The Role of mHealth Application Design in Individually Tailored Self-Management Interventions to Promote Adherence to an Exercise Program for Older Adults with Osteoarthritis of the Knee and Hypertension

Little is known about how individually tailored self-management interventions (ITSMIs) and mobile health technology (mHealth) might work together to promote adoption and maintenance of exercise among people living with chronic conditions that impede physical functioning. The objective of this mixed-method study was to generate a contextually rich assessment of how adoption and maintenance of an exercise routine were supported within a mHealth-ITSMI designed specifically for older adults with osteoarthritis of the knee and hypertension. Quantitative and qualitative data from the intervention arm of the Staying Active with Arthritis (STAR) trial (R01 NR010904, PI Schlenk) were utilized in this mixed-method study. Latent trajectories of tailoring and adherence of lower extremity exercises (LEE) and fitness walking (FW) over the 24-week intervention period were identified using group based trajectory modeling. Bivariate associations between identified tailoring and adherence trajectory groups were evaluated. Multivariable multinomial logistic regression was used to identify predictors of adherence trajectory groups. Purposive sampling was performed based on adherence and tailoring trajectory group membership. Actor Network Theory was used to scaffold the descriptive analysis of transcribed audio-recorded participant-interventionist interactions to examine the role the eDiary played in tailoring and exercise adherence. Three distinct trajectories were identified for LEE adherence and tailoring; four were identified for FW adherence and tailoring. A moderate association was observed between LEE and FW adherence trajectories (p<.001), between LEE and FW tailoring trajectories (p=.001), and between LEE tailoring and adherence trajectories (p=.007), but not between FW tailoring and adherence trajectories (p=.12). The LEE “remained highly tailored” trajectory group had greater odds of belonging to the “quick decline” (OR=16.89) and “steady decline” (OR=3.74) adherence trajectory groups. The FW “slight rise/remained highly tailored” trajectory group had greater odds of belonging to the “quick/steady decline” adherence trajectory group (OR=5.65). The eDiary played a role in the participant-interventionist relationship, decision-making, and motivation to exercise. Motivation was explained by concepts from social cognitive theory, self-determination theory, and goal-setting theory. The degree of individual fit between how a goal was defined and the way it was measured via the eDiary impacted participants’ overall sense of accomplishment, thereby directly impacting one’s motivation to initiate and sustain an exercise routine

Exploratory pilot testing of the psychometric properties of the person engagement index instrument among older, community-dwelling adults

The objective of this paper was to evaluate the psychometric properties of the Person Engagement Index with community dwelling older adults and determine the factors that impact this population’s capacity to engage in healthcare. This non-experimental pilot evaluation of the psychometrics of the Person Engagement Index was performed in a convenience sample of 100 community-dwelling older adults. Exploratory factor analysis was conducted using dimension reduction to determine the underlying structure of a person’s capacity to engage in healthcare. Results indicated good internal consistency with Cronbach’s alpha=.882 for the overall scale. Exploratory factor analysis with varimax rotation was conducted resulting in a five-factor solution. Four of the five subscales exceeded Cronbach’s alpha \u3e .70 threshold for internal consistency. Cronbach’s alpha results for the five domains were: (Knowledge of Healthcare Status) =.886, (Proactive Approach to Healthcare) =.780, (Motivation to Manage Healthcare) =.742, (Psychosocial Support for Healthcare) =.658 and (Technology Use in Healthcare) =.796. Results suggest that the Person Engagement Index instrument is a valid and reliable instrument to measure a person’s capacity to engage in healthcare among community dwelling older adults. Testing in different settings with other populations and over time is warranted to further explore the reliability and validity of the Person Engagement Index for different subgroups and its sensitivity to changes in health status that may impact a person’s capacity to engage in care

Patient Portals as a Tool for Health Care Engagement: A Mixed-Method Study of Older Adults With Varying Levels of Health Literacy and Prior Patient Portal Use

Growing evidence that patient engagement improves health outcomes and reduces health care costs has fueled health providers' focus on patient portals as the primary access point for personal health information and patient-provider communication. Whereas much attention has been given to identifying characteristics of older adults who do and do not adopt patient portals and necessary adaptions to portal design, little is known about their attitudes and perceptions regarding patient portal use as a tool for engagement in their health care within the context of health literacy, experience navigating Web-based health information, and previous patient portal use. The specific aims of this study were to explore attitudes toward portal adoption and its perceived usefulness as a tool for health care engagement among adults (65 years and older) who have varying levels of health literacy and degrees of prior patient portal use. A phone survey of 100 community dwelling adults gathered sociodemographic, health, and technology related information. Older adults were purposefully selected for 4 follow-up focus groups based on survey responses to health literacy and previous patient portal use. A mixed-method approach was used to integrate phone survey data with thematic analysis of 4 focus groups. Due to variability in attitudes between focus group participants, an individual case analysis was performed and thematic patterns were used as the basis for subgroup formation. Differences in health literacy, comfort navigating health information on the Web, and previous portal experience explained some but not all differences related to the 7 themes that emerged in the focus groups analysis. Individual cases who shared attitudes were arranged into 5 subgroups from least to most able and willing to engage in health care via a patient portal. The subgroups' overall portal adoption attitudes were: (1) Don't want to feel pushed into anything, (2) Will only adopt if required, (3) Somebody needs to help me, (4) See general convenience of the portal for simple tasks and medical history, but prefer human contact for questions, and (5) Appreciates current features and excited about new possibilities . Most of the older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption, or experience navigating health information on the Web. Research targeting informal caregivers of older adults who are unable or unwilling to engage with information technology in health care on their own is warranted. Health care organizations should consider tailored strategies to meet the needs of older adults (and their informal caregivers) and explore alternative workflows that integrate patient portal information into phone conversations and face-to-face contact with health care providers

Automated Messaging Program to Facilitate Systematic Home Blood Pressure Monitoring: Qualitative Analysis of Provider Interviews

BackgroundHypertension is a leading cause of cardiovascular and kidney disease in the United States, yet blood pressure (BP) control at a population level is poor and worsening. Systematic home BP monitoring (HBPM) programs can lower BP, but programs supporting HBPM are not routinely used. The MyBP program deploys automated bidirectional text messaging for HBPM and disease self-management support. ObjectiveWe aim to produce a qualitative analysis of input from providers and staff regarding implementation of an innovative HBPM program in primary care practices. MethodsSemistructured interviews (average length 31 minutes) were conducted with physicians (n=11), nurses, and medical assistants (n=6) from primary care settings. The interview assessed multiple constructs in the Consolidated Framework for Implementation Research domains of intervention characteristics, outer setting, inner setting, and characteristics of individuals. Interviews were transcribed verbatim and analyzed using inductive coding to organize meaningful excerpts and identify salient themes, followed by mapping to the updated Consolidated Framework for Implementation Research constructs. ResultsHealth care providers reported that MyBP has good ease of use and was likely to engage patients in managing their high BP. They also felt that it would directly support systematic BP monitoring and habit formation in the convenience of the patient’s home. This could increase health literacy and generate concrete feedback to raise the day-to-day salience of BP control. Providers expressed concern that the cost of BP devices remains an encumbrance. Some patients were felt to have overriding social or emotional barriers, or lack the needed technical skills to interact with the program, use good measurement technique, and input readings accurately. With respect to effects on their medical practice, providers felt MyBP would improve the accuracy and frequency of HBPM data, and thereby improve diagnosis and treatment management. The program may positively affect the patient-provider relationship by increasing rapport and bidirectional accountability. Providers appreciated receiving aggregated HBPM data to increase their own efficiency but also expressed concern about timely routing of incoming HBPM reports, lack of true integration with the electronic health record, and the need for a dedicated and trained staff member. ConclusionsIn this qualitative analysis, health care providers perceived strong relative advantages of using MyBP to support patients. The identified barriers suggest the need for corrective implementation strategies to support providers in adopting the program into routine primary care practice, such as integration into the workflow and provider education. Trial RegistrationClinicalTrials.gov NCT03650166; https://tinyurl.com/bduwn6r