Clinician and Patient Perspectives on the Use of Passive Mobile Monitoring and Self-Tracking for Patients With Serious Mental Illness: User-Centered Approach.

BACKGROUND: Early intervention in mental health crises can prevent negative outcomes. A promising new direction is remote mental health monitoring using smartphone technology to passively collect data from individuals to rapidly detect the worsening of serious mental illness (SMI). This technology may benefit patients with SMI, but little is known about health IT acceptability among this population or their mental health clinicians. OBJECTIVE: We used the Health Information Technology Acceptability Model to analyze the acceptability and usability of passive mobile monitoring and self-tracking among patients with serious mental illness and their mental health clinicians. METHODS: Data collection took place between December 2020 and June 2021 in 1 Veterans Administration health care system. Interviews with mental health clinicians (n=16) assessed the acceptability of mobile sensing, its usefulness as a tool to improve clinical assessment and care, and recommendations for program refinements. Focus groups with patients with SMI (n=3 groups) and individual usability tests (n=8) elucidated patient attitudes about engaging in health IT and perceptions of its usefulness as a tool for self-tracking and improving mental health assessments. RESULTS: Clinicians discussed the utility of web-based data dashboards to monitor patients with SMI health behaviors and receiving alerts about their worsening health. Potential benefits included improving clinical care, capturing behaviors patients do not self-report, watching trends, and receiving alerts. Clinicians' concerns included increased workloads tied to dashboard data review, lack of experience using health IT in clinical care, and how SMI patients' associated paranoia and financial instability would impact patient uptake. Despite concerns, all mental health clinicians stated that they would recommend it. Almost all patients with SMI were receptive to using smartphone dashboards for self-monitoring and having behavioral change alerts sent to their mental health clinicians. They found the mobile app easy to navigate and dashboards easy to find and understand. Patient concerns centered on privacy and "government tracking," and their phone's battery life and data plans. Despite concerns, most reported that they would use it. CONCLUSIONS: Many people with SMI would like to have mobile informatics tools that can support their illness and recovery. Similar to other populations (eg, older adults, people experiencing homelessness) this population presents challenges to adoption and implementation. Health care organizations will need to provide resources to address these and support successful illness management. Clinicians are supportive of technological approaches, with adapting informatics data into their workflow as the primary challenge. Despite clear challenges, technological developments are increasingly designed to be acceptable to patients. The research development-clinical deployment gap must be addressed by health care systems, similar to computerized cognitive training. It will ensure clinicians operate at the top of their skill set and are not overwhelmed by administrative tasks, data summarization, or reviewing data that do not indicate a need for intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/39010.

Passive Mobile Self-tracking of Mental Health by Veterans With Serious Mental Illness: Protocol for a User-Centered Design and Prospective Cohort Study.

BACKGROUND: Serious mental illnesses (SMI) are common, disabling, and challenging to treat, requiring years of monitoring and treatment adjustments. Stress or reduced medication adherence can lead to rapid worsening of symptoms and behaviors. Illness exacerbations and relapses generally occur with little or no clinician awareness in real time, leaving limited opportunity to modify treatments. Previous research suggests that passive mobile sensing may be beneficial for individuals with SMI by helping them monitor mental health status and behaviors, and quickly detect worsening mental health for prompt assessment and intervention. However, there is too little research on its feasibility and acceptability and the extent to which passive data can predict changes in behaviors or symptoms. OBJECTIVE: The aim of this research is to study the feasibility, acceptability, and safety of passive mobile sensing for tracking behaviors and symptoms of patients in treatment for SMI, as well as developing analytics that use passive data to predict changes in behaviors and symptoms. METHODS: A mobile app monitors and transmits passive mobile sensor and phone utilization data, which is used to track activity, sociability, and sleep in patients with SMI. The study consists of a user-centered design phase and a mobile sensing phase. In the design phase, focus groups, interviews, and usability testing inform further app development. In the mobile sensing phase, passive mobile sensing occurs with participants engaging in weekly assessments for 9 months. Three- and nine-month interviews study the perceptions of passive mobile sensing and ease of app use. Clinician interviews before and after the mobile sensing phase study the usefulness and feasibility of app utilization in clinical care. Predictive analytic models are built, trained, and selected, and make use of machine learning methods. Models use sensor and phone utilization data to predict behavioral changes and symptoms. RESULTS: The study started in October 2020. It has received institutional review board approval. The user-centered design phase, consisting of focus groups, usability testing, and preintervention clinician interviews, was completed in June 2021. Recruitment and enrollment for the mobile sensing phase began in October 2021. CONCLUSIONS: Findings may inform the development of passive sensing apps and self-tracking in patients with SMI, and integration into care to improve assessment, treatment, and patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT05023252; https://clinicaltrials.gov/ct2/show/NCT05023252. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39010.

Predictors of VA Primary Care Clerical Staff Burnout Using the Job Demands-Resources Model.

Primary care clerical staff may experience burnout if not adequately prepared and supported for patient-facing customer service tasks. Guided by the Job Demands-Resources (JD-R) model, we use national survey data from 707 primary care clerks at 349 VA clinics (2018; response rate: 12%) to evaluate associations between clerks' perceptions of tasks, work environment, training, and burnout. We found challenges with customer-facing tasks contribute to higher burnout, and supportive work environment was associated with lower burnout. Although perceptions of training were not associated with burnout, our results combined with the JD-R model suggest that customer service training may protect against burnout.

Health System Resiliency and the COVID-19 Pandemic: A Case Study of a New Nationwide Contingency Staffing Program.

When COVID-19 emerged, the U.S. Veterans Health Administration (VA) was in the process of implementing a national contingency staffing program called Clinical Resource Hubs (CRHs). CRHs were intended to provide regional contingency staffing for primary and mental health clinics experiencing staffing shortages primarily through telehealth. Long-term plans (year 2) included emergency management support. Early in the implementation, we conducted semi-structured interviews with CRH directors and national program leaders (n = 26) and used a rapid analysis approach to identify actions taken by CRHs to support the resiliency of the VA healthcare system during the pandemic. We found that the CRH program was flexible and nimble enough to allow VA to leverage providers at hubs to better respond to the demands of COVID-19. Actions taken at hubs to sustain patient access and staff resiliency during the pandemic included supporting call centers and training VA providers on virtual care delivery. Factors that facilitated CRH's emergency response included hub staff expertise in telehealth and the increased acceptability of virtual care among key stakeholders. We conclude that hub providers serving as contingency staff, as well as specialization in delivering virtual outpatient and inpatient care, enabled VA health system resiliency and recovery during the COVID-19 pandemic.

The Unrecognized Role of VA Call Center and Primary Care Clerical Staff in Assisting Patients with Obtaining Needed Care.

BACKGROUND: VA clerks, or medical support assistants (MSAs), are a critical part of patients' primary care (PC) experiences and are often the first points of contact between Veterans and the healthcare system. Despite the important role they might play in assisting Veterans with accessing care, research is lacking on the specific tasks they perform and what training and preparation they receive to perform their roles. OBJECTIVE: Our primary aim in this study was to document MSA perceptions of their roles, the tasks they undertake helping Veterans with accessing healthcare, and additional training they may need to optimally perform their role. DESIGN: Thematic analysis of semi-structured qualitative interviews with VA call center and PC MSAs (n=29) collected as part of in-person site visits from August to October 2019. PARTICIPANTS: MSAs at administrative call centers and primary care clinics in one large VA regional network representing 8 healthcare systems serving nearly 1.5 million Veterans. KEY RESULTS: We identified three key findings from the interviews: (1) MSAs perform tasks in addition to scheduling that help Veterans obtain needed care; (2) MSAs may not be fully prepared for their roles as first points of contact; and (3) low status and lack of recognition of the important and complex tasks performed by MSAs contribute to high turnover. CONCLUSIONS: As healthcare systems continue expanding virtual access, the roles of administrative call center and PC MSAs as first points of contact will be increasingly important for shaping patient experiences. Our research suggests that MSAs may need better training and preparation for the roles they perform assisting Veterans with accessing care, coupled with an intentional approach by healthcare systems to address MSAs' concerns about recognition/compensation. Future research should explore the potential for enhanced MSA customer service training to improve the Veteran patient experience.

Predictors of Internet Health Information-Seeking Behaviors Among Young Adults Living With HIV Across the United States: Longitudinal Observational Study.

BACKGROUND: Consistent with young adults' penchant for digital communication, young adults living with HIV use digital communication media to seek out health information. Understanding the types of health information sought online and the characteristics of these information-seeking young adults is vital when designing digital health interventions for them. OBJECTIVE: This study aims to describe characteristics of young adults living with HIV who seek health information through the internet. Results will be relevant to digital health interventions and patient education. METHODS: Young adults with HIV (aged 18-34 years) self-reported internet use during an evaluation of digital HIV care interventions across 10 demonstration projects in the United States (N=716). Lasso (least absolute shrinkage and selection operator) models were used to select characteristics that predicted whether participants reported seeking general health and sexual and reproductive health (SRH) information on the internet during the past 6 months. RESULTS: Almost a third (211/716, 29.5%) and a fifth (155/716, 21.6%) of participants reported searching for general health and SRH information, respectively; 26.7% (36/135) of transgender young adults with HIV searched for gender-affirming care topics. Areas under the curve (>0.70) indicated success in building models to predict internet health information seeking. Consistent with prior studies, higher education and income predicted health information seeking. Higher self-reported antiretroviral therapy adherence, substance use, and not reporting transgender gender identity also predicted health information seeking. Reporting a sexual orientation other than gay, lesbian, bisexual, or straight predicted SRH information seeking. CONCLUSIONS: Young adults living with HIV commonly seek both general health and SRH information online, particularly those exploring their sexual identity. Providers should discuss the most commonly sought SRH topics and the use of digital technology and be open to discussing information found online to better assist young adults with HIV in finding accurate information. Characteristics associated with health information-seeking behavior may also be used to develop and tailor digital health interventions for these young adults.

Smartphone Self-Monitoring by Young Adolescents and Parents to Assess and Improve Family Functioning: Qualitative Feasibility Study.

BACKGROUND: The natural integration of mobile phones into the daily routines of families provides novel opportunities to study and support family functioning and the quality of interactions between family members in real time. OBJECTIVE: This study aimed to examine user experiences of feasibility, acceptability, and reactivity (ie, changes in awareness and behaviors) of using a smartphone app for self-monitoring of family functioning with 36 participants across 15 family dyads and triads of young adolescents aged 10 to 14 years and their parents. METHODS: Participants were recruited from 2 family wellness centers in a middle-to-upper income shopping area and a low-income school site. Participants were instructed and prompted by alarms to complete ecological momentary assessments (EMAs) by using a smartphone app over 2 weeks 4 times daily (upon waking in the morning, afternoon, early evening, and end of day at bedtime). The domains assessed included parental monitoring and positive parenting, parent involvement and discipline, parent-child conflict and resolution, positive interactions and support, positive and negative affect, sleep, stress, family meals, and general child and family functioning. Qualitative interviews assessed user experiences generally and with prompts for positive and negative feedback. RESULTS: The participants were primarily white and Latino of mixed-income- and education levels. Children were aged 10 to 14 years, and parents had a mean age of 45 years (range 37-50). EMA response rates were high (95% to over 100%), likely because of cash incentives for EMA completion, engaging content per user feedback, and motivated sample from recruitment sites focused on social-emotional programs for family wellness. Some participants responded for up to 19 days, consistent with some user experience interview feedback of desires to continue participation for up to 3 or 4 weeks. Over 80% (25/31) of participants reported increased awareness of their families' daily routines and functioning of their families. Most also reported positive behavior changes in the following domains: decision making, parental monitoring, quantity and quality of time together, communication, self-regulation of stress and conflict, discipline, and sleep. CONCLUSIONS: The results of this study support the feasibility and acceptability of using smartphone EMA by young adolescents and parents for assessing and self-monitoring family daily routines and interactions. The findings also suggest that smartphone self-monitoring may be a useful tool to support improvement in family functioning through functions of reflection on antecedents and consequences of situations, prompting positive and negative alternatives, seeding goals, and reinforcement by self-tracking for self-correction and self-rewards. Future studies should include larger samples with more diverse and higher-risk populations, longer study durations, the inclusion of passive phone sensors and peripheral biometric devices, and integration with counseling and parenting interventions and programs.

Authorship Correction: Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative.

[This corrects the article DOI: 10.2196/10681.].

The Experiences of Young Men, Their Families, and Their Coaches Following a Soccer and Vocational Training Intervention to Prevent HIV and Drug Abuse in South Africa.

Young men in South Africa are at high-risk for HIV, substance abuse, and gender-based violence. This article presents qualitative results from a pilot study testing soccer leagues and vocational training to engage young-adult township men to deliver preventive interventions, including rapid HIV and alcohol/drug testing, shifting attitudes toward gender-based violence, and promoting other prosocial behaviors. Three groups participated in focus groups and in-depth interviews on experiences with the program: (1) a subset of 15 participants, (2) 15 family members, and (3) five intervention coaches. Results suggest that participants first reduced substance use on tournament days and then gradually reduced to practice days and beyond. Families suggested that "keeping young men occupied" and encouragement of prosocial behaviors was critical to risk reduction and led to increased community respect for the men. Coaches noted that behavioral and attitudinal changes were incremental and slow. The use of incentives was problematic and more research is needed to understand how incentives can be used in interventions of this nature.

Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative.

BACKGROUND: In the United States, disparities in the rates of HIV care among youth and young adults result from the intersections of factors that include stigma, substance use, homelessness or marginal housing, institutional neglect, and mental health issues. Novel interventions are needed that are geared to youth and young adults. OBJECTIVE: In this paper, we aim to describe the interventions used by participating sites for Using Social Media initiative, the process for classifying the intervention components, and the methods for conducting a comprehensive evaluation of the interventions. METHODS: In 2015, the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, Special Projects of National Significance (SPNS) funded the Evaluation and Technical Assistance Center (ETAC) at the University of California, Los Angeles and 10 demonstration projects at sites across the United States that incorporated innovative approaches using a variety of social media and mobile technology strategies designed specifically for youth and young adults living with HIV. The ETAC developed a typology, or a classification system, that systematically summarizes the principal components of the interventions into broader groups and developed a multisite, mixed-methods approach to evaluate them based on the Department of Health and Human Services HIV health outcomes along the HIV care continuum. The mixed-methods approach is key to remove potential biases in assessing the effectiveness of demonstration projects. RESULTS: This SPNS project was funded in September 2015, and enrollment was completed on May 31, 2018. A total of 984 participants have been enrolled in the multisite evaluation. Data collection will continue until August 2019. However, data analysis is currently underway, and the first results are expected to be submitted for publication in 2019. CONCLUSIONS: This HRSA-funded initiative seeks to increase engagement in HIV medical care, improve health outcomes for people living with HIV, and reduce HIV-related health disparities and health inequities that affect HIV-positive youth and young adults. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10681.

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa.

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.

Adherence to self-monitoring healthy lifestyle behaviours through mobile phone-based ecological momentary assessments and photographic food records over 6 months in mostly ethnic minority mothers.

OBJECTIVE: Mobile phones can replace traditional self-monitoring tools through cell phone-based ecological momentary assessment (CEMA) of lifestyle behaviours and camera phone-based images of meals, i.e. photographic food records (PFR). Adherence to mobile self-monitoring needs to be evaluated in real-world treatment settings. Towards this goal, we examine CEMA and PFR adherence to the use of a mobile app designed to help mothers self-monitor lifestyle behaviours and stress. Design/Setting In 2012, forty-two mothers recorded CEMA of diet quality, exercise, sleep, stress and mood four times daily and PFR during meals over 6 months in Los Angeles, California, USA. SUBJECTS: A purposive sample of mothers from mixed ethnicities. RESULTS: Adherence to recording CEMA at least once daily was higher compared with recording PFR at least once daily over the study period (74 v. 11 %); adherence to both types of reports decreased over time. Participants who recorded PFR for more than a day (n 31) were more likely to be obese v. normal- to overweight and to have higher blood pressure, on average (all P<0·05). Based on random-effects regression, CEMA and PFR adherence was highest during weekdays (both P<0·01). Additionally, PFR adherence was associated with older age (P=0·04). CEMA adherence was highest in the morning (P<0·01). PFR recordings occurred throughout the day. CONCLUSIONS: Variations in population and temporal characteristics should be considered for mobile assessment schedules. Neither CEMA nor PFR alone is ideal over extended periods.

Sowing the seeds of transformative practice to actualize women's rights to respectful maternity care: reflections from Kenya using the consolidated framework for implementation research.

BACKGROUND: Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. METHODS: We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. RESULTS: The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima's successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. CONCLUSION: We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to understanding a range of interventions that can begin to address issues of mistreatment in maternity care; replication of these activities is needed globally to better understand if the Heshima implementation process can be successful in different countries and regions.

HIV Care Providers' Attitudes regarding Mobile Phone Applications and Web-Based Dashboards to support Patient Self-Management and Care Coordination: Results from a Qualitative Feasibility Study.

In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools.

Smartphone self-monitoring to support self-management among people living with HIV: perceived benefits and theory of change from a mixed-methods randomized pilot study.

BACKGROUND: Self-monitoring by mobile phone applications offers new opportunities to engage patients in self-management. Self-monitoring has not been examined thoroughly as a self-directed intervention strategy for self-management of multiple behaviors and states by people living with HIV (PLH). METHODS: PLH (n = 50), primarily African American and Latino, were recruited from 2 AIDS services organizations and randomly assigned to daily smartphone (n = 34) or biweekly Web-survey only (n = 16) self-monitoring for 6 weeks. Smartphone self-monitoring included responding to brief surveys on medication adherence, mental health, substance use, and sexual risk behaviors, and brief text diaries on stressful events. Qualitative analyses examine biweekly open-ended user-experience interviews regarding perceived benefits and barriers of self-monitoring, and to elaborate a theoretical model for potential efficacy of self-monitoring to support self-management for multiple domains. RESULTS: Self-monitoring functions include reflection for self-awareness, cues to action (reminders), reinforcements from self-tracking, and their potential effects on risk perceptions, motivations, skills, and behavioral activation states. Participants also reported therapeutic benefits related to self-expression for catharsis, nonjudgmental disclosure, and in-the-moment support. About one-third of participants reported that surveys were too long, frequent, or tedious. Some smartphone group participants suggested that daily self-monitoring was more beneficial than biweekly due to frequency and in-the-moment availability. About twice as many daily self-monitoring group participants reported increased awareness and behavior change support from self-monitoring compared with biweekly Web-survey only participants. CONCLUSIONS: Self-monitoring is a potentially efficacious disruptive innovation for supporting self-management by PLH and for complementing other interventions, but more research is needed to confirm efficacy, adoption, and sustainability.