Implementation of an Interactive Voice Response System for Cancer Awareness in Uganda: Mixed Methods Study.

BACKGROUND: Cancer awareness is crucial for cancer care and prevention. However, cancer awareness in Uganda is low, and access to cancer information is limited. OBJECTIVE: This study aims to (1) understand the cancer awareness situation in Uganda (perceptions, beliefs, information needs, and challenges to accessing cancer information) and opinions about interactive voice response (IVR) systems; (2) develop cancer awareness messages and implement them in an IVR system; and (3) evaluate user acceptance and use of the IVR system. METHODS: A participatory design approach was adopted. To understand cancer awareness needs and challenges, 3 interviews and 7 focus group discussions (FGDs) were conducted with cancer health care providers, patients with cancer, caregivers and survivors, administrators, and lay citizens (n=73). On the basis of the resulting qualitative data, audio messages addressing cancer information needs were developed and implemented in an IVR system. The system and messages were tested with users (n=12) during 2 co-design workshops before final rollout. Finally, the system was evaluated over 6 months after going live, using call records and user feedback from telephone interviews with callers (n=40). RESULTS: The cancer information needs included general topics such as what cancer is, what causes it, cancer screening and diagnosis, cancer treatment, and practical information on what to expect during cancer care. There were also myths and misconceptions that need to be addressed, such as that cancer is due to witchcraft and has no treatment. Information on COVID-19 was also sought after following the outbreak. We developed 20 audio cancer messages (approximately 2 minutes each) in English and Luganda, along with 14 IVR navigation instructions. These were implemented in an IVR system with 24/7 availability from all over Uganda via a toll-free multi-channel telephone number. The total number of calls made to the IVR system 6 months after going live was 3820. Of these, 2437 (63.8%) lasted at least 30 seconds and were made from 1230 unique telephone numbers. There were 191 voice messages and 760 calls to live agents, most of which (681/951, 71.6%) were in Luganda. Call volumes peaked following advertisement of the system and lockdowns due to COVID-19. Participants were generally familiar with IVR technology, and caller feedback was largely positive. Cited benefits included convenience, toll-free access, and detailed information. Recommendations for improvement of the system included adding live agents and marketing of the system to target users. CONCLUSIONS: IVR technology provides an acceptable and accessible method for providing cancer information to patients and the general public in Uganda. However, a need remains for health system reforms to provide additional cancer information sources and improve cancer care services in general.

Gaining Insights Into the Estimation of the Circadian Rhythms of Social Activity in Older Adults From Their Telephone Call Activity With Statistical Learning: Observational Study.

BACKGROUND: Understanding the social mechanisms of the circadian rhythms of activity represents a major issue in better managing the mechanisms of age-related diseases occurring over time in the elderly population. The automated analysis of call detail records (CDRs) provided by modern phone technologies can help meet such an objective. At this stage, however, whether and how the circadian rhythms of telephone call activity can be automatically and properly modeled in the elderly population remains to be established. OBJECTIVE: Our goal for this study is to address whether and how the circadian rhythms of social activity observed through telephone calls could be automatically modeled in older adults. METHODS: We analyzed a 12-month data set of outgoing telephone CDRs of 26 adults older than 65 years of age. We designed a statistical learning modeling approach adapted for exploratory analysis. First, Gaussian mixture models (GMMs) were calculated to automatically model each participant's circadian rhythm of telephone call activity. Second, k-means clustering was used for grouping participants into distinct groups depending on the characteristics of their personal GMMs. RESULTS: The results showed the existence of specific structures of telephone call activity in the daily social activity of older adults. At the individual level, GMMs allowed the identification of personal habits, such as morningness-eveningness for making calls. At the population level, k-means clustering allowed the structuring of these individual habits into specific morningness or eveningness clusters. CONCLUSIONS: These findings support the potential of phone technologies and statistical learning approaches to automatically provide personalized and precise information on the social rhythms of telephone call activity of older individuals. Futures studies could integrate such digital insights with other sources of data to complete assessments of the circadian rhythms of activity in elderly populations.

Telephone-guided self-help for mental health difficulties in neurological conditions: a randomised pilot trial.

OBJECTIVE: This study aimed to conduct a randomised pilot trial to assess the feasibility of a randomised controlled trial (RCT) to investigate the effect of telephone-guided self-help for the treatment of mental health difficulties in children with neurological conditions. DESIGN: Preliminary RCT. The primary outcome measure was the Strengths and Difficulties Questionnaire. SETTING: Neurology clinics in a national tertiary paediatric hospital. PATIENTS: Young people attending neurology clinics who met criteria for mental health difficulties according to the Development and Wellbeing Assessment. INTERVENTIONS: 12 weeks of telephone-guided self-help based on a modular approach to psychological therapy for children delivered to children and/or their parents (n=17; eight males; mean age 12.04 years, SD=3.34) or a waiting list for telephone-guided self-help with no additional intervention over 12 weeks (n=17; nine males; mean age 10.53 years, SD=3.14). RESULTS: 124 participants completed the DAWBA, and 34 children and young people were entered into the trial. 65% of those randomised to the intervention arm completed the full intervention, and the intervention was acceptable to those completing it. However, there were significant problems related to lack of data completion (38% data loss for primary outcome measure), choice of control comparator and outcome measures. Due to significant loss of data at follow-up, the effect size findings are considered unreliable. CONCLUSIONS: Further feasibility work should be conducted to improve data completeness before progression to a definitive trial of guided self-help for mental health problems in children with neurological conditions can be recommended. TRIAL REGISTRATION NUMBER: ISRCTN21184717.

Phone Speech Recognition Improvement in Noisy Environment: Use of a Bluetooth Accessory.

OBJECTIVE: To evaluate speech understanding in noise and patient satisfaction using the new Cochlear Wireless Phone Clip device. MATERIAL AND METHODS: Twenty-nine experienced cochlear implant (CI) users (>6 months usage) were situated in a soundproof room where a 65 dB SPL Spanish cocktail noise was generated continuously from 4 loudspeakers. Lists of disyllabic words were presented through the clinic landline telephone to the patients. Patients were tested first holding the phone and then with the Cochlear Phone Clip© paired to the CP910 using various mixing ratios (2:1, 4:1, and Phone Clip© only). RESULTS: Statistically significant (P < .001) improvement of speech recognition performance was found in cell phone usage by wireless transmission and also when using this new device. Kepler questionnaire results showed that before using Phone Clip in everyday life, 55.2% of patients described themselves highly or greatly affected by their deafness for telephone use and 80% moderately to greatly affected. Kim questionnaire results showed statistically significant differences (P < .001) in the subjective satisfaction of the Bluetooth-implemented CI compared to the conventional mode for sound quality, noise interference, and sound accuracy. CONCLUSIONS: The wireless Phone Clip© device helps implanted people to improve subjective and objective speech recognition performance through the phone in noisy environments.

The role of a virtual telephone clinic in the follow-up management of lateral skull base tumours.

OBJECTIVE: The purpose of this article was to determine the impact of employing a telephone clinic for follow-up of patients with stable lateral skull-base tumours. METHOD: An analysis of 1515 patients in the national lateral skull-base service was performed, and 148 patients enrolled in the telephone clinic to date were identified. The length of time that patients waited for results of their follow-up scans and the travel distance saved by patients not having to attend the hospital for their results was determined. RESULTS: The mean time from scan to receiving results was 30.5 ± 32 days, 14 days sooner than in the face-to-face group (p = 0.0016). The average round-trip distance travelled by patients to the hospital for results of their scans was 256 ± 131 km. CONCLUSION: The telephone clinic led to a significant reduction in time until patients received their scan results and helped reduce travel distance and clinic numbers in traditional face-to-face clinics.

Patients' Experiences of Telephone-Based and Web-Based Cognitive Behavioral Therapy for Irritable Bowel Syndrome: Longitudinal Qualitative Study.

BACKGROUND: Cognitive behavioral therapy (CBT) is recommended in guidelines for people with refractory irritable bowel syndrome (IBS). However, the availability of CBT is limited, and poor adherence has been reported in face-to-face CBT. OBJECTIVE: Nested within a randomized controlled trial of telephone- and web-delivered CBT for refractory IBS, this qualitative study aims to identify barriers to and facilitators of engagement over time with the interventions, identify social and psychological processes of change, and provide insight into trial results. METHODS: A longitudinal qualitative study was nested in a randomized controlled trial. Repeated semistructured interviews were conducted at 3 (n=34) and 12 months (n=25) post baseline. Participants received telephone-based CBT (TCBT; n=17 at 3 months and n=13 at 12 months) or web-based CBT (WCBT; n=17 at 3 months and n=12 at 12 months). Inductive thematic analysis was used to analyze the data. RESULTS: Participants viewed CBT as credible for IBS, perceived their therapists as knowledgeable and supportive, and liked the flexibility of web-based and telephone-based delivery; these factors facilitated engagement. Potential barriers to engagement in both groups (mostly overcome by our participants) included initial skepticism and concerns about the biopsychosocial nature of CBT, initial concerns about telephone-delivered talking therapy, challenges of maintaining motivation and self-discipline given already busy lives, and finding nothing new in the WCBT (WCBT group only). Participants described helpful changes in their understanding of IBS, attitudes toward IBS, ability to recognize IBS patterns, and IBS-related behaviors. Consistent with the trial results, participants described lasting positive effects on their symptoms, work, and social lives. Reasons and remedies for some attenuation of effects were identified. CONCLUSIONS: Both TCBT and WCBT for IBS were positively received and had lasting positive impacts on participants' understanding of IBS, IBS-related behaviors, symptoms, and quality of life. These forms of CBT may broaden access to CBT for IBS.

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities: A Randomized Clinical Trial.

Importance: Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities. Objective: To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. Design, Setting, and Participants: This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019. Interventions: Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss. Main Outcomes and Measures: The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up. Results: Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99). Conclusions and Relevance: This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. Trial Registration: ClinicalTrials.gov Identifier: NCT02054624.

Patient Empowerment Using Electronic Telemonitoring With Telephone Support in the Transition to Insulin Therapy in Adults With Type 2 Diabetes: Observational, Pre-Post, Mixed Methods Study.

BACKGROUND: Initiation of insulin therapy for the management of type 2 diabetes can be an unwelcome and distressful development for patients. Current evidence suggests that telemonitoring can help improve glycemic control in type 2 diabetes and can support empowerment to self-manage diabetes. This telemonitoring intervention was underpinned by an empowerment approach. OBJECTIVE: This study aimed to evaluate the clinical effectiveness and feasibility and the patients' and health care providers' experiences of a 12-week telemonitoring intervention with telephone support for patients commencing insulin therapy. This paper focuses on the impact on patient empowerment. METHODS: An observational, pre-post, multimethod, and triangulation design was employed to study a 12-week automated electronic telemonitoring intervention with telephone support from a diabetes clinical nurse specialist (CNS). Forty patients were recruited from the clinic as they were about to commence insulin therapy. In the quantitative arm, biometric data (hemoglobin A1c [HbA1c] and weight) and psychosocial data (diabetes empowerment scale [DES] scores and diabetes distress scale [DDS] scores) were gathered by the research team at baseline (T1), the end of the intervention (T2), and 3 months postintervention (T3). Data on hospital admission and general practitioner (GP) visits were collected for the duration of the study. In the qualitative arm, separate focus group interviews were conducted with the CNS team supporting the intervention (n=2) and patients (n=16). RESULTS: Of 39 patients who completed the intervention, 23 (59%) were male. The mean age of the sample was 62.4 years (range 37-80 years). The mean HbA1c (mmol/mol) decreased significantly between T1 and T2 (mean difference [MD] -17.13; P<.001) and T1 and T3 (MD -18.16; P<.001), with no significant impact on weight. In the focus groups, patients reported an increased awareness to self-manage diabetes and feelings of safety and comfort. There were 13% (5/39) of patients who had hypoglycemia on two or more occasions. A significant increase in the mean DES score occurred between T1 and T2 (MD 0.62; P=.001) and T1 and T3 (MD 0.72; P<.001). The mean DDS score decreased between T1 and T2 (MD -0.64; P=.002) and T1 and T3 (MD -0.6; P=.002). The mean patient satisfaction with the intervention was above 4 out of possible 5 on all items on the Telemedicine Satisfaction and Usefulness Questionnaire. We observed a reduction in diabetes clinic attendances and GP visits. A significant increase in workload was reported by the CNS team. CONCLUSIONS: This intervention had an empowering effect for patients in the self-management of type 2 diabetes and has the potential to meet the need for safer and more effective care in insulin initiation in the community setting. We observed a significant increase in workload for health care staff. Telemonitoring needs to be streamlined with health care delivery and accompanied by adequate support services.

Incorporation of a mock drug information telephone call exercise in a health-systems pharmacy laboratory.

BACKGROUND AND PURPOSE: Hospital pharmacists routinely receive and answer drug information questions via telephone while performing order verification. This report describes the development, implementation, and evaluation of a mock learning experience for student performance of these tasks in a health-systems pharmacy laboratory course. EDUCATIONAL ACTIVITY AND SETTING: An active learning skills-based exercise involving students receiving and answering a standardized drug information question via telephone during an order verification activity, referred to as a cold-call exercise, was developed and implemented. Data collected included student grades on a baseline assessment, the cold call exercise, order verification exercises, and student perceptions from a voluntary post-exercise survey. Student performance on the cold-call exercise was further evaluated via individual sections of the cold-call rubric. Data were summarized using descriptive statistics. Thematic analysis of student opinion and an estimate of faculty time were also executed. FINDINGS: Student grades on the cold call and order verification exercises were 86.14% and 88.8%, respectively. Students often failed to ask category-specific questions because they did not categorize the ultimate question appropriately. Students found the activity organized and applicable. Time dedicated to creation was extensive, but execution and grading were reasonable. SUMMARY: Students performed well on the drug information exercise as well as the order verification component. Students and faculty enjoyed the experience, and students found the exercise relevant and challenging. This exercise could be implemented into any pharmacy curriculum in order to prepare students using authentic learning experiences.

A telephone-based education and support intervention for Rural Breast Cancer Survivors: a randomized controlled trial comparing two implementation strategies in rural Florida.

PURPOSE: To compare two implementation telephone-based strategies of an evidence-based educational and support intervention to Rural Breast Cancer Survivors (RBCS) in which education was delivered early or after the support component. METHODS: Florida RBCS participated in a 12-month randomized clinical trial (RCT) with two arms: Early Education and Support (EE-S) and Support and Delayed Education (S-DE). Arms differed in the timing of 6 support and 3 education sessions. Main outcome was quality of life (QOL, SF-36 physical and mental composite scores [PCS, MCS]). Secondary outcomes were depressive symptoms (Centers for Epidemiologic Studies Depression Scale, CES-D), mood (Profile of Mood States, POMS), and social support (Medical Outcomes Study Social Support Survey, MOS-SSS). Outcomes were analyzed longitudinally using repeated measures models fitted with linear mixed methods. RESULTS: Of 432 RBCS (mean 25.6 months from diagnosis), about 48% were 65+, 73% married/partnered, and 28% with ≤high school education. There were no differences between EE-S and S-DE in demographics or outcomes at baseline (mean (standard deviation): SF-36 PCS, 44.88 (10.6) vs. 45.08 (10.6); MCS, 49.45 (11.1) vs. 48.1 (11.9); CES-D, 10.11 (9.8) vs. 10.86 (10.5); POMS-SF, 23.95 (38.6) vs. 26.35 (38.8); MOS-SSS, 79.2 (21.2) vs. 78.66 (21.2)) or over time. One exception was slightly worse mean scores at month 9 in MCS (Cohen's d, - 0.22; 95% CI, - 0.38, - 0.06) and POMS (Cohen's d, 0.23; 95% CI, 0.07, 0.39) for EE-S vs. S-DE. CONCLUSIONS: The implementation strategies were equivalent. IMPLICATIONS FOR CANCER SURVIVORS: Enhancing support may be considered before delivering not-in-person interventions to RBCS.

Telecommunicator Cardiopulmonary Resuscitation: A Policy Statement From the American Heart Association.

Every year in the United States, >350 000 people have sudden cardiac arrest outside of a hospital environment. Sudden cardiac arrest is the unexpected loss of heart function, breathing, and consciousness and is commonly the result of an electric disturbance in the heart. Unfortunately, only ≈1 in 10 victims survives this dramatic event. Early access to 9-1-1 and early cardiopulmonary resuscitation (CPR) are the first 2 links in the chain of survival for out-of-hospital cardiac arrest. Although 9-1-1 is frequently accessed, in the majority of cases, individuals with out-of-hospital cardiac arrest do not receive lay rescuer CPR and wait for the arrival of professional emergency rescuers. Telecommunicators are the true first responders and a critical link in the cardiac arrest chain of survival. In partnership with the 9-1-1 caller, telecommunicators have the first opportunity to identify a patient in cardiac arrest and provide initial care by delivering CPR instructions while quickly dispatching emergency medical services. The telecommunicator and the caller form a unique team in which the expertise of the telecommunicator is provided just in time to a willing caller, transforming the caller into a lay rescuer delivering CPR. The telecommunicator CPR (T-CPR) process, also previously described as dispatch CPR, dispatch-assisted CPR, or telephone CPR, represents an important opportunity to improve survival from sudden cardiac arrest. Conversely, failure to provide T-CPR in this manner results in preventable harm. This statement describes the public health impact of out-of-hospital cardiac arrest, provides guidance and resources to construct and maintain a T-CPR program, outlines the minimal acceptable standards for timely and high-quality delivery of T-CPR instructions, and identifies strategies to overcome common implementation barriers to T-CPR.

Web-Based Parent Training Intervention With Telephone Coaching for Disruptive Behavior in 4-Year-Old Children in Real-World Practice: Implementation Study.

BACKGROUND: Parent training is the most effective approach to the psychosocial treatment of disruptive behavioral problems in childhood. However, no studies exist on how well Web-based training programs work when they make the transition from the research setting to implementation in primary health care. OBJECTIVE: The study aimed to examine how the randomized controlled trial (RCT) and implementation study groups of the Strongest Families Smart Website (SFSW) intervention differed in child psychopathology, family demographics and treatment-related factors, such as therapeutic alliance and parents' satisfaction rates. The intervention was conducted in the pediatric primary health care in Finland. METHODS: The study focused on 232 parents who had taken part in the SFSW intervention, which formed part of a 2-arm RCT study, and 882 families that would participate in the subsequent SFSW implementation study group. Both groups comprised parents whose children displayed high levels of parent-reported disruptive behavioral problems when they were screened in child health clinics at 4 years of age. Parents in both groups were provided with the SFSW intervention, which consisted of a Web-based training program with 11 weekly themes and associated telephone sessions. RESULTS: Demographic factors or duration of behavioral problems did not differ statistically or clinically between the RCT and implementation groups. Overall, 42.0% (362/862) of children in the implementation group and 35.4% (80/226) in the RCT intervention group had suffered from behavioral difficulties more than 1 year before the screening phase (χ12=3.2; P=.07). The mean duration of telephone coaching calls was very similar in the implementation and RCT intervention groups, that is, 38 and 37 min per call, respectively (t279.5=0.26; P=.79). The total time spent on the website of the program was 451 min in the implementation group and 431 min in the RCT intervention group (t318.8=1.38; P=.17). In the RCT intervention group, 52 of the 232 participants (22.4%) discontinued the program before the tenth week, whereas in the implementation group, 109 of the 882 participants (12.4%; odds ratio 2.05, 95% CI 1.4-3.0; P<.001) discontinued. Parents in both the implementation (77.1% to 98.5%, 498/742 to 731/742, respectively) and the RCT (64.8% to 98.2%, N=105/162- to 159/162, respectively) groups reported qualitatively similar and high level of posttreatment satisfaction rates in improved parenting skills, expectations, and stress relief. Parents in both groups reported a high level of satisfaction in skills and professionalism of the telephone coaches. CONCLUSIONS: The implementation of population-based screening of Web-based parent training intervention with telephone coaching resulted in good feasibility, fidelity, accessibility, and similar satisfaction level post treatment when compared with intervention in RCT research setting. The discontinuation of treatment in the implementation group was exceptionally low.

Telephone-Delivered Cognitive Behavioural Therapy for Treating Symptoms of Anxiety and Depression in Parkinson's Disease: A Pilot Trial.

Objectives: To determine the feasibility, acceptability and initial efficacy of telephone-delivered cognitive behavioral therapy (CBT) for the treatment of anxiety and depressive symptoms in people with Parkinson's disease. Methods: A small randomized controlled trial compared telephone-based CBT to waitlist control. Eleven participants aged >50 years with Parkinson's disease and anxiety and/or depressive symptoms above recommended clinical cut-offs, were randomized to one of two conditions. Participants completed self-report measures of symptom severity and quality of life. Their carers were invited to participate and completed self-reported measures of symptoms and carer burden. At the end of the 10-week intervention period, participants and carers were reassessed on baseline measures, and again one month later. Results: The CBT program was associated with significantly reduced depressive symptoms (Cohen's d = .90) at post-treatment with gains maintained at one-month follow-up. Anxiety symptom decreases (Cohen's d = 0.36) were not statistically different. Waitlist was associated with significantly worsened anxiety. Carer symptoms also reduced with CBT. No changes on quality of life were found. Good acceptability and feedback was received. Conclusions: Telephone-based CBT reduced symptoms of depression in participants with Parkinson's disease but not anxiety. Clinical Implications: Telephone-based CBT is a promising treatment option.

Feasibility of a Smartphone-based pilot intervention for Hispanic breast cancer survivors: a brief report.

Hispanic breast cancer survivors (BCS) are at high risk for experiencing poor health-related quality of life (HRQoL) after completion of active breast cancer treatment. Therefore, there is a need to develop culturally tailored interventions for Hispanic BCS. To date, there have been limited interventions that have demonstrated that increasing cancer-related knowledge, self-efficacy in communication, and self-management skills can improve HRQoL among Hispanic BCS. These interventions have been delivered in person or by phone, which may be burdensome for Hispanic BCS. To facilitate intervention delivery, we developed My Guide, a Smartphone application aimed at improving HRQoL among Hispanic BCS. The purpose of the current study is to describe the feasibility results of a 4-week pilot trial testing My Guide among Hispanic BCS. Twenty-five women enrolled in the study (75% recruitment rate) and 22 women were retained (91.6% retention rate). Mean time spent using My Guide across the 4 weeks was 9.25 hr, and mean score on the satisfaction survey was 65.91 (range 42-70), in which higher scores reflect greater satisfaction. Participants' scores on the Breast Cancer Knowledge Questionnaire significantly improved from study baseline (M = 9.50, SD = 2.92) to the postintervention assessment (M = 11.14, SD = 2.66), d = 0.59. Participants' HRQoL scores improved over the course of 4 weeks, but these improvements were not statistically significant. Overall, My Guide was feasible and acceptable. Future studies will assess the preliminary efficacy of My Guide in improving HRQoL in a larger, randomized trial of Hispanic BCS.

EXPOSURE ASSESSMENT OF PORTABLE WIRELESS DEVICES ABOVE 6 GHz.

The emerging 5 G wireless devices working at frequencies above 6 GHz are expected to have antenna arrays formed by dipoles, slots, patches or their combination. At lower frequencies, the accepted criteria for exposure compliance is stated in terms of specific absorption rate. IEEE and ICNIRP are adopting epithelial or transmitted power density (PD through body surface) as the dosimetric reference for frequencies above 6 GHz, which entails the measurement of free space PD. Theoretical and numerical results presented in this article show that it is possible to perform meaningful free space PD assessments at half wave (λ/2) distance from arrays and, with the proper instrumentation, as close as λ/(2π). However, if a dissipative body is placed very close (<λ/2π) to the arrays, its reflection and absorption of RF energy can change the electric currents and charges over the antenna. The relevance of such an effect should be further investigated, for instance by means of experimental analysis including measurements of tissue heating when in the presence of a strong reactive near field.

Interactive voice response interventions targeting behaviour change: a systematic literature review with meta-analysis and meta-regression.

OBJECTIVE: A number of promising automated behaviour change interventions have been developed using advanced phone technology. This paper reviewed the effectiveness of interactive voice response (IVR)-based interventions designed to promote changes in specific health behaviours. METHODS: A systematic literature review of papers published between January 1990 and September 2017 in MEDLINE, CINAHL, Embase, PsycINFO, SCOPUS and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. From the total of 2546 papers identified, 15 randomised control trials (RCTs) met the eligibility criteria and were included in a random effects meta-analysis. Meta-regression analysis was used to explore whether behaviour change techniques (BCTs) that were used in the interventions were associated with intervention effectiveness. RESULTS: Meta-analysis of 15 RCTs showed that IVR-based interventions had small but significant effects on promoting medication adherence (OR=1.527, 95% CI 1.207 to 1.932, k=9, p=0.000) and physical activity (Hedges' g=0.254, 95% CI 0.068 to 0.439, k=3, p=0.007). No effects were found for alcohol (Hedges' g=-0.077, 95% CI -0.162 to 0.007, k=4, p=0.073) or diet (Hedges' g=0.130, 95% CI -0.088 to 0.347, k=2, p=0.242). In the medication adherence studies, multivariable meta-regression including six BCTs explained 100% of the observed variance in effect size, but only the BCT 'information about health consequences' was significantly associated with effect size (ß=0.690, SE=0.199, 95% CI 0.29 to 1.08, p=0.000). CONCLUSION: IVR-based interventions appear promising in changing specific health behaviours, such as medication adherence and physical activity. However, more studies are needed to elucidate further the combination of active components of IVR interventions that make them effective and test their feasibility and effectiveness using robust designs and objective outcome measures.

The feasibility of an interactive voice response system (IVRS) for monitoring patient safety after discharge from the ED.

BACKGROUND: Return ED visits are frequent and may be due to adverse events: adverse outcomes related to healthcare received. An interactive voice response system (IVRS) is a technology that translates human telephone input into digital data. Use of IVRS has been explored in many healthcare settings but to a limited extent in the ED. We determined the feasibility of using an IVRS to assess for adverse events after ED discharge. METHODS: This before and after study assessed detection of adverse events among consecutive high-acuity patients discharged from a tertiary care ED pre-IVRS and post-IVRS over two 2-week periods. The IVRS asked if the patient was having a health problem and if they wanted to speak to a nurse. Patients responding yes received a telephone interview. We searched health records for deaths, admissions to hospital and return ED visits. Three trained emergency physicians independently determined adverse event occurrence. We analysed the data using descriptive statistics. RESULTS: Of 968 patients studied, patients' age, sex, acuity and presenting complaint were comparable pre-IVRS and post-IVRS. Postimplementation, 393 (81.7%) of 481 patients had successful IVRS contact. Of these, 89 (22.6%) wanted to speak to a nurse. A total of 37 adverse events were detected over the two periods: 10 patients with 10 (6.5%) adverse events pre-IVRS and 16 patients with 27 (16.9%) adverse events post-IVRS. In the postimplementation period, the adverse events of seven patients were detected by the IVRS and five patients spontaneously requested assistance navigating post-ED care. CONCLUSIONS: This was a successful proof-of-concept study for applying IVRS technology to assess patient safety issues for discharged high-acuity ED patients.

SymptomCare@Home: Developing an Integrated Symptom Monitoring and Management System for Outpatients Receiving Chemotherapy.

SymptomCare@Home, an integrated symptom monitoring and management system, was designed as part of randomized clinical trials to help patients with cancer who receive chemotherapy in ambulatory clinics and often experience significant symptoms at home. An iterative design process was informed by chronic disease management theory and features of assessment and clinical decision support systems used in other diseases. Key stakeholders participated in the design process: nurse scientists, clinical experts, bioinformatics experts, and computer programmers. Especially important was input from end users, patients, and nurse practitioners participating in a series of studies testing the system. The system includes both a patient and clinician interface and fully integrates two electronic subsystems: a telephone computer-linked interactive voice response system and a Web-based Decision Support-Symptom Management System. Key features include (1) daily symptom monitoring, (2) self-management coaching, (3) alerting, and (4) nurse practitioner follow-up. The nurse practitioner is distinctively positioned to provide assessment, education, support, and pharmacologic and nonpharmacologic interventions to intensify management of poorly controlled symptoms at home. SymptomCare@Home is a model for providing telehealth. The system facilitates using evidence-based guidelines as part of a comprehensive symptom management approach. The design process and system features can be applied to other diseases and conditions.

The impact of using computer decision-support software in primary care nurse-led telephone triage: interactional dilemmas and conversational consequences.

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.

How do patients respond when confronted with telephone access barriers to care?

OBJECTIVE: To gain an in-depth understanding of patient barriers to accessing telephone care, subsequent responses to telephone access issues and recommendations for system improvement within a large integrated health-care system. STUDY DESIGN: Cross-sectional qualitative focus group study. METHODS: One focus group was conducted at each of 17 Veterans Affairs facilities with a total of 123 Veteran users of VA health care. All facilities followed a focus group discussion guide, and purposively sampled patients receiving care at their VA facility in primary and/or specialty care. Focus groups' recordings were sent to the authors' independent evaluation centre, transcribed verbatim and analysed using qualitative content analysis methodology. RESULTS: Participants described many issues with the phone system that resulted in delays to care needs being addressed, including difficulty getting someone to answer the phone, out-dated phone directories, frequent disconnections and incorrect transfers. Participants most frequently responded to access issues by doing nothing or waiting to contact at a later time, or seeking unscheduled in-person care in the emergency department or primary care clinic. Participants offered recommendations for improving telephone care, including access to direct extensions, and upgrades to the telephone system. CONCLUSIONS: Telephone access issues could result in increased patient harm and/or increased wait times for in-person primary care or emergency services. Periodic evaluation of telephone systems is necessary to ensure telephone systems adequately meet patient needs while using resources efficiently to optimize the delivery of high quality, safe health care.