Development and Usability Evaluation of an mHealth Application for Symptom Self-Management in Underserved Persons Living with HIV

Effective symptom management is essential to decrease symptom severity and improve health-related quality of life for persons living with HIV (PLWH). A mobile health (mHealth) application (app) has the potential to be an effective delivery mode of an existing paper-based symptom management manual with self-management strategies for underserved PLWH. The quality of the mHealth app requires a thorough understanding of the needs of the intended end-users and ensuring the app’s usability. The purpose of this study was to translate paper-based health information into an mHealth app for symptom self-management in underserved PLWH, entitled mVIP (mobile Video Information Provider), and assess its usability. To achieve this goal, usability was evaluated rigorously throughout the development process of mVIP. Based on a stratified view of health information technology (IT) usability evaluation framework, usability evaluation was sequentially conducted with the following three levels: 1) user-task, 2) user-task-system, and 3) user-task-system-environment. At level 1 (user-task), we applied a user-centered design method to guide the information architecture of mVIP. Using a reverse in-person card sorting technique, symptoms and self-management strategies from a paper-based HIV/AIDS symptom management manual were ranked. The rank order of the 13 symptoms and 151 self-management strategies determined the order of appearance to end-users of the mVIP app, with higher-ranked symptoms and strategies appearing first. Based on the findings, we developed a prototype of mVIP as following: 1) once users log in, they are guided by an avatar through a series of 13 symptom questions ascertaining the nature and severity of their symptoms, and 2) the avatar recommends three self-management strategies for each symptom reported. At level 2 (user-task-system), we conducted a usability evaluation of the mVIP prototype in a laboratory setting through end-user usability testing and heuristic evaluation. In end-user usability testing, we used an eye-tracking and retrospective think-aloud method to examine task performance by 20 PLWH. For the heuristic evaluation, five usability experts in informatics assessed the user interface. In the two usability evaluations conducted in a laboratory setting, we found strong user acceptance of the mVIP prototype while identifying a number of usability issues with this prototype. Based on the recommendations from the end-users and heuristic evaluators, we iteratively refined the app’s content, functionality, and interface. We then inserted videos of the finalized symptom self-management strategies into the refined mVIP prototype. At level 3 (user-task-system-environment), the usability of the refined mVIP prototype was evaluated in a real-world setting. Through 10 in-depth interviews and four focus groups conducted at the conclusion of a three-month randomized controlled trial, we explored in-depth understandings of users’ experiences, perceptions, and satisfaction of mVIP use. Findings from the study showed that first, mVIP is useful for HIV-related symptom self-management and has the potential for being used as a communication tool with healthcare providers; and second, mVIP is easy to use to monitor symptom experience over time. At the same time, participants suggested mVIP be more sensitively tailored based on years from initial diagnosis of HIV, an individuals’ age, and conditions. The overall user satisfaction with the mVIP prototype was high, which reflects strong user acceptance of mVIP. Integral to the findings from the three-level usability evaluation, we assessed the quality of the mVIP prototype in use and found the prototype was highly accepted by PLWH with high user satisfaction. This study will add to the body of literature on translation of evidence-based health information into an mHealth app and its usability assessment, which highlights the importance of the use of mobile technology for PLWH, specifically racial and ethnic minorities and those from low-socioeconomic groups who have limited health literacy and low level of education

AIDS Behav

Mobile health (mHealth) technology can be a valuable tool in the management of chronic illnesses, including HIV. Qualitative research methods were used to identify the desired content and features of a mobile app for meeting and improving the healthcare needs of persons living with HIV (PLWH). We conducted six focus group sessions with 50 English-or Spanish-speaking PLWH in New York City. To inform data analysis and to illustrate how mHealth technology can be used as a persuasive strategy for improving the health of PLWH, we integrated Fogg's functional role triad for computing technology model with the self-determination theory to illustrate how mHealth technology can be used as a persuasive strategy for improving the health of PLWH. Participants suggested several tools for meeting their healthcare needs, including: reminders/alerts, lab results tracking, and notes on health status. mHealth technology can function as a social actor by providing chat boxes/forums, testimonials of lived experiences, and personal outreach. Examples of media that can be used as a persuasive technology include games/virtual rewards, coding of health tasks, and simulations on how to connect with PLWH. Findings from these focus groups can be used to design a mobile app for PLWH\uc2\ua0that is targeted to meet their healthcare needs.1U01PS00371501/PS/NCHHSTP CDC HHS/United StatesK12 RR017648/RR/NCRR NIH HHS/United States2016-06-01T00:00:00Z25572830PMC449793

Comput Inform Nurs

R01 NR015737/NR/NINR NIH HHS/United StatesU01 PS003715/PS/NCHHSTP CDC HHS/United States2017-05-01T00:00:00Z27153226PMC494452

Protocol of the randomized control trial: the WiseApp trial for improving health outcomes in PLWH (WiseApp)

Background Poor adherence to antiretroviral therapy (ART) is one of the primary barriers to viral load suppression. mHealth technology can help overcome challenges with ART adherence. This paper outlines the protocol for the WiseApp randomized control trial. The WiseApp contains real-time medication monitoring linking an electronic pill bottle and fitness tracker to the app, helping persons living with HIV (PLWH) self-manage their medication adherence and improve their overall quality of life. The primary objective of the trial is to test the effect of the WiseApp's medication adherence features on antiretroviral adherence in underserved PLWH in New York City. Methods This ongoing study is a two-arm randomized control trial. Participants are randomized 1:1 to the WiseApp intervention arm or the control arm at baseline and followed for 6 months. Eligibility criteria include: 18 years of age, have a diagnosis of HIV, speak and understand English or Spanish, live in the United States, own a smartphone, currently taking ART medications, and report the past 30 days adherence of 80% or less as measured using the Visual Analogue Scale (VAS), or have a viral load of over 400 copies/mL. The sample size for the trial is 200 people. All study participants receive the WiseApp, a CleverCap electronic pill bottle, and a fitness tracker. The intervention group also receives videos and health surveys centered on medication adherence and managing living with HIV as well as medication reminders. In contrast, the control group receives walk step reminders, videos, and surveys focused on overall wellness. Discussion The WiseApp Trial has the potential to improve HIV self-management applications, being one of the few randomized controlled trials of a mHealth medication adherence and HIV self-management application in the United States. The trial could also bring new opportunities for advancement in reaching economically disenfranchised and underserved populations in the United States. The real-time monitoring of the WiseApp has the potential to help providers initiate interventions to help patients resume treatment before drug resistance begins. Trial registration This trial was registered with ClinicalTrials.gov ( NCT03205982 ) on July 2, 2017

Effect of an Internet-Based Education Program on Self-Care Agency in People Living with Human Immunodeficiency Virus

Both low health literacy and insufficient electronic health literacy (ehealth) impede access to reliable internet health information for people living with chronic illnesses such as HIV/AIDS. Use of reliable internet health information has been shown to improve self-care through increased understanding of symptoms, disease processes, and improvements in adherence with treatment plans. This study examined the effectiveness of two interventions that taught people living with HIV/AIDS (PLWH) how to recognize reliable internet based HIV health information. Orem’s Self-Care Theory was the framework for this quasi-experimental study that used a non-equivalent two-group design with two experimental interventions (MEDLINE and E-HELP). Participants (N=100) in both interventions watched the NLM video, Evaluating Internet Health Information, and completed an at-home assignment that consisted of navigating to an HIV health information website and identifying the six criteria of a reliable internet health information website as described on the video. The E-HELP group (n=50) received a teach-back session averaging about 12 minutes with an expert clinician. Participants in both groups returned one week later to demonstrate their ehealth. HIV health literacy, electronic health literacy, and ability to identify reliable internet health information were measured before and after the interventions and one week later; self-care agency was measured before the interventions and one week later. The mixed model procedure, a Generalized Linear Modeling technique, was used to account for the longitudinal nature of the data. The mixed procedure allows for the modeling of the covariance structure to account for this correlation of the same subject responses. A restricted maximum likelihood approach (REML) was used and the covariance type was unstructured since we were not imposing any constraints on the values. A full model was fitted first for all study variables and included the basic conditioning factors of age, gender, race, ethnicity, education, and AIDS diagnosis. Model fitting was repeated eliminating the non-significant variables with the exception of time and the interaction of time and group. The independent variables (HIV health literacy, ehealth, and ability to identify reliable internet health information) were loaded to determine the effect of the intervention on the dependent variable, self-care agency. Some differences were found in basic conditioning factors. Non-Hispanics had significantly more self-care agency compared with Hispanics (207.98 vs. 183.36, p=.000); this may be related to English proficiency, acculturation, and cultural factors. Younger age was significant for HIV health literacy (p=.020), ehealth (p=.001), and ability to identify reliable internet health information (p=.024) which is consistent with previous research. Women had significantly better HIV health literacy compared to men (p=.039). No significant within group differences for self-care agency were found for either the MEDLINE group (p=.780) or the E-HELP group (p=.631). Participants may have needed more than one session of either intervention to produce an increase in self-care agency, or there may not have been adequate time between the two sessions of either intervention to produce increases in self-care agency. Results of this study did not provide sufficient evidence that, within the scope of Orem’s theory of self-care agency, health literacy is a foundational capability or that ehealth and ability to identify reliable internet health information are constituents of power component #7. There were no significant differences in scores between groups for HIV health literacy (p=.748), ehealth literacy (p=.308), ability to identify reliable internet health information (p=.259), and self-care agency (p=.887). Possible reasons for the lack of significant difference between the two intervention groups include the short time between sessions, participants’ limited access to computers, and a preference for information from healthcare providers. In addition, the interventions may not have been sufficiently different to produce significantly different results. There were, however, significant within group improvements from baseline to the final session in HIV health literacy (MEDLINE: p=.005; E-HELP: p=.045), ehealth (MEDLINE: p=.003; E-HELP: p=.000), and ability to identify reliable internet health information (MEDLINE: p=.000; E-HELP: p=.000), which indicates that some components of the interventions made a difference. Participants’ demonstration of ehealth skills belied the lack of difference between groups on electronic health literacy and ability to identify reliable internet health information. Scores on the at home assignment, which required participants to navigate to an HIV health-related website, then find and identify the six website reliability criteria, were higher for the E-HELP group (received the teach-back session) compared with the MEDLINE group that just watched the video. When the investigator observed the participant find an HIV health-related website and identify the six website reliability criteria, there was an increase in ehealth for the E-HELP group compared to a decrease in ehealth for the MEDLINE group. Although further testing and refinement of the interventions are needed, evidence from this study indicates that either intervention may be a low cost and effective means to teach people how to identify reliable internet health information for self-care

Physical activity behaviours of persons with HIV and AIDS in low-income populations: The design of a context-sensitive randomised control trial

Philosophiae Doctor - PhDThe Human immunodeficiency virus (HIV) and acquired Immunodeficiency syndrome (AIDS) are serious health issues that continue to affect many nations. Specifically, the sub-Saharan African region has the highest prevalence of HIV and AIDS worldwide. Africans living in informal settlements or townships have the highest prevalence of HIV in South Africa. Persons of low socioeconomic status (SES) in general become socialised into unhealthy behaviours and risk factors at early ages, and experience poor health outcomes. Physical activity (PA) is one cost-effective, non-pharmacological approach that has been reported as conjunctive therapy for HIV to effectively address these impairments. Aim: The aim of the study was to develop a contextualized intervention that promotes PA among persons living with HIV and AIDS (PLWHA) of low SES. Methods: A mixed methods approach was used. Studies included (1) a systematic review which assessed (a) specific and useful intervention techniques that were previously used in successful PA interventions (b) relevant behaviour change theories used to develop the intervention content, (2) a narrative review which examined the available literature on PA, social support and SES with a view to inform the design of effective PA interventions for PLWHA of low SES, (3) a cross sectional study which aimed at determining if age, body weight, height, gender, waist-to-hip ratio (WHR), educational attainment, employment status, CD4+ cell count, and body mass index (BMI) could predict overall PA among PLWHA of low SES in Cross roads Township in the Western Cape Province, South Africa (4) a cross-sectional study which (a) examined the PA profile of PLWHA of low SES based on PA domains and intensity and (b) determined whether employment status and level of education can predict PA among PLWHA of low SES in Cross roads Township in the Western Cape Province, South Africa (5) a mixed methods study which investigated the benefits and barriers of PA for HIV-positive women of low SES using the Exercise Benefits/Barriers Scale and focus group discussions, (6) a study which sought to develop a contextualised intervention for promoting PA among PLWHA of low SES and (7) a crossover study conducted at a community centre caring for HIV positive Black African Xhosa-speaking women of low SES in Nyanga Township in the Western Cape Province in South Africa. Results: The systematic literature review showed that the following techniques, namely, ‘provide feedback on performance’, ‘goal setting (behaviour)’, and ‘plan social support/social change’ were the most frequently used behavioural change techniques in interventions focusing on promoting PA for the management of chronic diseases amongst individuals of low SES. The review also showed that the Transtheoretical model of behaviour change and the Social Cognitive theory were the common theoretical frameworks of most study interventions

The Utility of Mobile Phones for Health Among Women Living with HIV in Urban Malawi

The use of mobile phones are becoming ubiquitous with growing interest by healthcare providers to utilize mobile phone technology for various health-related applications, called mHealth. This is especially true in low-income countries such as those in sub-Saharan Africa. When implementing mHealth applications, it is important to understand the dynamic social, cultural and environmental factors where mHealth will be implemented to ensure that interventions developed are effective. A qualitative study to explore the sociotechnical factors experienced by women participating in an HIV support group in urban Malawi was conducted to enhance our understanding of women’s experience with mobile phone use and its implications on their health. Ten individual interviews and one focus group interview were completed with women, using narrative methods and a sociotechnical view to inform data analysis. Narrative structural and thematic analysis were used to analyze the individual interview data, and thematic analysis was used to analyze the focus group interview data. This study offers valuable insights into the sociotechnical factors impacting mobile phone use and its implications on health within this urban context. Findings are discussed under four main areas: 1. Health-related activities and tasks; 2. Social related activities and tasks; 3. Income generation activities and tasks; and 4. Technical challenges. Implications for policy discussed include the scaling up of programs incorporating mobile phones in sub-Saharan Africa as part of the HIV prevention and treatment plan and partnering with NGO’s and churches to leverage funding and existing community based resources. Implications for future research include an opportunity for further theory development around community health frameworks that are sensitive to the African world view of person and community in addition to further exploring the utility of mobile phone technology in enhancing health outcomes for people living with HIV

The American Academy of Health Behavior 2021 Annual Scientific Meeting: Transforming the Narrative to Meet Emerging Health Behavior Challenges

The American Academy of Health Behavior (AAHB) hosted it\u27s 21th Annual Scientific Meeting online in March 2021. The meeting\u27s theme was Transforming the Narrative to Meet Emerging Health Behavior Challenges . This publication describes the meeting theme and includes the refereed abstracts presented at the 2021 Annual Scientific Meeting

The PACT of Patient Engagement: Unraveling the Meaning of Engagement with Hybrid Concept Analysis

Patient engagement has become a widely used term, but remains a poorly understood concept in healthcare. Citations for the term during the past two decades have increased markedly throughout the healthcare-related disciplines without a common definition. Patient engagement has been credited for contributing to improved outcomes and experiences of care. Means of identifying and evaluating practices that facilitate patient engagement in care have become an ethical imperative for patient-centered care. This process begins with a definition of the concept. Concept analysis is a means of establishing a common definition of a concept through identification of its attributes, antecedents and consequences within the context of its use. Concept analysis is a methodology that has been used in social science and nursing as a means to resolve conceptual barriers to theory development in an evolving field. The methodological theory was based in the analytic philosophical tradition and sustained during the 20th century by the strength of philosophical positivism in the health sciences. This concept analysis is guided procedurally by Rogers’ evolutionary approach that incorporates postmodern philosophical principles and well-defined techniques. This dissertation is informed by the expanded and updated perspective of the neomodern era in nursing research, which advances the concept analysis methodology further. An analysis of the concept underlying the term patient engagement in the scientific literature revealed four defining attributes: personalization, access, commitment and therapeutic alliance. These defining attributes were derived through thematic analysis of over 100 individual attributes shared among six categories and three domains. The resultant definition revealed that patient engagement is both process and behavior shaped by the relationship between patient and provider and the environment where healthcare delivery takes place. Patient engagement is defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or improving experiences of care. In addition to the attributes of the concept identified in the literature, themes relevant to patient engagement were identified through inputs from six focus groups of persons living with HIV in New York City. The focus group participants were convened to inform the development of a mobile application designed to support their healthcare needs. Their experiences, insights and expectations were valuable in ascertaining those actions or behaviors that may serve to assist the patient in obtaining and adhering to care. The focus group transcripts were coded twice. The first round occurred prior to the concept analysis of the literature and used emergent coding methodology to capture meanings independent of the findings of the concept analysis. The second round occurred after the concept analysis of the literature and used the resultant attributes to perform a directed concept analysis of the transcripts. The content analyses of the transcripts from the patient perspective supported and reinforced the attributes from the concept analysis. The focus groups also highlighted another important aspect of patient engagement, that of privacy/confidentiality, which had not been specifically addressed in the concept analysis of the literature. The definition and the identified attributes serve as a heuristic in designing patient engagement strategies and as a basis for future development of the engagement concept in healthcare. The supporting concepts for engagement, especially the role of empathy in the therapeutic alliance, require further clarification and debate. While patient engagement may be promoted through face-to-face interactions or through health information technology, the defining attributes are invariable and should guide the design of engagement processes and tools. Finally, the value of understanding and exploring the defining attributes of patient engagement in medical and nursing education becomes clear, as is the need for continuing clinical training to support and encourage patient engagement skills

Facilitating implementation of research evidence (FIRE): A randomised controlled trial and process evaluation of two models of facilitation informed by the promoting action on research implementation in health services (PARIHS) framework

Background: The PARIHS framework proposes that successful implementation of research evidence results from the complex interplay between the evidence to be implemented, the context of implementation and the facilitation processes employed. Facilitation is defined as a role (the facilitator) and a process (facilitation strategies/methods). Empirical evidence comparing different facilitation approaches is limited; this paper reports a trial of two different types of facilitation represented in the PARIHS framework. Methods: A pragmatic cluster randomised controlled trial with embedded process evaluation was undertaken in 24 long-term nursing care settings in four European countries. In each country, sites were randomly allocated to standard dissemination of urinary incontinence guideline recommendations and one of two types of external-internal facilitation, labelled Type A and B. Type A facilitation was a less resource intensive approach, underpinned by improvement methodology; Type B was a more intensive, emancipatory model of facilitation, informed by critical social science. The primary outcome was percentage documented compliance with guideline recommendations. Process evaluation was framed by realist methodology and involved quantitative and qualitative data collection from multiple sources. Findings: Quantitative data were obtained from reviews of 2313 records. Qualitative data included over 332 hours of observations of care; 39 hours observation of facilitation activity; 471 staff interviews; 174 resident interviews; 120 next of kin/carer interviews; and 125 stakeholder interviews. There were no significant differences in the primary outcome between study arms and all study arms improved over time. Process data revealed three core mechanisms that influenced the trajectory of the facilitation intervention: alignment of the facilitation approach to the needs and expectations of the internal facilitator and colleagues; engagement of internal facilitators and staff in attitude and action; and learning over time. Data from external facilitators demonstrated that the facilitation interventions did not work as planned, issues were cumulative and maintenance of fidelity was problematic. Implications for D&I Research: Evaluating an intervention - in this case facilitation - that is fluid and dynamic within the methodology of a randomised controlled trial is complex and challenging. For future studies, we suggest a theoretical approach to fidelity, with a focus on mechanisms, as opposed to dose and intensity of the intervention