Personalized Digital Health Communications to Increase COVID-19 Vaccination in Underserved Populations: A Double Diamond Approach to Behavioral Design.

The COVID-19 pandemic exacerbated pre-existing health disparities. People of historically underserved communities, including racial and ethnic minority groups and people with lower incomes and educational attainments, experienced disproportionate premature mortality, access to healthcare, and vaccination acceptance and adoption. At the same time, the pandemic increased reliance on digital devices, offering a unique opportunity to leverage digital communication channels to address health inequities, particularly related to COVID-19 vaccination. We offer a real-world, systematic approach to designing personalized behavior change email and text messaging interventions that address individual barriers with evidence-based behavioral science inclusive of underserved populations. Integrating design processes such as the Double Diamond model with evidence-based behavioral science intervention development offers a unique opportunity to create equitable interventions. Further, leveraging behavior change artificial intelligence (AI) capabilities allows for both personalizing and automating that personalization to address barriers to COVID-19 vaccination at scale. The result is an intervention whose broad component library meets the needs of a diverse population and whose technology can deliver the right components for each individual.

Implementing a Peer Advocate Mental Health Digital Intervention Program for Ohio Youth: Descriptive Pilot Study.

BACKGROUND: In the United States, millions of adolescents report poor mental health, where 1 in 5 teenagers considers suicide. Reducing stigma and fostering peer support remains critical for positive mental health interventions and programs. Increasingly, digital mental health tools have emerged with great promise, leveraging social networks. Despite the potential, limited understanding of such comprehensive programs and their implementation exist. OBJECTIVE: The objective of this study investigates a piloted digital mental health training program (Be Present) for youth, specifically describing the impact on youth behavioral outcomes and user engagement and identifying high-risk youth in the early phases of prevention. METHODS: Eligibility included Ohio residents (aged 14 to 22 years) to be enrolled as either a Friend or a Peer Advocate. From May 1 to June 1, 2019, participants completed the Advocate training course, taking pretest and posttest surveys. Single-arm descriptive analyses measured youth outcomes (self-efficacy, intentions, behaviors, social support, knowledge, and sources of strength) and engagement and assessed risk based on survey responses. RESULTS: A total of 65 adolescents participated, with 54 completing both pretest and posttest surveys. The majority of participants included non-Hispanic White females. Findings illustrated a significant increase in self-report of referrals for mental health services as well as in perceptions that youth had of experiencing social support; however, no significant differences were found for measures of self-efficacy, knowledge, and sources of strength between pretest and posttest surveys. Roughly two-thirds of the participants completed all of the Advocate training modules, and we observed a gradual decline in engagement. Most respondents who received escalated high-risk response messages identified as female. CONCLUSIONS: The pilot presented promise for implementing a digital mental health program focused on peer support, specifically observing reported youth behavioral outcomes and user engagement and identifying high-risk youth. Various limitations exist given the small nonrepresentative sample and lack of control group. All findings should be considered preliminary to a larger trial and underscore the feasibility of delivering online training programs to bolster adolescent mental health. Such formative evaluation proved critical for future implementation and research, offering opportunity for substantial improvements for real-world digital mental health programs.

"I Like the Idea of It But Probably Wouldn't Use It" - Health Care Provider Perspectives on Heart Failure mHealth: Qualitative Study.

BACKGROUND: Many mobile health (mHealth) technologies exist for patients with heart failure (HF). However, HF mhealth lacks evidence of efficacy, caregiver involvement, and clinically useful real-time data. OBJECTIVE: We aim to capture health care providers' perceived value of HF mHealth, particularly for pairing patient-caregiver-generated data with clinical intervention to inform the design of future HF mHealth. METHODS: This study is a subanalysis of a larger qualitative study based on interviewing patients with HF, their caregivers, and health care providers. This analysis included interviews with health care providers (N=20), focusing on their perceived usefulness of HF mHealth tools and interventions. RESULTS: A total of 5 themes emerged: (1) bio-psychosocial-spiritual monitoring, (2) use of sensors, (3) interoperability, (4) data sharing, and (5) usefulness of patient-reported outcomes in practice. Providers remain interested in mHealth technologies for HF patients and their caregivers. However, providers report being unconvinced of the clinical usefulness of robust real-time patient-reported outcomes. CONCLUSIONS: The use of assessments, sensors, and real-time data collection could provide value in patient care. Future research must continually explore how to maximize the utility of mHealth for HF patients, their caregivers, and health care providers.

Using Grounded Theory to Inform the Human-Centered Design of Digital Health in Geriatric Palliative Care.

CONTEXT: Digital health offers innovative mechanisms to engage in palliative care, yet digital systems are typically designed for individual users, rather than integrating the patient's caregiving "social convoy" (i.e., family members, friends, neighbors, formal caregiving supports) to maximize benefit. As older adults with serious illness increasingly rely on the support of others, there is a need to foster effective integration of the social convoy in digitally supported palliative care. OBJECTIVES: Conduct a qualitative study examining patient, social convoy, and health care provider perspectives on digital health for palliative care to inform the design of future digital solutions for older adults with serious illness and their social convoy. METHODS: Grounded theory approach using semi-structured interviews (N = 81) with interprofessional health care providers, older adults with serious illness, and their social convoy participants at home, clinic, or Zoom. Interviews were conducted using question guides relevant to the participant group and audio-recorded for verbatim transcription. Two coders lead the inductive analysis using open and axial coding. RESULTS: Thematic results aligned with the human-centered design framework, which is a participatory approach to the design process that incorporates multiple user stakeholders to develop health solutions. The human-centered design process and corresponding theme included the following: 1) Empathy: Patient, Caregiver, and Provider Experience reports participants' experience with managing serious illness, caregiving, social support, and technology use. 2) Define: Reactions to Evidence-Based Care Concepts and Barriers illustrates participants' perspectives on the domains of palliative care ranging from symptom management to psychosocial-spiritual care. 3) Ideation: Desired Features reports participant recommendations for designing digital health tools for palliative care domains. CONCLUSION: Digital health provides an opportunity to expand the reach of geriatric palliative care interventions. This paper documents human-centered preferences of geriatric palliative care digital health to ensure technologies are relevant and meaningful to health care providers, patients, and the caregiving social convoy.

Elements of Social Convoy Theory in Mobile Health for Palliative Care: Scoping Review.

BACKGROUND: Mobile health (mHealth) provides a unique modality for improving access to and awareness of palliative care among patients, families, and caregivers from diverse backgrounds. Some mHealth palliative care apps exist, both commercially available and established by academic researchers. However, the elements of family support and family caregiving tools offered by these early apps is unknown. OBJECTIVE: The objective of this scoping review was to use social convoy theory to describe the inclusion and functionality of family, social relationships, and caregivers in palliative care mobile apps. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines, a systematic search of palliative care mHealth included (1) research-based mobile apps identified from academic searches published between January 1, 2010, and March 31, 2019 and (2) commercially available apps for app stores in April 2019. Two reviewers independently assessed abstracts, app titles, and descriptions against the inclusion and exclusion criteria. Abstracted data covered app name, research team or developer, palliative care element, target audience, and features for family support and caregiving functionality as defined by social convoy theory. RESULTS: Overall, 10 articles describing 9 individual research-based apps and 22 commercially available apps were identified. Commercially available apps were most commonly designed for both patients and social convoys, whereas the majority of research apps were designed for patient use only. CONCLUSIONS: Results suggest there is an emerging presence of apps for patients and social convoys receiving palliative care; however, there are many needs for developers and researchers to address in the future. Although palliative care mHealth is a growing field, additional research is needed for apps that embrace a team approach to information sharing, target family- and caregiver-specific issues, promote access to palliative care, and are comprehensive of palliative needs.

Youth Study Recruitment Using Paid Advertising on Instagram, Snapchat, and Facebook: Cross-Sectional Survey Study.

BACKGROUND: The use of paid social media advertising for targeted study recruitment is an effective strategy in health research and evaluation, specifically to reach diverse youth participants. Although the literature adequately describes the utility of Facebook in recruitment, limited information exists for social media platforms that are more popular with youth, specifically Instagram and Snapchat. OBJECTIVE: This paper outlines a paid advertising approach using Instagram, Snapchat, and Facebook to evaluate a statewide youth marijuana prevention campaign. The objective of this study was to compare recruitment metrics across Instagram, Snapchat, and Facebook for two surveys documenting youth knowledge, attitudes, and behaviors related to retail marijuana in Colorado post legalization. In addition, the study assessed the feasibility of using Instagram and Snapchat as effective additions to Facebook for youth study recruitment. METHODS: A social media recruitment strategy was used to conduct two cross-sectional surveys of youth, aged 13 to 20 years, in Colorado. Geographically targeted ads across 3 social media platforms encouraged the completion of a Web-based self-administered survey. Ad Words and Snap Ads were used to deploy and manage advertising campaigns, including ad design, placement, and analysis. Ad costs and recruitment metrics (ie, impressions, link clicks, and conversion rates) were calculated across the three social media platforms. RESULTS: Over two 1-month periods, 763,613 youth were reached (ie, impressions), 6089 of them clicked survey links (ie, clicks), and 828 eligible youth completed surveys about knowledge, attitudes, and behaviors related to retail marijuana. Instagram converted 36.13% (803/2222) of impressions to clicks (ie, conversion rate) in the first survey and 0.87% (864/98982) in the second survey. Snapchat generated the most impressions and link clicks, but it did so with the lowest conversion rate for both surveys, with a 1.40% (1600/114,200) conversion rate in the first survey and a 0.36% (1818/504700) conversion rate in the second survey. Facebook maintained a consistent conversion rate of roughly 2% across both surveys, despite reductions in budget for the second survey. The cost-per-click ranged between US $0.25 and $0.37 across the three platforms, with Snapchat as both the most cost-effective platform in the first survey and the most expensive platform in the second survey. CONCLUSIONS: Recruitment and enrollment outcomes indicate the use of Instagram and Snapchat, in addition to Facebook, may be a modern, useful, and cost-effective approach to reach youth with surveys on sensitive health topics. As the use of Facebook declines among youth, the use of more popular social media platforms can augment study recruitment for health research and evaluation efforts.

Assessment of attitudes towards future implementation of the "Surgical Risk Preoperative Assessment System" (SURPAS) tool: a pilot survey among patients, surgeons, and hospital administrators.

BACKGROUND: Risk assessment in surgery is essential to guide treatment decisions but is highly variable in practice. Providing formal preoperative risk assessment to surgical teams and patients may optimize understanding of risk. Implementation of the Surgical Risk Preoperative Assessment System (SURPAS), an innovative real time, universal, preoperative tool providing individualized risk assessment, may enhance informed consent and reduce adverse outcomes. To ensure optimal development and implementation of SURPAS we performed an in-depth pre-implementation evaluation of SURPAS at an academic tertiary referral center in Colorado. METHODS: Four focus groups with 24 patients, three focus groups with 29 surgical providers and clinic administrators, and five individual interviews with administrative officials were conducted to elicit their perspectives about the development and implementation of SURPAS. Qualitative data collection and analyses, utilizing a Matrix Analysis approach were used to explore insights regarding SURPAS. RESULTS: Participants were positive about SURPAS and provided suggestions to improve and address concerns regarding it. For healthcare personnel three major themes emerged: 1) The SURPAS tool - Important work especially for high risk patients, yet not a substitute for clinical judgment; 2) Benefits of SURPAS to the risk assessment process - Improves the processes, enhances patients' participation in shared decision-making process, and creates a permanent record; and 3) Facilitators and barriers of implementation of SURPAS - Easy to incorporate into clinical practice in spite of surgical providers' resistance to adoption of new technology. For patients three major themes emerged: 1) Past experience of preoperative risk assessment discussions - Patients were not made aware of possible complications that occurred; 2) The SURPAS tool - All patients liked SURPAS and believed having printed material would be useful to guide discussions and facilitate remembering conversations with the providers; and 3) Potential concerns with having risk assessment information - Patients were mixed in deciding to have an operation with high risks. CONCLUSIONS: Systematically capturing data from the beginning of the implementation process from key stakeholders (patients, surgical providers, clinical staff, and administrators) that includes adaptations to the tool and implementation process will help to inform pragmatic approaches for implementing the SURPAS tool in various settings, scaling-up, and sustaining it.