Associations Between Immigration-Related User Factors and eHealth Activities for Self-Care: Case of First-Generation Immigrants From Pakistan in the Oslo Area, Norway.

BACKGROUND: Immigrant populations are often disproportionally affected by chronic diseases, such as type 2 diabetes mellitus (T2DM). Use of information and communication technology (ICT) is one promising approach for better self-care of T2DM to mitigate the social health inequalities, if designed for a wider population. However, knowledge is scarce about immigrant populations' diverse electronic health (eHealth) activities for self-care, especially in European countries. OBJECTIVE: With a target group of first-generation immigrants from Pakistan in the Oslo area, Norway, we aimed to understand their diverse eHealth activities for T2DM self-care in relation to immigration-related user factors specific to this target group: proficiency in relevant languages (Urdu, Norwegian, English), length of residence in Norway, and diagnosis of T2DM compared with general user factors (age, gender, education and digital skills, and self-rated health status). METHODS: Data were from a survey among the target population (N=176) conducted in 2015-2016. Using logistic regression, we analyzed associations between user factors and experiences of each of the following eHealth activities for T2DM self-care in the last 12 months: first, information seeking by (1) search engines and (2) Web portals or email subscriptions; second, communication and consultation (1) by closed conversation with a few acquaintances using ICT and (2) on social network services; and third, active decision making by using apps for (1) tracking health information and (2) self-assessment of health status. Using Poisson regression, we also assessed the relationship between user factors and variety of eHealth activities experienced. The Bonferroni correction was used to address the multiple testing problem. RESULTS: Regression analyses yielded the following significantly positive associations: between Urdu literacy and (1) information seeking by Web portals or email subscriptions (odds ratio [OR] 2.155, 95% CI 1.388-3.344), (2) communication and consultation on social network services (OR 5.697, 95% CI 2.487-13.053), and (3) variety (estimate=0.350, 95% CI 0.148-0.552); between length of residence in Norway and (1) communication and consultation by closed conversation with a few acquaintances using ICT (OR 1.728, 95% CI 1.193-2.503), (2) communication and consultation on social network services (OR 2.098, 95% CI 1.265-3.480), and (3) variety (estimate=0.270, 95% CI 0.117-0.424); between Norwegian language proficiency and active decision making by using apps for self-assessment of health status (OR 2.285, 95% CI 1.294-4.036); between education and digital skills and active decision making by using apps for tracking health information (OR 3.930, 95% CI 1.627-9.492); and between being a female and communication and consultation by closed conversation with a few acquaintances using ICT (OR 2.883, 95% CI 1.335-6.227). CONCLUSIONS: This study implies immigration-related factors may confound associations between general user factors and eHealth activities. Further studies are needed to explore the influence of immigration-related user factors for eHealth activities in other immigrant groups and countries. INTERNATIONAL REGISTERED REPORT: RR2-DOI 10.2196/resprot.5468.

Correction: The Association Between Commonly Investigated User Factors and Various Types of eHealth Use for Self-Care of Type 2 Diabetes: Case of First-Generation Immigrants From Pakistan in the Oslo Area, Norway.

[This corrects the article DOI: 10.2196/publichealth.7009.].

The Association Between Commonly Investigated User Factors and Various Types of eHealth Use for Self-Care of Type 2 Diabetes: Case of First-Generation Immigrants From Pakistan in the Oslo Area, Norway.

BACKGROUND: Sociodemographic and health-related factors are often investigated for their association with the active use of electronic health (eHealth). The importance of such factors has been found to vary, depending on the purpose or means of eHealth and the target user groups. Pakistanis are one of the biggest immigrant groups in the Oslo area, Norway. Due to an especially high risk of developing type 2 diabetes (T2D) among this population, knowledge about their use of eHealth for T2D self-management and prevention (self-care) will be valuable for both understanding this vulnerable group and for developing effective eHealth services. OBJECTIVE: The aim of this study was to examine how commonly were the nine types of eHealth for T2D self-care being used among our target group, the first-generation Pakistani immigrants living in the Oslo area. The nine types of eHealth use are divided into three broad categories based on their purpose: information seeking, communication, and active self-care. We also aimed to investigate how sociodemographic factors, as well as self-assessment of health status and digital skills are associated with the use of eHealth in this group. METHODS: A survey was carried out in the form of individual structured interviews from September 2015 to January 2016 (N=176). For this study, dichotomous data about whether or not an informant had used each of the nine types of eHealth in the last 12 months and the total number of positive answers were used as dependent variables in a regression analysis. The independent variables were age, gender, total years of education, digital skills (represented by frequency of asking for help when using information and communication technology [ICT]), and self-assessment of health status. Principal component analyses were applied to make categories of independent variables to avoid multicollinearity. RESULTS: Principal component analysis yielded three components: knowledge, comprising total years of education and digital skills; health, comprising age and self-assessment of health status; and gender, as being a female. With the exception of closed conversation with a few specific acquaintances about self-care of T2D (negatively associated, P=.02) and the use of ICT for relevant information-seeking by using search engines (not associated, P=.18), the knowledge component was positively associated with all the other dependent variables. The health component was negatively associated with the use of ICT for closed conversation with a few specific acquaintances about self-care of T2D (P=.01) but not associated with the other dependent variables. Gender component showed no association with any of the dependent variables. CONCLUSIONS: In our sample, knowledge, as a composite measure of education and digital skills, was found to be the main factor associated with eHealth use regarding T2D self-care. Enhancing digital skills would encourage and support more active use of eHealth for T2D self-care.

Testing Universal Design of a Public Media Website with Diverse Users.

Testing with users can identify more issues than other testing methods. Many researchers have argued for the importance of user testing in Universal Design. However, testing Universal Design with diverse users poses many challenges. In this paper we will share our experience with testing the Universal Design of a public media website with real users. We discuss the challenges faced and lessons learned in the process.

eHealth Use Among First-Generation Immigrants From Pakistan in the Oslo Area, Norway, With Focus on Diabetes: Survey Protocol.

BACKGROUND: A variety of eHealth services are available and commonly used by the general public. eHealth has the potential to engage and empower people with managing their health. The prerequisite is, however, that eHealth services are adapted to the sociocultural heterogeneity of the user base and are available in a language and with contents that fit the users' preference, skills, and abilities. Pakistani immigrants in the Oslo area, Norway, have a much higher risk of Type-2 diabetes (T2D) than their Norwegian counterparts do. In spite of having access to information and communication technology (ICT) and the Internet, ICT skills in this population are reported to be relatively low. Further, there is insufficient information about their use of and attitudes toward eHealth services, necessitating investigation of this group in particular. OBJECTIVE: This study targets first-generation immigrants from Pakistan living in the Oslo area and examines their use of and attitudes toward eHealth services, specifically: information searches, communication using ICT, and use of ICT for self-management or decision making, all concerning T2D. METHODS: Due to a high prevalence of low literacy among the target population, we employed questionnaire-based individual interviews. The questionnaire was developed by implementing potentially relevant theoretical constructs (technology acceptance model (TAM) and health belief model (HBM)) as measures. To explore issues around language, culture, and general ICT skills, we also implemented questions that we assume were particularly relevant in the context studied but do not appear in any theoretical frameworks. The questionnaire was revised to reflect results of a pilot study involving 10 participants. We employed culturally sensitive sampling methods to reach informants who could otherwise fail to be included in the survey. RESULTS: This paper presents a survey protocol. The data collection is ongoing. The aim is to collect 200 responses in total by March 2016. CONCLUSIONS: For eHealth to become an influential social innovation, equal access to eHealth services regardless of users' language, culture, and ICT skills is a prerequisite. Results from this study will be of importance for understanding how people who may not maximally benefit from eHealth services today could be targeted in the future.

Usage and perceptions of a mobile self-management application for people with type 2 diabetes: qualitative study of a five-month trial.

Despite a growing number of clinical-intervention studies of mobile applications for diabetes self-management, details of participants' engagement with the intervention tools and of usability and feasibility issues are seldom reported. The Few Touch application is a mobile-phone-based self-management system for people with Type 2 diabetes mellitus (T2DM) developed by involving patient-users in design processes from an early phase to a long-term trial. An improved version was tested in a five-month trial by 11 individuals either with T2DM or at high risk of T2DM. Results showed clearer correlations between usage and perceived usefulness among these individuals compared with those involved in the design process. However, feedback on usability issues was mostly consistent between the two trials. This study therefore confirmed: 1) the value of including patient-users not only in design-concept development but also in a long-term trial to identify as many factors critical to usability and usage as possible, and 2) the importance of reflecting their feedback in design iterations to minimize the number of critical factors.

Designing a diabetes mobile application with social network support.

Although mobile applications and social media have emerged as important facets of the Internet, their role in healthcare is still not well-understood. We present design artefacts, inspired by persuasive technology concepts, from a study of social media as part of a diabetes mHealth application. We used the design science approach for mobile application design, and real-life user testing and focus group meetings to test the application over a 12-week period with 7 participants. Based on the System Usability Score (SUS), the mobile application scored an average of 84.6 (SD=13.2), which represents a fairly high usability score compared to the literature. Regression analysis on the daily blood glucose levels showed significant decreases for some patients, and although the study is not powered, the HbA1c showed a promising trend, and self-efficacy marginally increased. Incorporating persuasive elements such as blood glucose tracking and visualisation, and social media access directly from the mobile application produced promising results that warrant a larger study of behaviour change for people with diabetes.

Long-term engagement with a mobile self-management system for people with type 2 diabetes.

BACKGROUND: In a growing number of intervention studies, mobile phones are used to support self-management of people with Type 2 diabetes mellitus (T2DM). However, it is difficult to establish knowledge about factors associated with intervention effects, due to considerable differences in research designs and outcome measures as well as a lack of detailed information about participants' engagement with the intervention tool. OBJECTIVE: To contribute toward accumulating knowledge about factors associated with usage and usability of a mobile self-management application over time through a thorough analysis of multiple types of investigation on each participant's engagement. METHODS: The Few Touch application is a mobile-phone-based self-management tool for patients with T2DM. Twelve patients with T2DM who have been actively involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009. During this period, questionnaires and semistructured interviews were conducted. Recorded data were analyzed to investigate usage trends and patterns. Transcripts from interviews were thematically analyzed, and the results were further analyzed in relation to the questionnaire answers and the usage trends and patterns. RESULTS: The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring. A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely. Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application. Some of the problems stemmed from difficulties in integrating the use of the application into each participant's everyday life and needs, although the design concepts were developed in the process where the participants were involved. The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods. CONCLUSION: Many grounded design implications were identified through a thorough analysis of results from multiple types of investigations obtained through a year-long field trial of the Few Touch application. The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time. In addition, the study confirmed the importance of detailed analyses of each participant's usage of the provided tool for better understanding of participants' engagement over time.

Mobile health applications to assist patients with diabetes: lessons learned and design implications.

Self-management is critical to achieving diabetes treatment goals. Mobile phones and Bluetooth® can supportself-management and lifestyle changes for chronic diseases such as diabetes. A mobile health (mHealth) research platform--the Few Touch Application (FTA)--is a tool designed to support the self-management of diabetes. The FTA consists of a mobile phone-based diabetes diary, which can be updated both manually from user input and automatically by wireless data transfer, and which provides personalized decision support for the achievement of personal health goals. Studies and applications (apps) based on FTAs have included: (1) automatic transfer of blood glucose (BG) data; (2) short message service (SMS)-based education for type 1diabetes (T1DM); (3) a diabetes diary for type 2 diabetes (T2DM); (4) integrating a patient diabetes diary with health care (HC) providers; (5) a diabetes diary for T1DM; (6) a food picture diary for T1DM; (7) physical activity monitoring for T2DM; (8) nutrition information for T2DM; (9) context sensitivity in mobile self-help tools; and (10) modeling of BG using mobile phones. We have analyzed the performance of these 10 FTA-based apps to identify lessons for designing the most effective mHealth apps. From each of the 10 apps of FTA, respectively, we conclude: (1) automatic BG data transfer is easy to use and provides reassurance; (2) SMS-based education facilitates parent-child communication in T1DM; (3) the T2DM mobile phone diary encourages reflection; (4) the mobile phone diary enhances discussion between patients and HC professionals; (5) the T1DM mobile phone diary is useful and motivational; (6) the T1DM mobile phone picture diary is useful in identifying treatment obstacles; (7) the step counter with automatic data transfer promotes motivation and increases physical activity in T2DM; (8) food information on a phone for T2DM should not be at a detailed level; (9) context sensitivity has good prospects and is possible to implement on today's phones; and (10) BG modeling on mobile phones is promising for motivated T1DM users. We expect that the following elements will be important in future FTA designs: (A) automatic data transfer when possible; (B) motivational and visual user interfaces; (C) apps with considerable health benefits in relation to the effort required; (D) dynamic usage, e.g., both personal and together with HC personnel, long-/short-term perspective; and (E) inclusion of context sensitivity in apps. We conclude that mHealth apps will empower patients to take a more active role in managing their own health.

Review of mobile terminal-based tools for diabetes diet management.

Changing dietary habits is one of the most challenging tasks of diabetes self-management. Mobile terminals are increasingly used as platforms for tools to support diet management and health promotion. We present literature describing mobile terminal-based support tools for management of diabetes focused on diet. We also propose a summary of key success factors for designing such tools and discuss recommendations for future research.

Mobile phone-based self-management tools for type 2 diabetes: the few touch application.

BACKGROUND: Mobile phones and other mobile information and communication technology applications and technologies hold great potential as a basis for powerful patient-operated self-management tools within diabetes. The work presented shows how such tools can be designed for supporting lifestyle changes among people with type 2 diabetes and how these were perceived by a group of 12 patients during a 6-month period. METHOD: The study used focus groups, interviews, feasibility testing, questionnaires, paper prototyping, and prototyping of both software and hardware components. The design process was iterative, addressing the various elements several times at an increasing level of detail. The final test of the application was done qualitatively in everyday settings in a cohort of 12 people with type 2 diabetes, aged 44-70 (four men and eight women). RESULTS: A mobile phone-based system called the Few Touch application was developed. The system includes an off-the-shelf blood glucose (BG) meter, a tailor-made step counter, and software for recording food habits and providing feedback on how users perform in relation to their own personal goals. User feedback from the 6-month user intervention demonstrated good usability of the tested system, and several of the participants adjusted their medication, food habits, and/or physical activity. Of the five different functionalities, the cohort considered the BG sensor system the best. CONCLUSIONS: It was shown that it is possible and feasible to design an application where several sensors and feedback applications are integrated in an overall system. The presented Few Touch application challenges people with type 2 diabetes to think about how they can improve their health, providing them with a way to capture and analyze relevant personal information about their disease. The half-year user intervention demonstrated that the system had a motivational effect on the users.

A novel blood pressure monitoring device for ubiquitous healthcare services.

Hypertension is a world wide issue, and it is now generally accepted that its diurnal pattern has a prognostic significance. The purpose of this study is to develop a novel blood pressure (BP) monitoring device that causes less discomfort and is less disruptive of users' daily activities than conventional ambulatory blood pressure monitoring (ABPM) devices. The proposed device is worn at an ear orifice and measures BP at the tragus. This paper first covers the concept of the device, including the validity of measuring BP at the tragus, and describes the device's newly designed applicator, pad-type cuffs, electric circuit, and pressure reduction method. It then presents a preliminary validation of the basic function as BP measurement device. The developed device causes almost no discomfort and produces signals whose quality is high enough to be used for detecting BP values and useful for health care services.