Design and rationale of the mobile health intervention for rural atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a highly morbid condition which requires long-term adherence to oral anticoagulation and may be associated with adverse quality of life and health care utilization. We developed a relational agent-an interactive smartphone-based intervention accessible regardless of digital or health literacy-to assist individuals residing in rural, Western Pennsylvania, with AF with chronic disease self-management. METHODS: The "Mobile health intervention for rural atrial fibrillation" is a single center, parallel-arm randomized clinical trial for adults with AF funded by the National Institute of Health's National Heart, Lung, and Blood Institute to enroll 264 participants. All participants receive a smartphone with data plan: The intervention is a 4 month relational agent coupled with the AliveCor Kardia for heart rate and rhythm monitoring provided by smartphone, and the control a pre-installed, smartphone-based application for health-related information (WebMD). The study uses remote recruitment and engagement to enroll individuals who would otherwise be unlikely to participate in clinical research due to rurality. The primary outcome of the trial is adherence to oral anticoagulation, determined by proportion of days covered, as measured at 12 months. The secondary outcomes are quality of life, both AF-specific and general, and health care utilization. The study entails a baseline visit, a 4 month intervention phase, and 8 and 12 month follow-up visits. CONCLUSIONS: This mobile health trial tests the effectiveness of a smartphone-based relational agent to improve clinical and patient-reported outcomes in rural-dwelling individuals.

Designing Empathic Virtual Agents: Manipulating Animation, Voice, Rendering, and Empathy to Create Persuasive Agents.

Designers of virtual agents have a combinatorically large space of choices for the look and behavior of their characters. We conducted two between-subjects studies to explore the systematic manipulation of animation quality, speech quality, rendering style, and simulated empathy, and its impact on perceptions of virtual agents in terms of naturalness, engagement, trust, credibility, and persuasion within a health counseling domain. In the first study, animation was varied between manually created, procedural, or no animations; voice quality was varied between recorded audio and synthetic speech; and rendering style was varied between realistic and toon-shaded. In the second study, simulated empathy of the agent was varied between no empathy, verbal-only empathic responses, and full empathy involving verbal, facial, and immediacy feedback. Results show that natural animations and recorded voice are more appropriate for the agent's general acceptance, trust, credibility, and appropriateness for the task. However, for a brief health counseling task, animation might actually be distracting from the persuasive message, with the highest levels of persuasion found when the amount of agent animation is minimized. Further, consistent and high levels of empathy improve agent perception but may interfere with forming a trusting bond with the agent.

Mitigating Patient and Consumer Safety Risks When Using Conversational Assistants for Medical Information: Exploratory Mixed Methods Experiment.

BACKGROUND: Prior studies have demonstrated the safety risks when patients and consumers use conversational assistants such as Apple's Siri and Amazon's Alexa for obtaining medical information. OBJECTIVE: The aim of this study is to evaluate two approaches to reducing the likelihood that patients or consumers will act on the potentially harmful medical information they receive from conversational assistants. METHODS: Participants were given medical problems to pose to conversational assistants that had been previously demonstrated to result in potentially harmful recommendations. Each conversational assistant's response was randomly varied to include either a correct or incorrect paraphrase of the query or a disclaimer message-or not-telling the participants that they should not act on the advice without first talking to a physician. The participants were then asked what actions they would take based on their interaction, along with the likelihood of taking the action. The reported actions were recorded and analyzed, and the participants were interviewed at the end of each interaction. RESULTS: A total of 32 participants completed the study, each interacting with 4 conversational assistants. The participants were on average aged 42.44 (SD 14.08) years, 53% (17/32) were women, and 66% (21/32) were college educated. Those participants who heard a correct paraphrase of their query were significantly more likely to state that they would follow the medical advice provided by the conversational assistant (χ21=3.1; P=.04). Those participants who heard a disclaimer message were significantly more likely to say that they would contact a physician or health professional before acting on the medical advice received (χ21=43.5; P=.001). CONCLUSIONS: Designers of conversational systems should consider incorporating both disclaimers and feedback on query understanding in response to user queries for medical advice. Unconstrained natural language input should not be used in systems designed specifically to provide medical advice.

Black Men's Experiences With Health care: Individuals' Accounts of Challenges, Suggestions for Change, and the Potential Utility of Virtual Agent Technology to Assist Black Men With Health Management.

Black men have the highest age-adjusted death rate of any major race-gender group in America. Understanding their perceived barriers to accessing health care may benefit future interventions working to increase Black men's health care engagement. Data collected from focus groups of Black men(N = 67), key informant interviews(N = 12), and interviews(N = 5) with participants who pilot tested an online health education system (called "Gabe") were analyzed to explore their health care experiences and how computer-based health programs might better assist Black men. Concerns pertaining to health care systems' failure to recognize the diversity among Black men, and physicians' lack of sociocultural awareness about the challenges they regularly face, were most salient. Building trust with providers was cited as being central to engagement, with Gabe users perceiving the system to be both trustworthy and accessible. Participants reported an openness to technology assisting with health management and provided suggestions of how online systems can meet the needs of Black men.

Patient and Consumer Safety Risks When Using Conversational Assistants for Medical Information: An Observational Study of Siri, Alexa, and Google Assistant.

BACKGROUND: Conversational assistants, such as Siri, Alexa, and Google Assistant, are ubiquitous and are beginning to be used as portals for medical services. However, the potential safety issues of using conversational assistants for medical information by patients and consumers are not understood. OBJECTIVE: To determine the prevalence and nature of the harm that could result from patients or consumers using conversational assistants for medical information. METHODS: Participants were given medical problems to pose to Siri, Alexa, or Google Assistant, and asked to determine an action to take based on information from the system. Assignment of tasks and systems were randomized across participants, and participants queried the conversational assistants in their own words, making as many attempts as needed until they either reported an action to take or gave up. Participant-reported actions for each medical task were rated for patient harm using an Agency for Healthcare Research and Quality harm scale. RESULTS: Fifty-four subjects completed the study with a mean age of 42 years (SD 18). Twenty-nine (54%) were female, 31 (57%) Caucasian, and 26 (50%) were college educated. Only 8 (15%) reported using a conversational assistant regularly, while 22 (41%) had never used one, and 24 (44%) had tried one "a few times." Forty-four (82%) used computers regularly. Subjects were only able to complete 168 (43%) of their 394 tasks. Of these, 49 (29%) reported actions that could have resulted in some degree of patient harm, including 27 (16%) that could have resulted in death. CONCLUSIONS: Reliance on conversational assistants for actionable medical information represents a safety risk for patients and consumers. Patients should be cautioned to not use these technologies for answers to medical questions they intend to act on without further consultation from a health care provider.

From unemployment to disability? Relationship between unemployment rate and new disability pensions in Iceland 1992-2007.

BACKGROUND: The study was carried out in order to examine the effect of unemployment on the incidence of disability pension in Iceland by examining changes in this relationship from 1992 to 2007. METHODS: The annual incidence of disability pension for the period 1992-2007 was calculated. Correlations and significance tests for the relationship between unemployment rates and disability pension incidence rates were calculated. The relationship was examined for different disease groups. RESULTS: Two big fluctuations occurred in the unemployment rate during the study period with an upswing in unemployment from 1993 to 1995 and in 2002 and 2003. In both cases, there were corresponding increases in the incidence of disability pension. The incidence of disability pension declined again when the level of unemployment went down, even though not to the same extent. CONCLUSIONS: Health and mental and physical capability determine the overall incidence of disability pension, but marginal fluctuations over time seem to be related to environmental conditions in the labour market, especially the unemployment rate. The observed disability pension incidence pattern in the two unemployment cycles of the study period indicates mainly that people with impaired health are forced out of the labour market in times of increasing unemployment rather than pointing towards a negative effect of unemployment on health. Our findings indicate that there is a need to strengthen the vocational rehabilitation system in Iceland as well as the support system for employment and social participation.

Increased incidence of disability due to mental and behavioural disorders in Iceland 1990-2007.

AIMS: To explore longitudinal changes in the importance of mental and behavioural disorders and their subgroups among people receiving disability pension in Iceland in the period 1990 to 2007. METHOD: Estimation of the incidence of disability pension was based on national demographic data and information from the national disability register which includes the main diagnoses causing disability. RESULTS: The share of mental and behavioural disorders among new recipients of disability pension increased from 14 to 30% for women and 20 to 35% men. There was a marked increase in the incidence of disability due to disorders related to the use of alcohol and other psychoactive substances, mood disorders, disorders of psychological development and behavioural and emotional disorders with onset usually occurring in childhood and adolescence. The proportion of mental and behavioural disorders as the primary diagnosis among new recipients of disability pension increased. CONCLUSION: The most likely explanation for the changes we observe is alteration in social conditions leading to a lower threshold for seeking disability pension for mental disorders.

[Fluctuations in unemployment and disability in Iceland 1992-2006]. / Sveiflur í atvinnuleysi og örorku á Islandi 1992-2006.

OBJECTIVE: To examine and explain the effect of unemployment on the number of disability pensioners in Iceland by examining changes in this relationship from 1992 to 2006. MATERIAL AND METHODS: Information on gender and place of residence of new recipients of disability pension in Iceland and corresponding information on unemployment for each year in the period 1992 to 2006. The variables were correlated and disaggregated by gender and regions within Iceland. RESULTS: Two big fluctuations occurred in the rate of new disability pension receivers during the study period, with significant increases in disability from 1993 to 1995 and again from 2003 onwards. Both of these fluctuations are associated with considerable increases in the unemployment rate. The extent of new disability pensioners declined again when the level of unemployment went down, even though not to the same relative extent. In the upswing from 2003 a delay of about a year in the increase of disability pensioners' numbers, following the rise in unemployment rate, became more prominent and the overall rate of new disability pensioners reached new highs. The relationship applies equally to the capital area as well as the provincial areas as a whole. There is though a small deviation in three of the seven provincial areas, with less decline of the disability rate on the downswing. CONCLUSION: Health and capability condition determine the overall disability rate, but fluctuations over time are related to environmental conditions in the labour market, especially the unemployment rate. The features of the welfare system, especially the benefit and rehabilitation system, as well as the extent and character of activation measures in the labour market also influence the number of disability pensioners. A new method of disability assessment from late 1999 may have had some influence on the relationship during the latter part of the period and increasing applications from people with mental and psychiatric deficiencies seems to have had a significant influence on the growing disability rate during the last few years.

[Prevalence of disability in Iceland in December 2005]. / Algengi örorku á Islandi 1. desember 2005.

OBJECTIVE: To determine the size and main medical and social characteristics of the group of individuals receiving disability benefits in Iceland in December 2005. MATERIAL AND METHODS: The study includes all those receiving disability benefits in Iceland on December 1st 2005 as ascertained by the disability register at the State Social Security Institute of Iceland classified by gender, age and place of residence. Similar information was obtained on the Icelandic population. The prevalence of disability pension was calculated. RESULTS: On December 1st 2005 the prevalence of disability pension was 8.6% for females (8.0% for the higher and 0.6% for the lower pension level) and 5.5% for males (5.2% for the higher and 0.3% for the lower pension level). For females the prevalence of disability was lower in the capital region than in other regions, but this was not the case for males. The prevalence of disability increased with age. On the whole disability was more common among females than males. Mental and behavioural disorders and diseases of the musculoskeletal system and connective tissue were the most prevalent causes of disability. CONCLUSION: The prevailing trend over the last decade of increasing disability in Iceland has continued. Iceland appears to lag behind the other Nordic countries in the use of vocational rehabilitation and labour marked activation to prevent disability. Ample opportunities to slow down this trend are therefore available by greater emphasis on such measures.

Phases of earthquake experience: a case study of the June 2000 south Iceland earthquakes.

A case study of the impact factors of stress and relief in the wake of the south Iceland earthquakes in 2000 is presented. By applying axial coding analysis, the isolated concurrent and interplaying sociostructural impact factors were added sequentially to a time axis based on interviews with sufferers, as well as observations and a survey analysis. The data were obtained through a field survey using standardized questionnaires as well as numerous personal in-depth interviews, photographs, and field notes. An exposition of the different phases of the earthquake experience is presented, reflecting the victims' conscious and/or unconscious efforts to bring life back to "normal," though constantly burdened by a perceived lack of understanding of their experiences by "outsiders." The process was characterized by six main stress factors and three noteworthy mitigating factors. The findings are important for vulnerability and risk assessment as well as for planning pre-, pro-, and postearthquake reactions in the affected areas.

[Relationship between rate of unemployment and incidence of disability pension in Iceland 1992-2003.].

OBJECTIVE: To evaluate the effect of unemployment and the introduction of a new method of disability assessment on the number of recipients of disability pension in Iceland by examining changes in the incidence of disability pension and unemployment year by year from 1992 to 2003. MATERIAL AND METHODS: Information on gender, age and disability grade of new recipients of disability pension in Iceland and corresponding information on the Icelandic population for each year in the period 1992 to 2003 was used to calculate the incidence of disability pension. The results were compared with data on the rate of unemployment in Iceland. RESULTS: The incidence of disability pension was relatively high from 1992 to 1995, was lower from 1996 to 2002 and then increased markedly in 2003. There is a strong correlation between the incidence of disability pension and the rate of unemployment among both genders in Iceland during the period covered by the study. An increase from 1999 to 2000 in the incidence of disability pension among females coincided in time with the introduction of a new method of disability assessment in September 1999, but also with an increase in the rate of unemployment among females. CONCLUSION: It is not warranted to claim that the introduction of a new method of disability evaluation in September 1999 has resulted in a decisive increase in the incidence of disability pension in Iceland. The increase in the number of recipients of disability pension in Iceland recently has a strong statistical correlation with changes in the labour marked, especially with rising unemployment and increased pressure at work.

Changes in the prevalence of disability pension in Iceland 1976-1996.

AIMS: The objectives were to determine changes in the prevalence of disability pension in Iceland and its distribution according to gender, age, and main diagnoses. METHODS: The study includes all persons receiving either full or partial disability pension in 1976 and 1996. The age-standardized risk ratio between the years 1976 and 1996 was calculated for all disability pensions and for full disability pension only. RESULTS: The prevalence of all disability pensions decreased significantly among both men and women in 1996 as compared with 1976. When the figures were disaggregated, however, theyrevealed an increased risk of full disability pension and a decreased risk of partial disability pension. Th e prevalence of full disability pension had increased in most disease categories. CONCLUSION: The decreased prevalence of disability pension in 1996 as compared with 1976 is noteworthy, as unemployment was increasing during the years immediately preceding 1996. It seems likely, however, that the decrease of partial disability pension and increase of full disability pension is a reflection of increased competition for work in the labour market as well as increased attractiveness of full disability pension due to new supplementary sickness insurance benefits linked to full disability pension.