce students stress levels. The Calm app is a consumer-based mindfulness meditation mobile app. Here, 109 Arizona State University students were randomized to participate in daily meditation facilitated by the Calm app or waitlisted for future access. Most participants (85%) enjoyed the app and continued to use the app for the additional month offered after the study ended. Participants used Calm for an average of 38 minutes/week. After 8 weeks, users displayed lower stress levels than baseline and compared to control participants (p < 0.05). In addition, participants showed increased mindfulness (p < 0.001) and increased self-compassion (p < 0.001) compared to the control group. These beneficial effects of “Calm” guided meditation were maintained through the follow-up period, four weeks after the intervention. This data is encouraging for the future of digital mindfulness interventions to promote stress reduction in college students.


Reducing Intervention and Research-Induced Inequalities to Tackle the Digital Divide in Health Promotion

Konig LM, Krukowski RA, Kuntsche E, Busse H, Gumbert L, Gemesi K, Neter E, Mohamed NF, Ross K, John-Akinola Y, Cooper R, Allmeta A, Silva AM, Forbes CC, Western MJ. Reducing intervention- and research-induced inequalities to tackle the digital divide in health promotion. Int J Equity Health 2023;22(1):249. doi:10.1186/s12939-023-02055-6

This article summarizes discussions from an international expert workshop held in Kulmbach, Germany. The international representatives discussed the challenges facing the field of digital health in regards to social inequality. The primary goal was to outline global methods for improving digital health for all without widening already existing health disparities. Two main themes emerged during the workshop: intervention-induced inequalities and research-induced inequalities. To address intervention-induced inequalities the authors suggest supporting policy changes around healthcare costs, focusing on digital navigators, and expanding research on uptake and engagement cross-culturally. Generally, the goal is to make interventions cost-effective, user-friendly regardless of technology skill level, and accessible. To facilitate equality in research the authors suggest global use of online study registration platforms, including end users early in the intervention design process, diverse recruitment strategies including cross-cultural and language comparisons, and open access to results. Here, the ultimate aim is to increase diversity in research networks, promoting intersectional research and data sharing. Webpages maintaining summaries of recent research in digital health and healthcare-related areas are promoted as a critical method of preventing research waste and promoting collaborations. Without proper consideration of the above discussion points the authors reiterate that digital health research and interventions may widen rather than bridge existing health inequalities.

Smartphone Sensor Data Estimate Alcohol Craving in a Cohort of Patients with Alcohol-Associated Liver Disease and Alcohol Use Disorder

Wu T, Sherman G, Giorgi S, Thanneeru P, Ungar L, Kamath P, Simonetto D, Curtis B, Shah V. Smartphone sensor data estimate alcohol craving in a cohort of patients with alcohol-associated liver disease and alcohol use disorder. Hepatol Commun 2023;7(12). DOI:10.1097

This proof-of-concept study examined the feasibility of using passive smartphone sensors to predict alcohol cravings. For this pilot observational study, twenty-four adults with alcohol-associated liver disease (ALD) installed the AWARE platform onto their mobile phones. The platform allows for the collection of passive sensor data. For 30 days sensor data was collected and participants responded to daily prompts requesting self-reports of alcohol cravings, alcohol or substance use, and mood. While only half of the participants were retained in this study, their data provided useful insight into potential digital phenotyping for alcohol craving. Self-reported negative moods (loneliness, sadness, stress, anxiety, and fear) were positively correlated with craving (all p < 0.05). Conversely, positive moods (calmness, happiness, social support, and hope) were negatively correlated with craving (all p < 0.05). A similar directionality of correlations between craving and mood was found in the passive sensor data. For example, sensors that were associated with craving were highly associated with sadness (p < 0.001) and not associated with calmness (p < 0.001). Both decreases in distance traveled and increased phone movement were independently correlated with craving. Overall, this study provides novel insight into the potential use of smartphone sensors as a marker for alcohol craving and mood in ALD patients.