Perspectives of Sexual and Gender Minority Youth on Anti-Vaping Messages in Social Media.

INTRODUCTION: Sexual and gender minority (SGM) youth have higher rates of nicotine vaping than other youth in the United States. While social media can be effective in reaching youth and discouraging vaping, informed cultural tailoring is necessary to ensure effective messaging to SGM youth. This study aimed to understand SGM youth perspectives on anti-vaping social media messages and tailoring approaches. METHODS: In-depth, qualitative videoconference interviews were conducted from February to July 2022 with 34 SGM youth recruited in the United States via social media ads. The interview guide addressed participants' beliefs about vaping, the context of vaping, perspectives on tailoring messages, and responses to examples of social media anti-vaping messages. Coding and thematic analysis followed a team-based approach. RESULTS: SGM youth perspectives fell into four categories - representation and diversity, facts and evidence, empowering messages, and source credibility. Participants stressed the importance of accurate, genuine representation of SGM youth in messages, but also noted that more overt representation may be seen as tokenizing. Participants recommended partnering with known LGBTQ+ influencers who can promote or share anti-vaping messages on social media platforms. They also recommended using culturally tailored language, including statistics specific to SGM youth, and invoking themes of empowerment to improve the relevance, reach, and effectiveness of anti-vaping campaigns. CONCLUSIONS: Findings can inform future efforts to develop anti-vaping messages for SGM youth with effective reach through social media. Nuanced perspectives on SGM representation in messages suggest a careful approach to tailoring. Concerns around inauthenticity may be minimized by ensuring SGM youth are included in message development and dissemination. IMPLICATIONS: This study describes the importance of being attentive to the tailoring preferences among the current generation of sexual and gender minority youth. Findings will inform social media-based messaging strategies that discourage nicotine vaping tailored for SGM youth in health campaign material design and evaluation, ensuring that tailored messages are designed in ways that avoid unintended consequences. The study also describes methods for effectively engaging SGM youth in research to improve the relevance of health education materials for this population and increase reach, which in turn can lead to reduction in vaping practices among SGM youth.

Reducing risk for chronic disease: evaluation of a collective community approach to sustainable evidence-based health programming.

BACKGROUND: Community initiatives can shape health behaviors, such as physical activity and dietary habits, across a population and help reduce the risk of developing chronic disease. To achieve this goal and impact health outcomes, Pasadena Vibrant Community aimed to engage communities in an ongoing dialogue about the importance of healthy behaviors, implement and advance community-based strategies to promote health, and improve diet and physical activity behaviors. The initiative was centered around a collaboration between a backbone organization, steering committee, and 7 collaborating organizations funded to implement multicomponent, evidence-based programs.. The common agenda was detailed in a community action plan, which included 19 interventions targeting healthy eating and active living among adults and youth in Pasadena, Texas. METHODS: A mixed methods evaluation of the initiative was conducted over 4 years. Data sources included document reviews of quarterly progress reports (n = 86) and supplemental data reports (n = 16) provided by collaborating organizations, annual Steering Committee surveys (n = 4), and interviews conducted with staff from a subset of Collaborating Organizations (n = 4). RESULTS: The initiative reached over 50,000 community members per year through 19 evidence-based interventions and impacted health outcomes, including knowledge and adoption of healthy eating practices and increased physical activity. Thirty-one systems-level changes were implemented during the initiative, including 16 environmental changes. Steering Committee meetings and shared goals enabled connections, communication, and cooperation, which allowed Collaborating Organizations to address challenges and combine resources to deliver their programs. CONCLUSIONS: Community initiatives can effectively permeate the community by reaching individuals, improving physical activity and dietary habits, and ensuring sustainability. Based on the experience reported here, the success of a community initiative can be facilitated if collaborating organizations come together to implement evidence-based interventions and tailor them to the community, and if they are empowered by significant leadership and supportive collaboration and aligned by a common agenda.

The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders.

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

Identifying Implementation Strategies That Address Barriers and Facilitate Implementation of Digital Interventions in HIV Primary Care Settings: Results from the Pilot Implementation of Positive Health Check.

We used the 1-month pilot implementation of Positive Health Check, a brief web-based video counseling intervention that supports patients with HIV attending HIV primary care clinics, to exemplify how studying implementation strategies earlier in the evidence-generation process can improve implementation outcomes in later pragmatic trials. We identified how implementation strategies were operationalized and the barriers and facilitators these strategies addressed using multiple data sources, including adapted implementation procedures and weekly structured interviews conducted with 9 key stakeholders in 4 HIV primary care clinics. Nineteen of 73 discrete implementation strategies for clinical innovations were used in the pilot implementation of Positive Health Check. Clinic staff reported 17 barriers and facilitators related to the clinic environment, patient population, intervention characteristics, and training and technical assistance. Identifying the link between strategies, barriers, and facilitators helped plan for a subsequent larger multisite pragmatic trial.

"Tobacco-free nicotine" electronic cigarette perceptions and use among adolescents and adults in five New England states.

Introduction: More brands are using tobacco-free nicotine (TFN) in electronic cigarettes (e-cigarettes) and these products are becoming increasingly popular. The term TFN and claims about its properties can mislead consumers about the harms and addictiveness of TFN e-cigarettes, which may increase initiation of these products among non-smokers or influence current smokers' decisions to adopt TFN e-cigarettes as a harm reduction measure. Methods: We conducted an observational, cross-sectional survey of 777 adolesc aged 13-17 and 655 current adult cigarette smokers residing in Massachusetts, Connecticut, New Hampshire, Rhode Island, or Vermont about their TFN e-cigarette awareness, use, perceptions, and susceptibility. We examined the association between prior awareness of TFN and use, perceptions, and susceptibility. Results: One-third of adolescents and adults reported being aware of TFN. TFN e-cigarette use was less common than tobacco-derived nicotine (TDN) e-cigarette use among adolescents (8.9 % vs. 30.5 %) and adults (21.1 % vs. 79.4 %). Compared to unaware adolescents, adolescents who were aware of TFN more frequently reported being more likely to use TFN compared to TDN e-cigarettes and that TFN e-cigarettes are more addictive than those containing TDN. Aware adult smokers more frequently reported that TFN e-cigarettes are more addictive than TDN e-cigarettes, TFN e-cigarettes cause some harm, TDN e-cigarettes cause little harm, and that TFN and TDN e-cigarettes are equally harmful than those who were unaware previously. Conclusion: Public health education campaigns are needed to educate consumers about the harms and addictiveness of TFN e-cigarettes.

Using wiki surveys to rapidly test messages promoting COVID-19 vaccination boosters and child vaccination among Philadelphia residents.

Formative research is an important component of health communication campaign development. Rapid message testing approaches are useful for testing new messaging quickly and efficiently during public health emergencies, such as COVID-19, when guidance and recommendations are rapidly changing. Wiki surveys simultaneously collect quantitative message testing data and qualitative feedback on potential social media campaign messages. Philly CEAL used wiki surveys to test messages about COVID-19 vaccinations for dissemination on social media. A cross-sectional survey of Philadelphia residents (N = 199) was conducted between January and March 2023. Wiki surveys were used to assess the perceived effectiveness of messages promoting the updated COVID-19 booster and child vaccination. In each wiki survey, participants were presented with two messages and asked to select the one that they perceived as most effective. Participants could alternatively select "can't decide" or submit their own message. A score estimating the probability of selection was calculated for each message. Participant-generated messages were routinely reviewed and incorporated into the message pool. Participants cast a total of 32,281 votes on messages seeded by the research team (n = 20) and participants (n = 43). The highest scoring messages were those that were generated by participants and spoke to getting your child vaccinated to protect them against serious illness and getting the booster to protect your health and that of your community. These messages were incorporated into social media posts disseminated by Philly CEAL's social media accounts. Wiki surveys are a feasible and efficient method of rapid message testing for social media campaigns.

Culturally Tailored Anti-Smoking Messages: A Randomized Trial With U.S. Sexual Minority Young Women.

INTRODUCTION: This study evaluated effects of exposure to culturally tailored anti-smoking ads versus control ads on quitting intentions, cigarette purchase intentions, and tobacco industry perceptions among young adult, cisgender and transgender, sexual minority women (SMW). STUDY DESIGN: An online randomized controlled experiment with 1-month longitudinal follow-up was conducted. SETTING AND PARTICIPANTS: About 2,214 U.S. SMW ages 18-30 were recruited via online survey panels (The PRIDE Study and Prolific), social media ads and posts, and HER dating app ads. Data were collected in 2021-2022. INTERVENTION: Participants were randomly assigned to receive up to 20 tailored ads containing LGBTQ+ branding versus 20 control ads without LGBTQ+ branding over 4 weeks. Both conditions used identical anti-smoking statements and photographs (including several photographs of individuals who self-identified as SMW). MAIN OUTCOME MEASURES: One-month follow-up intention to purchase cigarettes, intention to quit, marketing receptivity, pro-industry attitudes, and pro-industry beliefs were measured. Analyses were conducted in 2022-2023. Linear regression models predicted outcomes at 1-month follow-up with the randomized arm, adjusted for baseline measures of each outcome and stratified by smoking status (those who currently smoked and those who did not smoke). RESULTS: Among those who smoked, follow-up intention to quit increased and intention to purchase cigarettes, marketing receptivity, pro-industry attitudes, and pro-industry beliefs decreased versus baseline in both arms. Follow-up pro-industry beliefs were significantly lower (B=-0.331, 95% CI -0.652, -0.010, p=0.043) in the tailored versus control arm, adjusted for baseline beliefs. Among those who did not smoke, marketing receptivity, pro-industry attitudes, and pro-industry beliefs decreased versus baseline in both arms. Follow-up outcomes did not differ significantly between arms. CONCLUSIONS: These findings can inform future anti-smoking campaign development to reduce cigarette smoking-related disparities among young adult, cisgender and transgender, sexual minority women and serve as the basis for developing similar ads for other LGBTQ+ audiences. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT04812795).

Effects of brief exposure to misinformation about e-cigarette harms on Twitter on knowledge and perceptions of e-cigarettes.

Background: This study examined whether exposure to misinformation found on Twitter about e-cigarette harms leads to inaccurate knowledge and misperceptions of harms of e-cigarette use among cigarette smokers. Methods: We conducted an online randomized controlled experiment in November 2019 among an online sample of 2400 adult US and UK cigarette smokers who did not currently use e-cigarettes. Participants viewed four tweets in one of four conditions: 1) e-cigarettes are as or more harmful than smoking, 2) e-cigarettes are completely harmless, 3) e-cigarette harms are uncertain and 4) control (physical activity). Outcomes were knowledge about e-cigarettes and harm perceptions of e-cigarette use for five diseases. We conducted multiple logistic and linear regressions to analyze the effect of experimental conditions on outcomes, controlling for baseline knowledge and perceived harms. Findings: Participants in the 'as or more harmful' condition (vs. control group) had higher odds of accurate knowledge about e-cigarettes containing toxic chemicals (p < 0.001), not containing only water vapor (p < 0.001) and containing formaldehyde (p < 0.001). However, these participants had lower odds of accurate knowledge that e-cigarettes did not contain tar (p < 0.001) and contained fewer toxins than cigarettes (p < 0.001). Exposure to 'as or more harmful' tweets also increased harm perceptions for five diseases (all p < 0.001), with the greatest effect observed for lung cancer (ß = 0.313, p < 0.001). This effect was greater among UK participants for all diseases. Interpretation: Brief exposure to misinformation on Twitter reduced accurate knowledge of the presence of tar and the level of toxins compared with smoking and increased harm perceptions of e-cigarette use.

The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study.

BACKGROUND: Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT). SETTING: Clinical and nonclinical HIV service organizations (HSOs) in the United States. METHODS: In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18). RESULTS: Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores. CONCLUSIONS: Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.

Effectiveness of an Interactive, Highly Tailored "Video Doctor" Intervention to Suppress Viral Load and Retain Patients With HIV in Clinical Care: A Randomized Clinical Trial.

BACKGROUND: To determine whether Positive Health Check, a highly tailored video doctor intervention, can improve viral suppression and retention in care. SETTING: Four clinics that deliver HIV primary care. METHODS: A hybrid type 1 effectiveness-implementation randomized trial design was used to test study hypotheses. Participants (N = 799) who were not virally suppressed, were new to care, or had fallen out of care were randomly assigned to receive Positive Health Check or the standard of care alone. The primary endpoint was viral load suppression, and the secondary endpoint was retention in care, both assessed at 12 months, using an intention-to-treat approach. A priori subgroup analyses based on sex assigned at birth and race were examined as well. RESULTS: There were no statistically significant differences between Positive Health Check (N = 397) and standard of care (N = 402) for either endpoint. However, statistically significant group differences were identified from a priori subgroup analyses. Male participants receiving Positive Health Check were more likely to achieve suppression at 12 months than male participants receiving standard of care adjusted risk ratio [aRR] [95% confidence interval (CI)] = 1.14 (1.00 to 1.29), P = 0.046}. For retention in care, there was a statistically significant lower risk for a 6-month visit gap in the Positive Health Check arm for the youngest participants, 18-29 years old [aRR (95% CI) = 0.55 (0.33 to 0.92), P = 0.024] and the oldest participants, 60-81 years old [aRR (95% CI) = 0.49 (0.30 to 0.81), P = 0.006]. CONCLUSIONS: Positive Health Check may help male participants with HIV achieve viral suppression, and younger and older patients consistently attend HIV care. REGISTRY NAME: Positive Health Check Evaluation Trial. Trial ID: 1U18PS004967-01. URL: https://clinicaltrials.gov/ct2/show/NCT03292913.

Challenges of and Solutions for Developing Tailored Video Interventions That Integrate Multiple Digital Assets to Promote Engagement and Improve Health Outcomes: Tutorial.

BACKGROUND: Video is a versatile and popular medium for digital health interventions. As mobile device and app technology advances, it is likely that video-based interventions will become increasingly common. Although clinic waiting rooms are complex and busy environments, they offer the opportunity to facilitate engagement with video-based digital interventions as patients wait to see their providers. However, to increase efficiency in public health, leverage the scalability and low cost of implementing digital interventions, and keep up with rapidly advancing technology and user needs, more design and development guidance is needed for video-based tailored interventions. OBJECTIVE: We provide a tutorial for digital intervention researchers and developers to efficiently design and develop video-based tailored digital health interventions. We describe the challenges and solutions encountered with Positive Health Check (PHC), a hybrid app used to deliver a brief, interactive, individually tailored video-based HIV behavioral counseling intervention. PHC uses video clips and multimedia digital assets to deliver intervention content, including interactive tailored messages and graphics, a repurposed animated video, and patient and provider handouts generated in real time by PHC. METHODS: We chronicle multiple challenges and solutions for the following: (1) using video as a medium to enhance user engagement, (2) navigating the complexity of linking a database of video clips with other digital assets, and (3) identifying the main steps involved in building an app that will seamlessly deliver to users individually tailored messages, graphics, and handouts. RESULTS: We leveraged video to enhance user engagement by featuring "video doctors," full-screen video, storyboards, and streamlined scripts. We developed an approach to link the database of video clips with other digital assets through script coding and flow diagrams of algorithms to deliver a tailored user experience. We identified the steps to app development by using keyframes to design the integration of video and digital assets, using agile development methods to gather iterative feedback from multidisciplinary teams, and creating an intelligent data-driven back-end solution to tailor message delivery to individual users. CONCLUSIONS: Video-based digital health interventions will continue to play an important role in the future of HIV prevention and treatment, as well as other clinical health practices. However, facilitating the adoption of an HIV video intervention in HIV clinical settings is a work in progress. Our experience in designing and developing PHC presented unique challenges due to the extensive use of a large database of videos tailored individually to each user. Although PHC focuses on promoting the health and well-being of persons with HIV, the challenges and solutions presented in this tutorial are transferable to the design and development of video-based digital health interventions focused on other areas of health.

Using 360-Degree Video as a Research Stimulus in Digital Health Studies: Lessons Learned.

Due to the accessibility of omnidirectional cameras to record 360-degree videos and the technology to view the videos via mobile phones and other devices, 360-degree videos are being used more frequently to place people in different contexts and convey health-related information. Increasingly, 360-degree videos are being employed in health marketing because they have the potential to enhance health-related attitudes and behaviors. As a case study on how this technology may be used for health-related information and its effect on health care providers, we created a 360-degree video that portrays the experience of a migraine sufferer to be used as a stimulus in an online study. We describe the challenges and lessons learned in designing and implementing a 360-degree video as part of an online experiment focused on inducing empathy among clinicians for understanding patient experience. Given the rapid change in digital technology, future research can use this knowledge to design and implement 360-degree video studies more effectively.

Positive Health Check evaluation: A type 1 hybrid design randomized trial to decrease HIV viral loads in patients seen in HIV primary care.

For people with HIV, important transmission prevention strategies include early initiation and adherence to antiretroviral therapy and retention in clinical care with the goal of reducing viral loads as quickly as possible. Consequently, at this point in the HIV epidemic, innovative and effective strategies are urgently needed to engage and retain people in health care to support medication adherence. To address this gap, the Positive Health Check Evaluation Trial uses a type 1 hybrid randomized trial design to test whether the use of a highly tailored video doctor intervention will reduce HIV viral load and retain people with HIV in health care. Eligible and consenting patients from four HIV primary care clinical sites are randomly assigned to receive either the Positive Health Check intervention in addition to the standard of care or the standard of care only. The primary aim is to determine the effectiveness of the intervention. A second aim is to understand the implementation potential of the intervention in clinic workflows, and a third aim is to assess the costs of intervention implementation. The trial findings will have important real-world applicability for understanding how digital interventions that take the form of video doctors can be used to decrease viral load and to support retention in care among diverse patients attending HIV primary care clinics.

Implementing Web-Based Interventions in HIV Primary Care Clinics: Pilot Implementation Evaluation of Positive Health Check.

BACKGROUND: Web-based interventions can help people living with HIV achieve better clinical outcomes and behaviors, but integrating them into clinical practice remains challenging. There is a gap in understanding the feasibility of implementing these interventions in HIV clinic settings from the clinicians' perspective. OBJECTIVE: The goal of the research was to determine whether Positive Health Check (PHC)-a Web-based, tailored video counseling tool focused on increasing patient adherence and retention in care and reducing HIV risk among HIV-positive patients-was acceptable, appropriate, and feasible for HIV primary care clinic staff to implement in clinic workflows. METHODS: A multiple-case study design was used to evaluate the pilot implementation. Four primary care clinics located in the southeastern United States implemented PHC over a 1-month period. Nine clinic staff across the clinics participated in structured interviews before, during, and after the implementation. In total, 54 interviews were conducted. We used a framework analysis approach to code the data and identify themes related to implementation outcomes, including acceptability, appropriateness, and feasibility. We also analyzed patient intervention use metrics (n=104) to quantify patient intervention completion rates (n=68). RESULTS: Overall, clinicians viewed PHC as acceptable and appropriate. Themes that emerged related to these implementation outcomes include the ability for PHC to increase provider-patient communication and its ability to engage patients due to the tailored and interactive design. While generally feasible to implement, challenges to the clinic workflow and physical environment were areas that clinics needed to manage to make PHC work in their clinics. CONCLUSIONS: Findings from this pilot implementation suggest that clinical staff viewed PHC as acceptable and appropriate, especially as more patients used the intervention over the pilot period. Feasibility of implementation was challenging in some cases, and lessons learned from this pilot implementation can provide information for larger scale tests of the intervention that include assessment of both implementation outcomes and clinical outcomes.

Factors That Mattered in Helping Travelers From Countries With Ebola Outbreaks Participate in Post-Arrival Monitoring During the 2014-2016 Ebola Epidemic.

During the 2014-2016 Ebola epidemic in West Africa, the US Centers for Disease Control and Prevention (CDC) developed the CARE+ program to help travelers arriving to the United States from countries with Ebola outbreaks to meet US government requirements of post-arrival monitoring. We assessed 2 outcomes: (1) factors associated with travelers' intention to monitor themselves and report to local or state public health authority (PHA) and (2) factors associated with self-reported adherence to post-arrival monitoring and reporting requirements. We conducted 1195 intercept in-person interviews with travelers arriving from countries with Ebola outbreaks at 2 airports between April and June 2015. In addition, 654 (54.7%) of these travelers participated in a telephone interview 3 to 5 days after intercept, and 319 (26.7%) participated in a second telephone interview 2 days before the end of their post-arrival monitoring. We used regression modeling to examine variance in the 2 outcomes due to 4 types of factors: (1) programmatic, (2) perceptual, (3) demographic, and (4) travel-related factors. Factors associated with the intention to adhere to requirements included clarity of the purpose of screening (B = 0.051, 95% confidence interval [CI], 0.011-0.092), perceived approval of others (B = 0.103, 95% CI, 0.058-0.148), perceived seriousness of Ebola (B = 0.054, 95% CI, 0.031-0.077), confidence in one's ability to perform behaviors (B = 0.250, 95% CI, 0.193-0.306), ease of following instructions (B = 0.053, 95% CI, 0.010-0.097), and trust in CARE Ambassador (B = 0.056, 95% CI, 0.009-0.103). Respondents' perception of the seriousness of Ebola was the single factor associated with adherence to requirements (odds ratio [OR] = 0.81, 95% CI, 0.673-0.980, for non-adherent vs adherent participants and OR = 0.86, 95% CI, 0.745-0.997, for lost to follow-up vs adherent participants). Results from this assessment can guide public health officials in future outbreaks by identifying factors that may affect adherence to public health programs designed to prevent the spread of epidemics.

Community-Based Health Education Programs Designed to Improve Clinical Measures Are Unlikely to Reduce Short-Term Costs or Utilization Without Additional Features Targeting These Outcomes.

Stakeholders often expect programs for persons with chronic conditions to "bend the cost curve." This study assessed whether a diabetes self-management education (DSME) program offered as part of a multicomponent initiative could affect emergency department (ED) visits, hospital stays, and the associated costs for an underserved population in addition to the clinical indicators that DSME programs attempt to improve. The program was implemented in Camden, New Jersey, by the Camden Coalition of Healthcare Providers to address disparities in diabetes care. Data used are from medical records and from patient-level information about hospital services from Camden's hospitals. Using multivariate regression models to control for individual characteristics, changes in utilization over time and changes relative to 2 comparison groups were assessed. No reductions in ED visits, inpatient stays, or costs for participants were found over time or relative to the comparison groups. High utilization rates and costs for diabetes are associated with longer term disease progression and its sequelae; thus, DSME or peer support may not affect these in the near term. Some clinical indicators improved among participants, and these might lead to fewer costly adverse health events in the future. DSME deployed at the community level, without explicit segmentation and targeting of high health care utilizers or without components designed to affect costs and utilization, should not be expected to reduce short-term medical needs for participating individuals or care-seeking behaviors such that utilization is reduced. Stakeholders must include financial outcomes in a program's design if those outcomes are to improve.

Identifying Synergies in Multilevel Interventions.

Social ecological models of health often describe multiple levels of influence that interact to influence health. However, it is still common for interventions to target only one or two of these levels, perhaps owing in part to a lack of guidance on how to design multilevel interventions to achieve optimal impact. The convergence strategy emphasizes that interventions at different levels mutually reinforce each other by changing patterns of interaction among two or more intervention audiences; this strategy is one approach for combining interventions at different levels to produce synergistic effects. We used semistructured interviews with 65 representatives in a cross-site national initiative that enhanced health and outcomes for patients with diabetes to examine whether the convergence strategy was a useful conceptual model for multilevel interventions. Using a framework analysis approach to analyze qualitative interview data, we found three synergistic themes that match the convergence strategy and support how multilevel interventions can be successful. These three themes were (1) enhancing engagement between patient and provider and access to quality care; (2) supporting communication, information sharing, and coordination among providers, community stakeholders, and systems; and (3) building relationships and fostering alignment among providers, community stakeholders, and systems. These results support the convergence strategy as a testable conceptual model and provide examples of successful intervention strategies for combining multilevel interventions to produce synergies across levels and promote diabetes self-management and that may extend to management of other chronic illnesses as well.

Supporting Tablet Configuration, Tracking, and Infection Control Practices in Digital Health Interventions: Study Protocol.

BACKGROUND: Tablet-based health care interventions have the potential to encourage patient care in a timelier manner, allow physicians convenient access to patient records, and provide an improved method for patient education. However, along with the continued adoption of tablet technologies, there is a concomitant need to develop protocols focusing on the configuration, management, and maintenance of these devices within the health care setting to support the conduct of clinical research. OBJECTIVE: Develop three protocols to support tablet configuration, tablet management, and tablet maintenance. METHODS: The Configurator software, Tile technology, and current infection control recommendations were employed to develop three distinct protocols for tablet-based digital health interventions. Configurator is a mobile device management software specifically for iPhone operating system (iOS) devices. The capabilities and current applications of Configurator were reviewed and used to develop the protocol to support device configuration. Tile is a tracking tag associated with a free mobile app available for iOS and Android devices. The features associated with Tile were evaluated and used to develop the Tile protocol to support tablet management. Furthermore, current recommendations on preventing health care-related infections were reviewed to develop the infection control protocol to support tablet maintenance. RESULTS: This article provides three protocols: the Configurator protocol, the Tile protocol, and the infection control protocol. CONCLUSIONS: These protocols can help to ensure consistent implementation of tablet-based interventions, enhance fidelity when employing tablets for research purposes, and serve as a guide for tablet deployments within clinical settings.