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BackgroundDeveloping innovative, efficient, and institutionally scalable biospecimen consent for remnant tissue that meets the National Institutes of Health consent guidelines for genomic and molecular analysis is essential for precision medicine efforts in cancer.ObjectiveThis study aims to pilot-test an electronic video consent that individuals could complete largely on their own.MethodsThe University of California, Los Angeles developed a video consenting approach designed to be comprehensive yet fast (around 5 minutes) for providing universal consent for remnant biospecimen collection for research. The approach was piloted in 175 patients who were coming in for routine services in laboratory medicine, radiology, oncology, and hospital admissions. The pilot yielded 164 completed postconsent surveys. The pilot assessed the usefulness, ease, and trustworthiness of the video consent. In addition, we explored drivers for opting in or opting out.ResultsThe pilot demonstrated that the electronic video consent was well received by patients, with high scores for usefulness, ease, and trustworthiness even among patients that opted out of participation. The revised more animated video pilot test in phase 2 was better received in terms of ease of use (P=.005) and the ability to understand the information (P

Background: Physical education teachers often experience stress and job disengagement. Objective: This study’s aims were as follows: (1) to adapt in the Arabic language and test the reliability and the validity of the work–family conflict (WFC) and family–work conflict (FWC) scales, (2) to develop and assess the psychometric properties of work disengagement among physical education teachers, and (3) to evaluate an explanatory model by presenting the mediating role of perceived stress as a major influencing factor in work disengagement and job satisfaction. Methods: A total of 303 primary and secondary school physical education teachers, comprising 165 (54.5%) men and 138 (45.5%) women participated voluntarily in our study. The measuring instruments are the Work Disengagement Scale, the Perceived Stress Scale, the WFC scale, the FWC scale, and the 9-item Teacher of Physical Education Job Satisfaction Inventory. Results: The Arabic language versions of the WFC and FWC scales had reasonably adequate psychometric properties, which were justified by confirmatory factor analyses and by the measurement of reliability, convergent, and discriminant validity through the measurement model using SmartPLS software. Similarly, the structural model established with SmartPLS confirmed strong links of the concepts of FWC, WFC, the job satisfaction questionnaire, and perceived stress with work disengagement among teachers of physical education. Conclusions: There is a growing interest in helping teachers cope with the daily pressures of work and family. A positive organizational context is a context with clear values regarding work priorities, which constitutes the basis of a feeling of shared responsibility and professional support. Good conditions can act as protective factors reducing work stress and positively influencing personal well-being, work attitudes, work commitment, and professional efficiency. Additional research on teachers is needed to examine the relationship between perceived work stress and the role of families, along with the extent to which this association can have a significant impact on teachers’ commitment to work. [ABSTRACT FROM AUTHOR]

Background: Detailed self-monitoring (or tracking) of dietary intake is a popular and effective weight loss approach that can be delivered via digital tools, although engagement declines over time. Simplifying the experience of self-monitoring diet may counteract this decline in engagement. Testing these strategies among racial and ethnic minority groups is important as these groups are often disproportionately affected by obesity yet underrepresented in behavioral obesity treatment. Objective: In this 2-arm pilot study, we aimed to evaluate the feasibility and acceptability of a digital weight loss intervention with either detailed or simplified dietary self-monitoring. Methods: We recruited racial and ethnic minority adults aged ≥21 years with a BMI of 25 kg/m² to 45 kg/m² and living in the United States. The Pacific time zone was selected for a fully remote study. Participants received a 3-month stand-alone digital weight loss intervention and were randomized 1:1 to either the detailed arm that was instructed to self-monitor all foods and drinks consumed each day using the Fitbit mobile app or to the simplified arm that was instructed to self-monitor only red zone foods (foods that are highly caloric and of limited nutritional value) each day via a web-based checklist. All participants were instructed to self-monitor both steps and body weight daily. Each week, participants were emailed behavioral lessons, action plans, and personalized feedback. In total, 12 a priori benchmarks were set to establish feasibility, including outcomes related to reach, retention, and self-monitoring engagement (assessed objectively via digital tools). Acceptability was assessed using a questionnaire. Weight change was assessed using scales shipped to the participants’ homes and reported descriptively. Results: The eligibility screen was completed by 248 individuals, of whom 38 (15.3%) were randomized, 18 to detailed and 20 to simplified. At baseline, participants had a mean age of 47.4 (SD 14.0) years and BMI of 31.2 (SD 4.8) kg/m² . More than half (22/38, 58%) were identified as Hispanic of any race. The study retention rate was 92% (35/38) at 3 months. The detailed arm met 9 of 12 feasibility benchmarks, while the simplified arm met all 12. Self-monitoring engagement was moderate to high (self-monitoring diet: median of 49% of days for detailed, 97% for simplified; self-monitoring steps: 99% for detailed, 100% for simplified; self-monitoring weight: 67% for detailed, 80% for simplified). Participants in both arms reported high satisfaction, with 89% indicating that they would recommend the intervention. Weight change was −3.4 (95% CI −4.6 to −2.2) kg for detailed and −3.3 (95% CI −4.4 to −2.2) kg for simplified. Conclusions: A digital weight loss intervention that incorporated either detailed or simplified dietary self-monitoring was feasible, with high retention and engagement, and acceptable to racial and ethnic minority adults. [ABSTRACT FROM AUTHOR]

Background: Mobile health (mHealth) technology using apps or devices to self-manage health behaviors is an effective strategy to improve lifestyle-related health problems such as hypertension, obesity, and diabetes. However, few studies have tested an mHealth intervention with Hispanic/Latino adults, and no studies were found testing mHealth with rural Hispanic/Latino adults, the fastest-growing population in rural areas. Objective: The purpose of this study was to evaluate the feasibility, usability, and acceptability of an mHealth cardiovascular risk self-management intervention with rural Hispanic/Latino adults. Methods: A descriptive study using quantitative and qualitative methods was used to evaluate the feasibility, usability, and acceptability of delivering a 12-week mHealth self-management intervention to reduce cardiovascular risk with rural Hispanic/Latino adults who were randomized to 1 of 2 groups. Both groups were asked to use MyFitnessPal to self-monitor daily steps, weight, and calories. The intervention group received support to download, initiate, and troubleshoot technology challenges with MyFitnessPal (Under Armour) and a smart scale, while the enhanced usual care group received only a general recommendation to use MyFitnessPal to support healthy behaviors. The usability of MyFitnessPal and the smart scale was measured using an adapted Health Information Technology Usability EvaluationScale (Health-ITUES). Adherence data in the intervention group (daily steps, weight, and calories) were downloaded from MyFitnessPal. Acceptability was evaluated using semistructured interviews in a subsample (n=5) of intervention group participants. Results: A sample of 70 eligible participants (enhanced usual care group n=34; intervention group n=36) were enrolled between May and December 2019. The overall attrition was 28% at 12 weeks and 54% at 24 weeks. mHealth usability in the intervention group increased at each time point (6, 12, and 24 weeks). Adherence to self-monitoring using mHealth in the intervention group after week 1 was 55% for steps, 39% for calories, and 35% for weights; at the end of the 12-week intervention, the adherence to self-monitoring was 31% for steps, 11% for weight, and 8% for calories. Spikes in adherence coincided with scheduled in-person study visits. Structured interviews identified common technology challenges including scale and steps not syncing with the app and the need for additional technology support for those with limited mHealth experience. Conclusions: Recruitment of rural Hispanic/Latino adults into the mHealth study was feasible using provider and participant referrals. The use of MyFitnessPal, the smart scale, and SMS text messages to self-monitor daily steps, weights, and calories was acceptable and feasible if technology support was provided. Future research should evaluate and support participants’ baseline technology skill level, provide training if needed, and use a phone call or SMS text message follow-ups as a strategy to minimize attrition. A wearable device, separate from the smartphone app, is recommended for activity tracking. [ABSTRACT FROM AUTHOR]

Background: Regular HIV and sexually transmitted infection (STI) testing for men who have sex with men (MSM) is an important means of infection prevention, the adoption of which remains suboptimal in the community. Objective: On the hypothesis that engagement plays an important role in sexual health monitoring, this study aimed to pilot-test internet-based HIV and STI testing with self-sampling to enhance engagement of MSM with regular testing. Methods: This 1-year cohort study was conducted on HIV-negative MSM aged 18 years or older. A designated website was set up to enable participants to make appointments for baseline and follow-up visits at 3-monthly intervals. On-site blood sampling was performed for HIV and syphilis tests, along with self-collection of pharyngeal swabs, rectal swabs, and urine samples for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Full engagement, as defined by having made at least 3 visits over a 6-12 months' follow-up period, was compared with partial engagement in the bivariable logistic regression model. Results: Between August 2019 and October 2020, 204 MSM were recruited, after the exclusion of 2 baseline HIV-positive MSM. The majority (189/204, 92.7%) were Chinese, the median age was 31 (IQR 26-39) years, and 58.0% (116/200) had experience with pre-exposure prophylaxis (PrEP) at baseline. Full engagement (146/204, 71.6%) was associated with incident STI during the follow-ups (odds ratio [OR] 4.23, 95% CI 1.63-10.94), seeking a medical referral after STI detection (OR 10.25, 95% CI 3.25-29.79), and a synchronized schedule of HIV and STI testing with PrEP visits (OR 51.85, 95% CI 19.30-139.34). No incident HIV was detected in the follow-up period. At baseline, the overall STI (CT, NG, or syphilis) prevalence was 30%, with CT at 18%, NG at 13%, and syphilis at 5%. During follow-up, the incidences were 59.08/100 person-years (py) for any STI, 33.05/100 py for CT, 29.86/100 py for NG, and 10.4/100 py for syphilis. The detection rates of CT and NG in urine samples were lower than with pharyngeal swabs and rectal swabs. The scores for convenience, confidence of correct sampling, and accuracy of self-sampling were high (7 to 8 out of 10). Conclusions: Both baseline prevalence and incidence of STI were high among MSM engaged in regular testing. A high degree of engagement in regular STI and HIV testing was positively associated with incident STI, history of health-seeking behaviors, and perceived convenience of self-sampling. Self-sampling could be introduced as a means of enhancing engagement in regular HIV and STI testing. [ABSTRACT FROM AUTHOR]

Background: Smartphones are increasingly used in health research. They provide a continuous connection between participants and researchers to monitor long-term health trajectories of large populations at a fraction of the cost of traditional research studies. However, despite the potential of using smartphones in remote research, there is an urgent need to develop effective strategies to reach, recruit, and retain the target populations in a representative and equitable manner. Objective: We aimed to investigate the impact of combining different recruitment and incentive distribution approaches used in remote research on cohort characteristics and long-term retention. The real-world factors significantly impacting active and passive data collection were also evaluated. Methods: We conducted a secondary data analysis of participant recruitment and retention using data from a large remote observation study aimed at understanding real-world factors linked to cold, influenza, and the impact of traumatic brain injury on daily functioning. We conducted recruitment in 2 phases between March 15, 2020, and January 4, 2022. Over 10,000 smartphone owners in the United States were recruited to provide 12 weeks of daily surveys and smartphone-based passive-sensing data. Using multivariate statistics, we investigated the potential impact of different recruitment and incentive distribution approaches on cohort characteristics. Survival analysis was used to assess the effects of sociodemographic characteristics on participant retention across the 2 recruitment phases. Associations between passive data-sharing patterns and demographic characteristics of the cohort were evaluated using logistic regression. Results: We analyzed over 330,000 days of engagement data collected from 10,000 participants. Our key findings are as follows: first, the overall characteristics of participants recruited using digital advertisements on social media and news media differed significantly from those of participants recruited using crowdsourcing platforms (Prolific and Amazon Mechanical Turk; P<.001). Second, participant retention in the study varied significantly across study phases, recruitment sources, and socioeconomic and demographic factors (P<.001). Third, notable differences in passive data collection were associated with device type (Android vs iOS) and participants' sociodemographic characteristics. Black or African American participants were significantly less likely to share passive sensor data streams than non-Hispanic White participants (odds ratio 0.44-0.49, 95% CI 0.35-0.61; P<.001). Fourth, participants were more likely to adhere to baseline surveys if the surveys were administered immediately after enrollment. Fifth, technical glitches could significantly impact real-world data collection in remote settings, which can severely impact generation of reliable evidence. Conclusions: Our findings highlight several factors, such as recruitment platforms, incentive distribution frequency, the timing of baseline surveys, device heterogeneity, and technical glitches in data collection infrastructure, that could impact remote long-term data collection. Combined together, these empirical findings could help inform best practices for monitoring anomalies during real-world data collection and for recruiting and retaining target populations in a representative and equitable manner. [ABSTRACT FROM AUTHOR]

Background: Digital health interventions provide a cost effective and accessible means for positive behavior change. However, high participant attrition is common and facilitators for implementation of behaviors are not well understood. Objective: The goal of the research was to identify elements of a digital mindfulness course that aided in course completion and implementation of teachings. Methods: Inductive thematic analysis was used to assess participant comments regarding positive aspects of the online mindfulness course Mindfulness for Well-being and Peak Performance. Participants were aged 18 years and older who had self-selected to register and voluntarily completed at least 90% the course. The course comprised educator-guided lessons and discussion forums for participant reflection and feedback. Participant comments from the final discussion forum were analyzed to identify common themes pertaining to elements of the course that aided in course completion and implementation of teachings. Results: Of 3355 course completers, 283 participants provided comments related to the research question. Key themes were (1) benefits from the virtual community, (2) appeal of content, (3) enablers to participation and implementation, and (4) benefits noted in oneself. Of subthemes identified, some, such as community support, variety of easily implementable content, and free content access, align with that reported previously in the literature, while other subthemes, including growing together, repeating the course, evidence-based teaching, and immediate benefits on physical and mental well-being, were novel findings. Conclusions: Themes identified as key elements for aiding participant completion of a mindfulness digital health intervention and the implementation of teachings may inform the effective design of future digital health interventions to drive positive health behaviors. Future research should focus on understanding motivations for participation, identification of effective methods for participant retention, and behavior change techniques to motivate long-term adherence to healthy behaviors. [ABSTRACT FROM AUTHOR]

Background: The use of digital technologies and software allows for new opportunities to communicate and engage with research participants over time. When software is coupled with automation, we can engage with research participants in a reliable and affordable manner. Research Electronic Data Capture (REDCap), a browser-based software, has the capability to send automated text messages. This feature can be used to automate delivery of tailored intervention content to research participants in interventions, offering the potential to reduce costs and improve accessibility and scalability. Objective: This study aimed to describe the development and use of 2 REDCap databases to deliver automated intervention content and communication to index participants and their partners (dyads) in a 2-arm, 24-month weight management trial, Partner2Lose. Methods: Partner2Lose randomized individuals with overweight or obesity and cohabitating with a partner to a weight management intervention alone or with their partner. Two databases were developed to correspond to 2 study phases: one for weight loss initiation and one for weight loss maintenance and reminders. The weight loss initiation database was programmed to send participants (in both arms) and their partners (partner-assisted arm) tailored text messages during months 1-6 of the intervention to reinforce class content and support goal achievement. The weight maintenance and reminder database was programmed to send maintenance-related text messages to each participant (both arms) and their partners (partner-assisted arm) during months 7-18. It was also programmed to send text messages to all participants and partners over the course of the 24-month trial to remind them of group classes, dietary recall and physical activity tracking for assessments, and measurement visits. All text messages were delivered via Twilio and were unidirectional. Results: Five cohorts, comprising 231 couples, were consented and randomized in the Partner2Lose trial. The databases will send 53,518 automated, tailored text messages during the trial, significantly reducing the need for staff to send and manage intervention content over 24 months. The cost of text messaging will be approximately US $450. Thus far, there is a 0.004% known error rate in text message delivery. Conclusions: Our trial automated the delivery of tailored intervention content and communication using REDCap. The approach described provides a framework that can be used in future behavioral health interventions to create an accessible, reliable, and affordable method for intervention delivery and engagement that requires minimal trial-specific resources and personnel time. [ABSTRACT FROM AUTHOR]

Background: Low engagement with mental health apps continues to limit their impact. New approaches to help match patients to the right app may increase engagement by ensuring the app they are using is best suited to their mental health needs., Objective: This study aims to pilot how digital phenotyping, using data from smartphone sensors to infer symptom, behavioral, and functional outcomes, could be used to match people to mental health apps and potentially increase engagement., Methods: After 1 week of collecting digital phenotyping data with the mindLAMP app (Beth Israel Deaconess Medical Center), participants were randomly assigned to the digital phenotyping arm, receiving feedback and recommendations based on those data to select 1 of 4 predetermined mental health apps (related to mood, anxiety, sleep, and fitness), or the control arm, selecting the same apps but without any feedback or recommendations. All participants used their selected app for 4 weeks with numerous metrics of engagement recorded, including objective screentime measures, self-reported engagement measures, and Digital Working Alliance Inventory scores., Results: A total of 82 participants enrolled in the study; 17 (21%) dropped out of the digital phenotyping arm and 18 (22%) dropped out from the control arm. Across both groups, few participants chose or were recommended the insomnia or fitness app. The majority (39/47, 83%) used a depression or anxiety app. Engagement as measured by objective screen time and Digital Working Alliance Inventory scores were higher in the digital phenotyping arm. There was no correlation between self-reported and objective metrics of app use. Qualitative results highlighted the importance of habit formation in sustained app use., Conclusions: The results suggest that digital phenotyping app recommendation is feasible and may increase engagement. This approach is generalizable to other apps beyond the 4 apps selected for use in this pilot, and practical for real-world use given that the study was conducted without any compensation or external incentives that may have biased results. Advances in digital phenotyping will likely make this method of app recommendation more personalized and thus of even greater interest., (©Bridget Dwyer, Matthew Flathers, James Burns, Jane Mikkelson, Elana Perlmutter, Kelly Chen, Nanik Ram, John Torous. Originally published in JMIR Formative Research (https://formative.jmir.org), 19.11.2024.)

Background: Digital mental health applications (DMHAs) are emerging, novel solutions to address gaps in behavioral health care. Accordingly, Kaiser Permanente Mid-Atlantic States (KPMAS) integrated referrals for 6 unique DMHAs into clinical care in 2019., Objective: This study investigated patient and health care professional (HCP) experiences with DMHA referral; DMHA use; and perceived importance of engagement, functionality, design, and information attributes in real-world practice., Methods: Separate cross-sectional surveys were developed and tested for patients and HCPs. Surveys were administered to KPMAS participants through REDCap (Research Electronic Data Capture), and completed between March 2022 and June 2022. Samples included randomly selected patients who were previously referred to at least 1 DMHA between April 2021 and December 2021 and behavioral health and primary care providers who referred DMHAs between December 2019 and December 2021., Results: Of the 119 patients e-mailed a survey link, 58 (48.7%) completed the survey and 44 (37%) confirmed receiving a DMHA referral. The mean age of the sample was 42.21 (SD 14.08) years (29/44, 66%); 73% (32/44) of the respondents were female, 73% (32/44) of the respondents had at least a 4-year college degree, 41% (18/44) of the respondents were Black or African American, and 39% (17/44) of the respondents were White. Moreover, 27% (12/44) of the respondents screened positive for anxiety symptoms, and 23% (10/44) of the respondents screened positive for depression. Overall, 61% (27/44) of the respondents reported DMHA use for ≤6 months since referral, 36% (16/44) reported use within the past 30 days, and 43% (19/44) of the respondents reported that DMHAs were very or extremely helpful for improving mental and emotional health. The most important patient-reported DMHA attributes by domain were being fun and interesting to use (engagement); ease in learning how to use (functionality); visual appeal (design); and having well-written, goal- and topic-relevant content (information). Of the 60 sampled HCPs, 12 (20%) completed the survey. Mean HCP respondent age was 46 (SD 7.75) years, and 92% (11/12) of the respondents were female. Mean number of years since completing training was 14.3 (SD 9.94) years (10/12, 83%). Of the 12 HCPs, 7 (58%) were physicians and 5 (42%) were nonphysicians. The most important HCP-reported DMHA attributes by domain were personalized settings and content (engagement); ease in learning how to use (functionality); arrangement and size of screen content (design); and having well-written, goal- and topic-relevant content (information). HCPs described "typical patients" referred to DMHAs based on perceived need, technical capability, and common medical conditions, and they provided guidance for successful use., Conclusions: Individual patient needs and preferences should match the most appropriate DMHA. With many DMHA choices, decision support systems are essential to assist patients and HCPs with selecting appropriate DMHAs to optimize uptake and sustained use., (©Michael J Miller, Lindsay G Eberhart, Jennifer L Heliste, Bhaskara R Tripuraneni. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.11.2024.)

Background: Games are increasingly used in eHealth as a strategy for user engagement. There is an enormous diversity of end users and objectives targeted by eHealth. Hence, identifying game content that drives and sustains engagement is challenging. More openness in the game design process and motivational strategies could aid researchers and designers of future game-based apps., Objective: This study aims to provide insights into our approach to develop game-based eHealth in practice with a case study (Personalised ICT Supported Services for Independent Living and Active Ageing [PERSSILAA]). PERSSILAA is a self-management platform that aims to counter frailty by offering training modules to older adults in the domains of healthy nutrition and physical and cognitive training to maintain a healthy lifestyle. We elaborate on the entire game design process and show the motivational strategies applied., Methods: We introduce four game design phases in the process toward game-based eHealth: (1) end-user research, (2) conceptualization, (3) creative design, and (4) refinement (ie, prototyping and evaluations)., Results: First, 168 participants participated in end-user research, resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include focusing game concepts on thinking, problem-solving, variation, discovery, and achievement and using high-quality aesthetics. Second, stakeholder sessions with development partners resulted in strategies for long-term engagement using indicators of user performance on the platform's training modules. These performance indicators, for example, completed training sessions or exercises, form the basis for game progression. Third, results from prior phases were used in creative design to create the game "Stranded!" The user plays a person who is shipwrecked who must gather parts for a life raft by completing in-game objectives. Finally, iterative prototyping resulted in the final prototype of the game-based app. A total of 35 older adults participated using simulated training modules. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the app (75/100), and intended future use (66/100), which implies that the app is ready for use by a larger population., Conclusions: The study resulted in a game-based app for which the entire game design process within eHealth was transparently documented and where engagement strategies were based on extensive user research. Our user evaluations indicate that the strategies for long-term engagement led to game content that was perceived as engaging by older adults. As a next step, research is needed on the user experience and actual engagement with the game to support the self-management of older adults, followed by clinical studies on its added value., (©Frederiek de Vette, Aurora Ruiz-Rodriguez, Monique Tabak, Wendy Oude Nijeweme-d'Hollosy, Hermie Hermens, Miriam Vollenbroek-Hutten. Originally published in JMIR Formative Research (https://formative.jmir.org), 08.11.2024.)

Background: Digital interventions hold promise for improving physical activity in adolescents. However, a lack of empirical decision points (eg, timing of intervention prompts) is an evidence gap in the optimization of digital physical activity interventions., Objective: The study examined the feasibility and acceptability, as well as the technical and functional reliability, of and participant engagement with a digital intervention that aligned its decision points to occur during times when adolescents typically exercise. This study also explored the impact of the intervention on adolescents' moderate to vigorous physical activity (MVPA) levels. Consistent with the Obesity-Related Behavioral Interventions Trials (ORBIT) model, the primary goal of the study was to identify opportunities to refine the intervention for preparation for future trials., Methods: Ten adolescents completed a 7-day baseline monitoring period and Temporally Augmented Goal Setting (TAGS), a 20-day digital physical activity intervention that included a midday self-monitoring message that occurred when adolescents typically start to exercise (3 PM). Participants wore an accelerometer to measure their MVPA during the intervention. Participants completed questionnaires about the acceptability of the platform. Rates of recruitment and attrition (feasibility), user and technological errors (reliability), and engagement (average number of text message responses to the midday self-monitoring message) were calculated. The investigation team performed multilevel models to explore the effect of TAGS on MVPA levels from preintervention to intervention. In addition, as exploratory analyses, participants were matched to adolescents who previously completed a similar intervention, Network Underwritten Dynamic Goals Engine (NUDGE), without the midday self-monitoring message, to explore differences in MVPA between interventions., Results: The TAGS intervention was mostly feasible, acceptable, and technically and functionally reliable. Adolescents showed adequate levels of engagement. Preintervention to intervention changes in MVPA were small (approximately a 2-minute change). Exploratory analyses revealed no greater benefit of TAGS on MVPA compared with NUDGE., Conclusions: TAGS shows promise for future trials with additional refinements given its feasibility, acceptability, technical and functional reliability, participants' rates of engagement, and the relative MVPA improvements. Opportunities to strengthen TAGS include reducing the burden of wearing devices and incorporating of other strategies at the 3 PM decision point. Further optimization of TAGS will inform the design of a Just-in-Time Adaptive Intervention for adolescent physical activity and prepare the intervention for more rigorous testing., (©Adrian Ortega, Christopher C Cushing. Originally published in JMIR Formative Research (https://formative.jmir.org), 10.10.2024.)

Background: During the pandemic in Peru, the COVIDA (Collaboration Network of Volunteer Brigade Members for the Investigation, Detection, and Primary Management of Community Cases Affected by COVID-19) project proposed an innovative way to provide telemonitoring and teleorientation to COVID-19 patients, led by health care student volunteers. However, it has not been described how this interaction is perceived from the patient's perspective and which factors increase their engagement with this service., Objective: The aim of this study is to describe the perceptions of patients about COVIDA and identify factors associated with their engagement with this service., Methods: A mixed methods study was conducted to evaluate perceptions of patients that participated in the COVIDA project. This telehealth intervention organized by the National University of San Marcos was implemented in Peru from August to December 2020. The service involved daily phone calls by volunteer students to monitor registered COVID-19 patients until the completion of the 14th day of the illness or if a warning sign was identified. The volunteers also provided teleorientation to address the patients' needs and concerns. Quantitative analysis was performed to describe the characteristics of the patients and to assess the factors related to their engagement with the service, which was defined by the percentage of participants who completed the follow-up according to their individual schedule. Qualitative analysis through semistructured interviews evaluated the patients' perceptions of the service regarding the aspects of communication, interaction, and technology., Results: Of the 770 patients enrolled in COVIDA, 422 (55.7%) were female; the median age was 39 (IQR 28-52) years. During the monitoring, 380 patients (49.4%) developed symptoms, and 471 (61.2%) showed warning signs of COVID-19. The overall median for engagement was 93% (IQR 35.7%-100%). Among those patients who did not develop warning signs, engagement was associated with the presence of symptoms (OR 3.04, 95% CI 2.22-4.17), a positive COVID-19 test at the start of follow-up (OR 1.97, 95% CI 1.48-2.61), and the presence of comorbidities (OR 1.83, 95% CI 1.29-2.59). Patients reported that the volunteers provided clear and valuable information and emotional support. Communication via phone calls took place smoothly and without interruptions., Conclusions: COVIDA represents a well-accepted and well-perceived alternative model for student volunteers to provide telemonitoring, teleorientation, and emotional support to patients with COVID-19 in the context of overwhelmed demand for health care services. The deployment of this kind of intervention should be prioritized among patients with symptoms and comorbidities, as they show more engagement with these services., (©Stefan Escobar-Agreda, Javier Silva-Valencia, Percy Soto-Becerra, C Mahony Reategui-Rivera, Kelly De la Cruz-Torralva, Max Chahuara-Rojas, Bruno Hernandez-Iriarte, Daniel Hector Espinoza-Herrera, Carlos Alberto Delgado, Silvana Matassini, Javier Vargas-Herrera, Leonardo Rojas-Mezarina. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.09.2024.)

Background: Engagement with and the potential impact of web-based interventions is often studied by tracking user behavior with web analytics. These metrics do provide insights into how users behave, but not why they behave as such., Objective: This paper demonstrates how a mixed methods approach consisting of (1) a theoretical analysis of intended use, (2) a subsequent analysis of actual use, and (3) an exploration of user perceptions can provide insights into engagement with and potential impact of web-based interventions. This paper focuses on the exploration of user perceptions, using the chlamydia page of the Dutch sexual health intervention, Sense.info, as a demonstration case. This prevention-focused platform serves as the main source of sexual and reproductive health information (and care if needed) for young people aged 12-25 years in the Netherlands., Methods: First, acyclic behavior change diagrams were used to theoretically analyze the intended use of the chlamydia page. Acyclic behavior change diagrams display how behavior change principles are applied in an intervention and which subbehaviors and target behaviors are (aimed to be) influenced. This analysis indicated that one of the main aims of the page is to motivate sexually transmitted infection (STI) testing. Second, the actual use of the chlamydia page was analyzed with the web analytics tool Matomo. Despite the page's aim of promoting STI testing, a relatively small percentage (n=4948, 14%) of the 35,347 transfers from this page were to the STI testing page. Based on these two phases, preliminary assumptions about use and impact were formulated. Third, to further explore these assumptions, a study combining the think-aloud method and semistructured interviews was executed with 15 young individuals aged 16-25 (mean 20, SD 2.5) years. Template analysis was used to analyze interview transcripts., Results: Participants found the information on the Sense.info chlamydia page reliable and would visit it mostly for self-diagnosis purposes if they experienced potential STI symptoms. A perceived facilitator for STI testing was the possibility to learn about the symptoms and consequences of chlamydia through the page. Barriers included an easily overlooked link to the STI testing page and the use of language not meeting the needs of participants. Participants offered suggestions for lowering the threshold for STI testing., Conclusions: The mixed methods approach used provided detailed insights into the engagement with and potential impact of the Sense.info chlamydia page, as well as strategies to further engage end users and increase the potential impact of the page. We conclude that this approach, which triangulates findings from theoretical analysis with web analytics and a think-aloud study combined with semistructured interviews, may also have potential for the evaluation of web-based interventions in general., (©Gido Metz, Rosa R L C Thielmann, Hanneke Roosjen, Rik Crutzen. Originally published in JMIR Formative Research (https://formative.jmir.org), 11.09.2024.)

Background: Hypertension affects one-third of adults in the United States and is the leading risk factor for death. Underserved populations are seen disproportionately in the emergency department (ED) and tend to have worse blood pressure (BP) control. For adults, a lack of hypertension knowledge is a common barrier to hypertension control, while social support is a strong facilitator, and providing information that is culturally sensitive and relevant is especially important in this context. The youth experience increased confidence when given the responsibility to provide health education and care navigation to others. As such, we planned a randomized controlled trial (RCT) for the effectiveness of a digital youth-led hypertension education intervention for adult patients in the ED with hypertension, focusing on change in BP and hypertension knowledge., Objective: In preparation for an RCT, we conducted a formative study to determine acceptable and easily comprehensible ways to present hypertension information to adults with hypertension and optimal ways to engage youth to support adults on how to achieve better hypertension control., Methods: After creating an intervention prototype with 6 weekly self-guided hypertension online modules, we recruited 12 youth (adolescents, aged 15-18 years) for 3 focus groups and 10 adult ED patients with hypertension for individual online interviews to garner feedback on the prototype. After completing a brief questionnaire, participants were asked about experiences with hypertension, preferences for a hypertension education intervention, and acceptability, feasibility, obstacles, and solutions for intervention implementation with youth and adults. The moderator described and showed participants the prototyped intervention process and materials and asked for feedback. Questionnaire data were descriptively summarized, and qualitative data were analyzed using the template organizing style of analysis by 3 study team members., Results: Participants showed great interest in the intervention prototype, thought their peers would find it acceptable, and appreciated its involvement of youth. Youth with family members with hypertension reported that their family members need more support for their hypertension. Youth suggested adding more nutrition education activities to the intervention, such as a sodium tracker and examples of high-sodium foods. Adults discussed the need for a hypertension support intervention for themselves and the expected benefits to youth. They mentioned the overwhelming amount of hypertension information available and appreciated the intervention's concise content presentation. They suggested adding more mental health and smoking cessation resources, information about specific hypertension medications, and adding active links for health care information., Conclusions: Based on focus groups and interviews with participants, a youth-led digital hypertension intervention is an acceptable strategy to engage both adults with hypertension and youth. Incorporating participant suggestions into the intervention may improve its clarity, engagement, and impact when used in a subsequent RCT., (©Sara W Heinert, Kelvin Guzman-Baez, Affan Aamir, Ananya Penugonda, Benjamin F Crabtree, Kathryn Greene, Carolyn J Heckman, Phillip Levy, Pamela Ohman Strickland, Shawna V Hudson. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.09.2024.)

Background: App-based mobile health exercise interventions can motivate individuals to engage in more physical activity (PA). According to the Fogg Behavior Model, it is important that the individual receive prompts at the right time to be successfully persuaded into PA. These are referred to as just-in-time (JIT) interventions. The Playful Active Urban Living (PAUL) app is among the first to include 2 types of JIT prompts: JIT adaptive reminder messages to initiate a run or walk and JIT strength exercise prompts during a walk or run (containing location-based instruction videos). This paper reports on the feasibility of the PAUL app and its JIT prompts. Objective: The main objective of this study was to examine user experience, app engagement, and users' perceptions and opinions regarding the PAUL app and its JIT prompts and to explore changes in the PA behavior, intrinsic motivation, and the perceived capability of the PA behavior of the participants. Methods: In total, 2 versions of the closed-beta version of the PAUL app were evaluated: a basic version (Basic PAUL) and a JIT adaptive version (Smart PAUL). Both apps send JIT exercise prompts, but the versions differ in that the Smart PAUL app sends JIT adaptive reminder messages to initiate running or walking behavior, whereas the Basic PAUL app sends reminder messages at randomized times. A total of 23 participants were randomized into 1 of the 2 intervention arms. PA behavior (accelerometer-measured), intrinsic motivation, and the perceived capability of PA behavior were measured before and after the intervention. After the intervention, participants were also asked to complete a questionnaire on user experience, and they were invited for an exit interview to assess user perceptions and opinions of the app in depth. Results: No differences in PA behavior were observed (Z=-1.433; P=.08), but intrinsic motivation for running and walking and for performing strength exercises significantly increased (Z=-3.342; P<.001 and Z=-1.821; P=.04, respectively). Furthermore, participants increased their perceived capability to perform strength exercises (Z=2.231; P=.01) but not to walk or run (Z=-1.221; P=.12). The interviews indicated that the participants were enthusiastic about the strength exercise prompts. These were perceived as personal, fun, and relevant to their health. The reminders were perceived as important initiators for PA, but participants from both app groups explained that the reminder messages were often not sent at times they could exercise. Although the participants were enthusiastic about the functionalities of the app, technical issues resulted in a low user experience. Conclusions: The preliminary findings suggest that the PAUL apps are promising and innovative interventions for promoting PA. Users perceived the strength exercise prompts as a valuable addition to exercise apps. However, to be a feasible intervention, the app must be more stable. [ABSTRACT FROM AUTHOR]

Background: COVID-19 vaccines are vital tools in the defense against infection and serious disease due to SARS-CoV-2. There are many challenges to implementing mass vaccination campaigns for large, diverse populations from crafting vaccine promotion messages to reaching individuals in a timely and effective manner. During this unprecedented period, with COVID-19 mass vaccination campaigns essential for protecting vulnerable patient populations and attaining herd immunity, health care systems were faced with the dual challenges of vaccine outreach and distribution. Objective: The aim of this cross-sectional study was to assess the effectiveness of a COVID-19 vaccine text outreach approach for patients aged 65 years and older. Our goal was to determine whether this approach was successful in scheduling patients for COVID-19 vaccine appointments. Methods: We developed SMS text messages using the Tavoca platform. These messages informed patients of their vaccine eligibility and allowed them to indicate their interest in scheduling an appointment via a specific method (email or phone) or indicate their lack of interest in the vaccine. We tracked the status of these messages and how patients responded. Messages were sent to patients aged 65 years and older (N=30,826) at a nonprofit health care system in Washington, DC. Data were collected and examined from January 14 to May 10, 2021. Data were analyzed using multivariate multinomial and binary logistic regression models in SAS (version 9.4; SAS Institute Inc). Results: Approximately 57% of text messages were delivered to patients, but many messages received no response from patients (40%). Additionally, 42.1% (12,978/30,826) of messages were not delivered. Of the patients who expressed interest in the vaccine (2938/30,826, 9.5%), Black or African American patients preferred a phone call rather than an email for scheduling their appointment (odds ratio [OR] 1.69, 95% CI 1.29-2.21) compared to White patients. Patients aged 70-74 years were more likely to schedule an appointment (OR 1.38, 95% CI 1.01-1.89) than those aged 65-69 years, and Black or African American patients were more likely to schedule an appointment (OR 2.90, 95% CI 1.72-4.91) than White patients. Conclusions: This study provides insights into some advantages and challenges of using a text messaging vaccine outreach for patients aged 65 years and older. Lessons learned from this vaccine campaign underscore the importance of using multiple outreach methods and sharing of patient vaccination status between health systems, along with a patient-centered approach to address vaccine hesitancy and access issues. [ABSTRACT FROM AUTHOR]

Background: There is a growing bottleneck in mental health care, as the demand for services has outpaced the availability of mental health professionals. Consequently, many health systems have shifted to teletherapy as a scalable approach to increasing accessibility to care. Within these care models, various treatment modalities (eg, coaching and clinical care) are used to deliver support for anxiety and depression. However, more research is needed to better understand the differences in treatment responses. Objective: The purpose of this study was to examine the association between different care modalities and the levels of use with symptom score changes for members seeking virtual care services. Methods: We conducted an observational study of 4219 members who accessed Ginger, an on-demand mental health service, between September 2020 and September 2021. Using a mobile app, members can access text-based behavioral health coaching and virtual clinical services. This study focused on members with clinically elevated depression or anxiety levels at baseline. Logistic regressions were used to assess the association between care modalities and the levels of use with treatment response in depression and anxiety, using the Patient Health Questionnaire and Generalized Anxiety Disorder Assessment, respectively. Results: Of the 4219 members, 1623 (38.47%) demonstrated a full response to depression, and 1684 (39.91%) demonstrated a full response to anxiety. Members who completed care (ie, text-based coaching, virtual clinical therapy, hybrid of coaching, and clinical care) beyond the introductory session showed significantly increased odds of a full response compared with those who completed only limited care. Members who completed a hybrid of care had the highest odds of improvement; the odds of showing a full response in depression were 2.31 times higher (95% CI 1.91-2.80; P<.001) and in anxiety were 2.23 times higher (95% CI 1.84-2.70; P<.001) compared with members who completed limited care. For members who completed only coaching or clinical care, the largest effects were observed among those with high use. For members who completed a hybrid care program, we observed similar treatment responses across all levels of use. Conclusions: Our real-world study found that members who completed text-based coaching achieved full treatment responses at similar rates compared with members who completed virtual clinical care and members who completed a hybrid of care. There were no significant differences in the predicted probabilities of full treatment response between coaching and clinical care. Generally, the odds for a full response were highest among members with high use within each care modality; however, there were no differences in full-response treatment odds across levels of use with hybrid care. The results support the utility of digital behavioral health interventions and further highlight text-based coaching protocols as an accessible and suitable option when considering virtual care for treating anxiety and depression. [ABSTRACT FROM AUTHOR]

Background: Social media-delivered lifestyle interventions have shown promising outcomes, often generating modest but significant weight loss. Participant engagement appears to be an important predictor of weight loss outcomes; however, engagement generally declines over time and is highly variable both within and across studies. Research on factors that influence participant engagement remains scant in the context of social media-delivered lifestyle interventions. Objective: This study aimed to identify predictors of participant engagement from the content generated during a social media-delivered lifestyle intervention, including characteristics of the posts, the conversation that followed the post, and participants' previous engagement patterns. Methods: We performed secondary analyses using data from a pilot randomized trial that delivered 2 lifestyle interventions via Facebook. We analyzed 80 participants' engagement data over a 16-week intervention period and linked them to predictors, including characteristics of the posts, conversations that followed the post, and participants' previous engagement, using a mixed-effects model. We also performed machine learning-based classification to confirm the importance of the significant predictors previously identified and explore how well these measures can predict whether participants will engage with a specific post. Results: The probability of participants'engagement with each post decreased by 0.28% each week (P<.001; 95% CI 0.16%-0.4%). The probability of participants engaging with posts generated by interventionists was 6.3% (P<.001; 95% CI 5.1%-7.5%) higher than posts generated by other participants. Participants also had a 6.5% (P<.001; 95% CI 4.9%-8.1%) and 6.1% (P<.001; 95% CI 4.1%-8.1%) higher probability of engaging with posts that directly mentioned weight and goals, respectively, than other types of posts. Participants were 44.8% (P<.001; 95% CI 42.8%-46.9%) and 46% (P<.001; 95% CI 44.1%-48.0%) more likely to engage with a post when they were replied to by other participants and by interventionists, respectively. A 1 SD decrease in the sentiment of the conversation on a specific post was associated with a 5.4% (P<.001; 95% CI 4.9%-5.9%) increase in the probability of participants'subsequent engagement with the post. Participants'engagement in previous posts was also a predictor of engagement in subsequent posts (P<.001; 95% CI 0.74%-0.79%). Moreover, using a machine learning approach, we confirmed the importance of the predictors previously identified and achieved an accuracy of 90.9% in terms of predicting participants' engagement using a balanced testing sample with 1600 observations. Conclusions: Findings revealed several predictors of engagement derived from the content generated by interventionists and other participants. Results have implications for increasing engagement in asynchronous, remotely delivered lifestyle interventions, which could improve outcomes. Our results also point to the potential of data science and natural language processing to analyze microlevel conversational data and identify factors influencing participant engagement. Future studies should validate these results in larger trials. [ABSTRACT FROM AUTHOR]

Background: Digital applications are commonly used to support mental health and well-being. However, successfully retaining and engaging users to complete digital interventions is challenging, and comorbidities such as chronic pain further reduce user engagement. Digital conversational agents (CAs) may improve user engagement by applying engagement principles that have been implemented within in-person care settings. Objective: To evaluate user retention and engagement with an artificial intelligence–led digital mental health app (Wysa for Chronic Pain) that is customized for individuals managing mental health symptoms and coexisting chronic pain. Methods: In this ancillary survival analysis of a clinical trial, participants included 51 adults who presented to a tertiary care center for chronic musculoskeletal pain, who endorsed coexisting symptoms of depression or anxiety (Patient-Reported Outcomes Measurement Information System score of ≥55 for depression or anxiety), and initiated onboarding to an 8-week subscription of Wysa for Chronic Pain. The study outcomes were user retention, defined as revisiting the app each week and on the last day of engagement, and user engagement, defined by the number of sessions the user completed. Results: Users engaged in a cumulative mean of 33.3 sessions during the 8-week study period. The survival analysis depicted a median user retention period (i.e., time to complete disengagement) of 51 days, with the usage of a morning check-in feature having a significant relationship with a longer retention period (P=.001). Conclusions: Our findings suggest that user retention and engagement with a CBT-based CA built for users with chronic pain is higher than standard industry metrics. These results have clear implications for addressing issues of suboptimal engagement of digital health interventions and improving access to care for chronic pain. Future work should use these findings to inform the design of evidence-based interventions for individuals with chronic pain and to enhance user retention and engagement of digital health interventions more broadly. [ABSTRACT FROM AUTHOR]

Background: The use and sharing of patient-generated health data (PGHD) by clinicians or researchers is expected to enhance the remote monitoring of specific behaviors that affect patient health. In addition, PGHD use could support patients’decision-making on preventive care management, resulting in reduced medical expenses. However, sufficient evidence on the use and sharing of PGHD is lacking, and the impact of PGHD recording on patients’ health behavior changes remains unclear. Objective: This study aimed to assess patients’engagement with PGHD recording and to examine the impact of PGHD recording on their health behavior changes. Methods: This supplementary analysis used the data of 47 postpartum women who had been assigned to the intervention group of our previous study for managing urinary incontinence. To assess the patients’ engagement with PGHD recording during the intervention period (8 weeks), the fluctuation in the number of patients who record their PGHD (ie, PGHD recorders) was evaluated by an approximate curve. In addition, to assess adherence to the pelvic floor muscle training (PFMT), the weekly mean number of pelvic floor muscle contractions performed per day among 17 PGHD recorders was examined by latent class growth modeling (LCGM). Results: The fluctuation in the number of PGHD recorders was evaluated using the sigmoid curve formula (R2=0.91). During the first week of the intervention, the percentage of PGHD recorders was around 64% (30/47) and then decreased rapidly from the second to the third week. After the fourth week, the percentage of PGHD recorders was 36% (17/47), which remained constant until the end of the intervention. When analyzing the data of these 17 PGHD recorders, PFMT adherence was categorized into 3 classes by LCGM: high (7/17, 41%), moderate (3/17, 18%), and low (7/17, 41%). Conclusions: The number of PGHD recorders declined over time in a sigmoid curve. A small number of users recorded PGHD continuously; therefore, patients’ engagement with PGHD recording was low. In addition, more than half of the PGHD recorders (moderate- and low-level classes combined: 10/17, 59%) had poor PFMT adherence. These results suggest that PGHD recording does not always promote health behavior changes. [ABSTRACT FROM AUTHOR]

Background: Patient portals are a safe and secure way for patients to connect with providers for video-based telepsychiatry and help to overcome the financial and logistical barriers associated with face-to-face mental health care. Due to the COVID-19 pandemic, telepsychiatry has become increasingly important to obtaining mental health care. However, financial and technological barriers, termed the "digital divide," prevent some patients from accessing the technology needed to use telepsychiatry services. Objective: As an extension to a clinic's outreach project during COVID-19 to improve patient engagement with video-based visits through the hospital's patient portal among adult behavioral health patients at an urban safety net hospital, we aim to assess patient preference for patient portal-based video visits or telephone-only visits and to identify the demographic variables associated with their preference. Methods: Patients in an outpatient psychiatry clinic were contacted by phone, and preference for telepsychiatry by phone or video through a patient portal, as well as device preference for video-based visits, were documented. Patient demographic characteristics were collected from the electronic medical record. Results: A total of 128 patients were reached by phone. A total of 79 (61.7%) patients chose video-based visits, and 69.6% (n=55) of these patients preferred to access the patient portal through a smartphone. Older patients were significantly less likely to agree to video-based visits. Conclusions: Among behavioral health patients at a safety net hospital, there was relatively low engagement with video-based visits through the hospital's patient portal, particularly among older adults. [ABSTRACT FROM AUTHOR]

Background: Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings. Objective: This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management? Methods: We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management. Results: We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were =45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants' age, race, or ethnicity. Conclusions: In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that--despite free access to mHealth with a live coach--most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users' lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all. [ABSTRACT FROM AUTHOR]

Background: Persons with multiple chronic conditions face complex medical regimens and clinicians may not focus on what matters most to these patients who vary widely in their health priorities. Patient Priorities Care is a facilitator-led process designed to identify patients' priorities and align decision-making and care, but the need for a facilitator has limited its widespread adoption., Objective: The aims of this study are to design and test mechanisms for patients to complete a self-directed process for identifying priorities and providing their priorities to clinicians., Methods: The study involved patients of at least 65 years of age at 2 family medicine practices with 5 physicians each. We first tested 2 versions of an interactive website and asked patients to bring their results to their visit. We then tested an Epic previsit questionnaire derived from the website's questions and included standard previsit materials. We completed postintervention phone interviews and an online survey with participating patients and collected informal feedback and conducted a focus group with participating physicians., Results: In the test of the first website version, 17.3% (35/202) of invited patients went to the website, 11.4% (23/202) completed all of the questions, 2.5% (5/202) brought results to their visits, and the median session time was 43.0 (IQR 28.0) minutes. Patients expressed confusion about bringing results to the visit. After clarifying that issue in the second version, 15.1% (32/212) of patients went to the website, 14.6% (31/212) completed the questions, 1.9% (4/212) brought results to the visit, and the median session time was 35.0 (IQR 35.0) minutes. In the test of the Epic questionnaire, 26.4% (198/750) of patients completed the questionnaire before at least 1 visit, and the median completion time was 14.0 (IQR 23.0) minutes. The 8 main questions were answered 62.9% (129/205) to 95.6% (196/205) of the time. Patients who completed questionnaires were younger than those who did not (72.3 vs 76.1 years) and were more likely to complete at least 1 of their other assigned questionnaires (99.5%, 197/198) than those who did not (10.3%, 57/552). A total of 140 of 198 (70.7%) patients responded to a survey, and 86 remembered completing the questionnaire; 78 (90.7%) did not remember having difficulty answering the questions and 57 (68.7%) agreed or somewhat agreed that it helped them and their clinicians to understand their priorities. Doctors noted that the sickest patients did not complete the questionnaire and that the discussion provided a good segue into end-of-life care., Conclusions: Embedding questionnaires assaying patient priorities into patient portals holds promise for expanding access to priorities-concordant care., (©Jody Naimark, Mary E Tinetti, Tom Delbanco, Zhiyong Dong, Kendall Harcourt, Jessica Esterson, Peter Charpentier, Jan Walker. Originally published in JMIR Formative Research (https://formative.jmir.org), 29.08.2024.)

Background: For many young people, the transition from child to adult mental health services is a vulnerable time associated with treatment disengagement and illness progression. Providing service information and options to youth, appealing to them, and tailoring to their needs during this period could help overcome systematic barriers to a successful transition. We know little about how SMS text message-based interventions might be leveraged to support the motivational, informational, and behavioral needs of youth during this time. Ascertaining youth preferences for the content and functionality of an SMS text message service could inform prototype development., Objective: This study investigated consensus preferences among youth on important content, technology features, and engagement supports to inform a transition-focused SMS text message service., Methods: A modified e-Delphi survey design was used to collect demographics, current levels of technology use, importance ratings on message content, preferred technical features, and barriers and enablers to engagement for youth in Canada aged 16-26 years who have accessed mental health services within the past 5 years. Survey items on content were categorized according to the information-motivation-behavioral skills (IMB) model. Survey items on technical features were categorized according to the persuasive system design (PSD) model. A predefined consensus rating matrix and descriptive statistics were used to characterize the sample. The high consensus threshold was 70%., Results: A total of 100 participants, predominantly non-White (n=47, 47%), aged 20-26 years (n=59, 59%), and who had first accessed mental health services between the ages of 13 and 19 years (n=60, 60%), were selected. The majority (n=90, 90%) identified as daily SMS text message users. A high level of consensus on importance ratings was reported in 45% (9/20) of content items based on the IMB model. There were higher levels of consensus on importance ratings related to behavior domain items (3/3, 100%) than information domain items (4/9, 44%) or motivation domain items (2/8, 25%). A high level of consensus on importance ratings was reported in only 19% (4/21) of feature and functionality items based on the PSD model. Among PSD model categories, there was a high level of consensus on importance ratings in 8% (1/12) of the primary task support domain items and 100% (3/3) of the system credibility support domain items. None of the dialogue-support and social-support domain items met the high level of consensus thresholds. In total, 27% (27/100) of youth indicated that the most significant enabler for engaging with a transition-focused SMS text message intervention was the personalization of text messages., Conclusions: Scientists developing next-generation SMS text messaging interventions for this population need to consider how levels of consensus on different features may impact feasibility and personalization efforts. Youth can (and should) play an integral role in the development of these interventions., (©Negar Vakili, Janet A Curran, Roisin Walls, Debbie Phillips, Alanna Miller, Christine Cassidy, Lori Wozney. Originally published in JMIR Formative Research (https://formative.jmir.org), 27.08.2024.)

Background: Limited guidance exists for analyzing participant engagement in provider-guided digital health interventions (DHIs). System usage is commonly assessed, with acknowledged limitations in measuring socio-affective and cognitive aspects of engagement. Nurse WRITE, an 8-week web-based nurse-guided DHI for managing symptoms among women with recurrent ovarian cancer, offers an opportunity to develop a framework for assessing multidimensional engagement., Objective: This study aims to develop a conceptual and analytic framework to measure socio-affective, cognitive, and behavioral engagement with provider-guided DHIs. We then illustrate the framework's ability to describe and categorize engagement using Nurse WRITE as an example., Methods: A sample of 68 participants from Nurse WRITE who posted on the message boards were included. We adapted a prior framework for conceptualizing and operationalizing engagement across 3 dimensions and finalized a set of 6 distinct measures. Using patients' posts, we created 2 socio-affective engagement measures-total count of socio-affective engagement classes (eg, sharing personal experience) and total word count-and 2 cognitive engagement measures-total count of cognitive engagement classes (eg, asking information-seeking questions) and average question completion percentage. Additionally, we devised behavioral engagement measures using website data-the total count of symptom care plans and plan reviews. k-Means clustering categorized the participants into distinct groups based on levels of engagement across 3 dimensions. Descriptive statistics and narratives were used to describe engagement in 3 dimensions., Results: On average, participants displayed socio-affective engagement 34.7 times, writing 14,851 words. They showed cognitive engagement 19.4 times, with an average of 78.3% completion of nurses' inquiries. Participants also submitted an average of 1.6 symptom care plans and 0.7 plan reviews. Participants were clustered into high (n=13), moderate (n=17), and low engagers (n=38) based on the 6 measures. High engagers wrote a median of 36,956 (IQR 26,199-46,265) words. They demonstrated socio-affective engagement approximately 81 times and cognitive engagement around 46 times, approximately 6 times that of the low engagers and twice that of the moderate engagers. High engagers had a median of 91.7% (IQR 82.2%-93.7%) completion of the nurses' queries, whereas moderate engagers had 86.4% (IQR 80%-96.4%), and low engagers had 68.3% (IQR 60.1%-79.6%). High engagers completed a median of 3 symptom care plans and 2 reviews, while moderate engagers completed 2 plans and 1 review. Low engagers completed a median of 1 plan with no reviews., Conclusions: This study developed and reported an engagement framework to guide behavioral intervention scientists in understanding and analyzing participants' engagement with provider-guided DHIs. Significant variations in engagement levels across 3 dimensions highlight the importance of measuring engagement with provider-guided DHIs in socio-affective, cognitive, and behavioral dimensions. Future studies should validate the framework with other DHIs, explore the influence of patient and provider factors on engagement, and investigate how engagement influences intervention efficacy., (©Yan Wang, Annette DeVito Dabbs, Teresa Hagan Thomas, Grace Campbell, Heidi Donovan. Originally published in JMIR Formative Research (https://formative.jmir.org), 22.07.2024.)

Background: Efficacy of smartphone-based interventions depends on intervention content quality and level of exposure to that content. Smartphone-based survey completion rates tend to decline over time; however, few studies have identified variables that predict this decline over longer-term interventions (eg, 26 weeks)., Objective: This study aims to identify predictors of survey completion and message viewing over time within a 26-week smoking cessation trial., Methods: This study examined data from a 3-group pilot randomized controlled trial of adults who smoke (N=152) and were not ready to quit smoking within the next 30 days. For 182 days, two intervention groups received smartphone-based morning and evening messages based on current readiness to quit smoking. The control group received 2 daily messages unrelated to smoking. All participants were prompted to complete 26 weekly smartphone-based surveys that assessed smoking behavior, quit attempts, and readiness to quit. Compliance was operationalized as percentages of weekly surveys completed and daily messages viewed. Linear regression and mixed-effects models were used to identify predictors (eg, intervention group, age, and sex) of weekly survey completion and daily message viewing and decline in compliance over time., Results: The sample (mean age 50, SD 12.5, range 19-75 years; mean years of education 13.3, SD 1.6, range 10-20 years) was 67.8% (n=103) female, 74.3% (n=113) White, 77% (n=117) urban, and 52.6% (n=80) unemployed, and 61.2% (n=93) had mental health diagnoses. On average, participants completed 18.3 (71.8%) out of 25.5 prompted weekly surveys and viewed 207.3 (60.6%) out of 345.1 presented messages (31,503/52,460 total). Age was positively associated with overall weekly survey completion (P=.003) and daily message viewing (P=.02). Mixed-effects models indicated a decline in survey completion from 77% (114/148) in the first week of the intervention to 56% (84/150) in the last week of the intervention (P<.001), which was significantly moderated by age, sex, ethnicity, municipality (ie, rural/urban), and employment status. Similarly, message viewing declined from 72.3% (1533/2120) in the first week of the intervention to 44.6% (868/1946) in the last week of the intervention (P<.001). This decline in message viewing was significantly moderated by age, sex, municipality, employment status, and education., Conclusions: This study demonstrated the feasibility of a 26-week smartphone-based smoking cessation intervention. Study results identified subgroups that displayed accelerated rates in the decline of survey completion and message viewing. Future research should identify ways to maintain high levels of interaction with mobile health interventions that span long intervention periods, especially among subgroups that have demonstrated declining rates of intervention engagement over time., Trial Registration: ClinicalTrials.gov NCT03405129; https://clinicaltrials.gov/ct2/show/NCT03405129., (©Clayton Ulm, Sixia Chen, Brianna Fleshman, Lizbeth Benson, Darla E Kendzor, Summer Frank-Pearce, Jordan M Neil, Damon Vidrine, Michael S Businelle. Originally published in JMIR Formative Research (https://formative.jmir.org), 07.06.2024.)

Background: With the global increase of cesarean deliveries, breech presentation is the third indication for elective cesarean delivery. Implementation of external cephalic version (ECV), in which the position of the baby is manipulated externally to prevent breech presentation at term, remains suboptimal. Increasing knowledge for caretakers and patients is beneficial in the uptake of ECV implementation. In recent decades, the internet has become the most important source of information for both patients and health care professionals. However, the use and availability of the internet also bring about concerns since the information is often not regulated or reviewed. Information needs to be understandable, correct, and easily obtainable for the patient. Owing to its global reach, YouTube has great potential to both hinder and support spreading medical information and can therefore be used as a tool for shared decision-making., Objective: The objective of this study was to investigate the available information on YouTube about ECV and assess the quality and usefulness of the information in the videos., Methods: A YouTube search was performed with five search terms and the first 35 results were selected for analysis. A quality assessment scale was developed to quantify the accuracy of medical information of each video. The main outcome measure was the usefulness score, dividing the videos into useful, slightly useful, and not useful categories. The source of upload was divided into five subcategories and two broad categories of medical or nonmedical. Secondary outcomes included audience engagement, misinformation, and encouraging or discouraging ECV., Results: Among the 70 videos, only 14% (n=10) were defined as useful. Every useful video was uploaded by educational channels or health care professionals and 80% (8/10) were derived from a medical source. Over half of the not useful videos were uploaded by birth attendants and vloggers. Videos uploaded by birth attendants scored the highest on audience engagement. The presence of misinformation was low across all groups. Two-thirds of the vloggers encouraged ECV to their viewers., Conclusions: A minor percentage of videos about ECV on YouTube are considered useful. Vloggers often encourage their audience to opt for ECV. Videos with higher audience engagement had a lower usefulness score compared to videos with lower audience engagement. Sources from medically accurate videos should cooperate with sources with high audience engagement to contribute to the uptake of ECV by creating more awareness and a positive attitude of the procedure, thereby lowering the chance for a cesarean delivery due to breech presentation at term., (©Merle R van Dijk, Anne-Fleur van der Marel, Leonie E van Rheenen-Flach, Wessel Ganzevoort, Etelka Moll, Fedde Scheele, Joost Velzel. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.06.2024.)

Background: Mental health is a highly stigmatized disease, especially for young people. Due to its free, accessible format, college students increasingly use video-based social media for many aspects of information needs, including how-to tips, career, or health-related needs. The accessibility of video-based social media brings potential in supporting stigmatized contexts, such as college students' mental health. Understanding which kinds of videos about college students' mental health have increased viewer engagement will help build a foundation for exploring this potential. Little research has been done to identify video types systematically, how they have changed over time, and their associations on viewer engagement both short term and long term. Objective: This study aims to identify strategies for using video-based social media to combat stigmatized diseases, such as mental health, among college students. We identify who, with what perspective, purpose, and content, makes up the videos available on social media (ie, YouTube) about college students' mental health and how these factors associate with viewer engagement. We then identify effective strategies for designing video-based social media content for supporting college students' mental health. Methods: We performed inductive content analysis to identify different types of YouTube videos concerning college students' mental health (N=452) according to video attributes, including poster, perspective, and purpose. Time analysis showed how video types have changed over time. Fisher's exact test was used to examine the relationships between video attributes. The Mann-Whitney U test was used to test the association between video types and viewer engagement. Lastly, we investigated the difference in viewer engagement across time between two major types of videos (ie, individuals' storytelling and organization's informational videos). Results: Time trend analysis showed a notable increase in the number of (1) videos by individuals, (2) videos that represent students' perspectives, and (3) videos that share stories and experiential knowledge over the recent years. Fisher's exact test found all video attributes (ie, poster, perspective, and purpose) are significantly correlated with each other. In addition, the Mann-Whitney U test found that poster (individual vs organization) and purpose (storytelling vs sharing information) type has a significant association with viewer engagement (P<.001). Lastly, individuals' storytelling videos had a greater engagement in the short term and the long term. Conclusions: The study shows that YouTube videos on college students' mental health can be well differentiated by the types of posters and the purpose of the videos. Taken together, the videos where individuals share their personal stories, as well as experiential knowledge (ie, tips and advice), engaged more viewers in both the short term and long term. Individuals' videos on YouTube showed the potential to support college students' mental health in unique ways, such as providing social support, validating experience, and sharing the positive experience of help-seeking. [ABSTRACT FROM AUTHOR]

Background: Developing innovative, efficient, and institutionally scalable biospecimen consent for remnant tissue that meets the National Institutes of Health consent guidelines for genomic and molecular analysis is essential for precision medicine efforts in cancer. Objective: This study aims to pilot-test an electronic video consent that individuals could complete largely on their own. Methods: The University of California, Los Angeles developed a video consenting approach designed to be comprehensive yet fast (around 5 minutes) for providing universal consent for remnant biospecimen collection for research. The approach was piloted in 175 patients who were coming in for routine services in laboratory medicine, radiology, oncology, and hospital admissions. The pilot yielded 164 completed postconsent surveys. The pilot assessed the usefulness, ease, and trustworthiness of the video consent. In addition, we explored drivers for opting in or opting out. Results: The pilot demonstrated that the electronic video consent was well received by patients, with high scores for usefulness, ease, and trustworthiness even among patients that opted out of participation. The revised more animated video pilot test in phase 2 was better received in terms of ease of use (P=.005) and the ability to understand the information (P<.001). There were significant differences between those who opted in and opted out in their beliefs concerning the usefulness of tissue, trusting researchers, the importance of contributing to science, and privacy risk (P<.001). The results showed that "I trust researchers to use leftover biological specimens to promote the public's health" and "Sharing a biological sample for research is safe because of the privacy protections in place" discriminated opt-in statuses were the strongest predictors (both areas under the curve were 0.88). Privacy concerns seemed universal in individuals who opted out. Conclusions: Efforts to better educate the community may be needed to help overcome some of the barriers in engaging individuals to participate in precision health initiatives. [ABSTRACT FROM AUTHOR]

Background: Display signage is ubiquitous and essential in hospitals to serve several clerical, operational, and clinical functions, including displaying notices, providing directions, and presenting clinical information. These functions improve efficiency and patient engagement, reduce errors, and enhance the continuity of care. Over time, signage has evolved from analog approaches such as whiteboards and handwritten notices to digital displays such as liquid crystal displays, light emitting diodes, and, now, electronic ink displays. Electronic ink displays are paper-like displays that are not backlit and show content by aligning microencapsulated color beads in response to an applied electric current. Power is only required to generate content and not to retain it. These displays are very readable, with low eye strain; minimize the emission of blue light; require minimal power; and can be driven by several data sources, ranging from virtual servers to electronic health record systems. These attributes make adapting electronic ink displays to hospitals an ideal use case. Objective: In this paper, we aimed to outline the use of signage and displays in hospitals with a focus on electronic ink displays. We aimed to assess the advantages and limitations of using these displays in hospitals and outline the various public-facing and patient-facing applications of electronic ink displays. Finally, we aimed to discuss the technological considerations and an implementation framework that must be followed when adopting and deploying electronic ink displays. Methods: The public-facing applications of electronic ink displays include signage and way-finders, timetables for shared workspaces, and noticeboards and bulletin boards. The clinical display applications may be smaller form factors such as door signs or bedside cards. The larger, =40-inch form factors may be used within patient rooms or at clinical command centers as a digital whiteboard to display general information, patient and clinician information, and care plans. In all these applications, such displays could replace analog whiteboards, noticeboards, and even other digital screens. Results: We are conducting pilot research projects to delineate best use cases and practices in adopting electronic ink displays in clinical settings. This will entail liaising with key stakeholders, gathering objective logistical and feasibility data, and, ultimately, quantifying and describing the effect on clinical care and patient satisfaction. Conclusions: There are several use cases in a clinical setting that may lend themselves perfectly to electronic ink display use. The main considerations to be studied in this adoption are network connectivity, content management, privacy and security robustness, and detailed comparison with existing modalities. Electronic ink displays offer a superior opportunity to future-proof existing practices. There is a need for theoretical considerations and real-world testing to determine if the advantages outweigh the limitations of electronic ink displays. [ABSTRACT FROM AUTHOR]

Background: The potential of health apps for health promotion and disease prevention is widely recognized. However, uptake is limited due to barriers individuals face in finding suitable and trustworthy apps, such as the overwhelming amount of available health apps. Therefore, the health app platform "FitKnip" was developed, enabling individuals to purchase preselected, trustworthy health apps with a budget of 100 euros (a currency exchange rate of EUR €1=US $1.0831 is applicable). The platform aimed to empower individuals to improve their health and vitality, ultimately supporting a more healthy society., Objective: The primary aim of this study was to evaluate the health app platform in terms of feasibility and acceptability. Potential effects on health empowerment and health outcomes were secondarily explored., Methods: This quantitative study was part of a mixed methods study with a prospective pre-post interventional design. We collected web-based user data, and self-reported web-based questionnaires were collected over 5 measurements over an 8-month period. Use statistics were tracked on the platform, including the number of purchased apps and euros spent per user registered within the health app platform. We measured the user-friendliness of the health app platform using the System Usability Scale (SUS) and satisfaction using the Client Satisfaction Questionnaire-8 (CSQ-8) and several 10-point Likert items. We asked participants to indicate, on a scale from 1 (not at all) to 10 (completely), how much the health app platform contributed to various areas related to health empowerment. We assessed health-related quality of life by the 12-item Short-Form Health Survey (SF-12) and one's perceived level of stress by the 10-item Perceived Stress Scale (PSS-10)., Results: A total of 1650 participants were included, of whom 42% (685/1650) bought at least 1 app. The majority of those purchased one app (244/685, 35.6%). The health app platform was rated as user-friendly (SUS mean 66.5, SD 20.7; range 66.5-70.0), and the acceptability of the health app platform was moderate (CSQ-8 mean 20.0, SD 1.5; range 19.6-20.0). Results furthermore showed that participants were generally satisfied to highly satisfied with the ease of the payment system to purchase apps on the platform (median 8, IQR 7-10), the look and feel of the platform (median 7, IQR 6-8), as well as the provided budget of 100 euros (median 9, IQR 7-10). Participants were less satisfied with the amount (median 6, IQR 4-7) and diversity (median 6, IQR 4-7) of apps offered on the platform., Conclusions: A health app platform is a promising initiative to enhance public health. Feasibility and acceptability are critical for success, as they ensure that such a platform is accessible, user-friendly, and meets end users' needs and preferences. This can help to increase uptake, engagement, and ultimately the platform's adoption and effectiveness., (©Romy Fleur Willemsen, Niels Henrik Chavannes, Jiska Joëlle Aardoom. Originally published in JMIR Formative Research (https://formative.jmir.org), 29.05.2024.)

Background: There is evidence that social interaction has an inverse association with the development of neurodegenerative diseases. PREDICT-Parkinson Disease (PREDICT-PD) is an online UK cohort study that stratifies participants for risk of future Parkinson disease (PD)., Objective: This study aims to explore the methodological approach and feasibility of assessing the digital social characteristics of people at risk of developing PD and their social capital within the PREDICT-PD platform, making hypotheses about the relationship between web-based social engagement and potential predictive risk indicators of PD., Methods: A web-based application was built to enable social interaction through the PREDICT-PD portal. Feedback from existing members of the cohort was sought and informed the design of the pilot. Dedicated staff used weekly engagement activities, consisting of PD-related research, facts, and queries, to stimulate discussion. Data were collected by the hosting platform. We examined the pattern of connections generated over time through the cumulative number of posts and replies and ego networks using social network analysis. We used network metrics to describe the bonding, bridging, and linking of social capital among participants on the platform. Relevant demographic data and Parkinson risk scores (expressed as an odd 1:x) were analyzed using descriptive statistics. Regression analysis was conducted to estimate the relationship between risk scores (after log transformation) and network measures., Results: Overall, 219 participants took part in a 4-month pilot forum embedded in the study website. In it, 200 people (n=80, 40% male and n=113, 57% female) connected in a large group, where most pairs of users could reach one another either directly or indirectly through other users. A total of 59% (20/34) of discussions were spontaneously started by participants. Participation was asynchronous, with some individuals acting as "brokers" between groups of discussions. As more participants joined the forum and connected to one another through online posts, distinct groups of connected users started to emerge. This pilot showed that a forum application within the cohort web platform was feasible and acceptable and fostered digital social interaction. Matching participants' web-based social engagement with previously collected data at individual level in the PREDICT-PD study was feasible, showing potential for future analyses correlating online network characteristics with the risk of PD over time, as well as testing digital social engagement as an intervention to modify the risk of developing neurodegenerative diseases., Conclusions: The results from the pilot suggest that an online forum can serve as an intervention to enhance social connectedness and investigate whether patterns of online engagement can impact the risk of developing PD through long-term follow-up. This highlights the potential of leveraging online platforms to study the role of social capital in moderating PD risk and underscores the feasibility of such approaches in future research or interventions., (©Xiancheng Li, Aneet Gill, Pietro Panzarasa, Jonathan Bestwick, Anette Schrag, Alastair Noyce, Anna De Simoni. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.05.2024.)

Background: Digital inclusion is considered a pivotal social determinant of health, particularly for older adults who may face significant barriers to digital access due to physical, sensory, and social limitations. Avatar for Global Access to Technology for Healthy Aging (AGATHA) is a virtual healthy aging coach developed by the World Health Organization to address these challenges. Designed as a comprehensive virtual coach, AGATHA comprises a gamified platform that covers multiple health-related topics and modules aimed at fostering user engagement and promoting healthy aging., Objective: The aim of this study was to explore the perception and user experience of Malaysian older adults in their interactions with the AGATHA app and its avatar. The focus of this study was to examine the engagement, usability, and educational impact of the app on health literacy and digital skills., Methods: We performed a qualitative study among adults 60 years and older from suburban and rural communities across six states in Malaysia. Participants were purposefully recruited to ensure representation across various socioeconomic and cultural backgrounds. Each participant attended a 1-hour training session to familiarize themselves with the interface and functionalities of AGATHA. Subsequently, all participants were required to engage with the AGATHA app two to three times per week for up to 2 weeks. Upon completion of this trial phase, an in-depth interview session was conducted to gather detailed feedback on their experiences., Results: Overall, the participants found AGATHA to be highly accessible and engaging. The content was reported to have a comprehensive structure and was delivered in an easily understandable and informative manner. Moreover, the participants found the app to be beneficial in enhancing their understanding pertaining to health-related issues in aging. Some key feedback gathered highlighted the need for increased interactive features that would allow for interaction with peers, better personalization of content tailored to the individual's health condition, and improvement in the user-experience design to accommodate older users' specific needs. Furthermore, enhancements in decision-support features within the app were suggested to better assist users in making health decisions., Conclusions: The prototype digital health coaching program AGATHA was well received as a user-friendly tool suitable for beginners, and was also perceived to be useful to enhance older adults' digital literacy and confidence. The findings of this study offer important insights for designing other digital health tools and interventions targeting older adults, highlighting the importance of a user-centered design and personalization to improve the adoption of digital health solutions among older adults. This study also serves as a useful starting point for further development and refinement of digital health programs aimed at fostering an inclusive, supportive digital environment for older adults., (©Pei-Lee Teh, Andrei O J Kwok, Wing Loong Cheong, Shaun Lee. Originally published in JMIR Formative Research (https://formative.jmir.org), 21.05.2024.)

Background: Digital patient-centered interventions may be important tools for improving and promoting social interaction, health, and well-being among older adults. In this regard, we developed a mobile app called DigiAdherence for an older adult population, which consisted of easy-to-access short videos and messages, to improve health-related knowledge among them and prevent common health conditions, such as falls, polypharmacy, treatment adherence, nutritional problems, and physical inactivity., Objective: This study aimed to assess the usability and utility of the DigiAdherence app among Portuguese older adults 65 years or older., Methods: In this pilot noncontrolled quasi-experimental study, older adults who were patients at the primary health care center in Portimão, Portugal, and owned a smartphone or tablet were recruited. Participants were assessed at baseline, given access to the DigiAdherence app for 1 month, and assessed again immediately after 30 days (first assessment) and 60 days after stopping the use of the app (second assessment). App usability and utility (primary outcomes) were analyzed in the first follow-up assessment using a structured questionnaire with 8 items. In the second follow-up assessment, our focus was on knowledge acquired through the app. Secondary outcomes such as treatment adherence and health-related quality of life were also assessed., Results: The study included 26 older adults. Most participants rated the different functionalities of the app positively and perceived the app as useful, attractive, and user-friendly (median score of 6 on a 7-point Likert scale). In addition, after follow-up, participants reported having a sense of security and greater knowledge in preventing falls (16/24, 67%) and managing therapies and polypharmacy (16/26, 62%)., Conclusions: The DigiAdherence mobile app was useful and highly accepted by older adults, who developed more confidence regarding health-related knowledge., International Registered Report Identifier (irrid): RR2-10.2196/29675., (©Marta Lemos, Ana Rita Henriques, David Gil Lopes, Nuno Mendonça, André Victorino, Andreia Costa, Miguel Arriaga, Maria João Gregório, Rute de Sousa, Helena Canhão, Ana M Rodrigues. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.05.2024.)

Background: Research has shown that heterosexual African American male individuals aged 18-24 years have a higher prevalence of sexually transmitted infections (STIs) and are more likely to engage in risky sexual behavior. There is a critical need to promote sexual reproductive health (SRH) services among this population, especially in urban settings. Young African American male individuals use social media platforms to access health information, showcasing the potential of social media and web-based links as tools to leverage electronic engagement with this population to promote SRH care., Objective: This study aims to explore electronic engagement with young African American male individuals in discussions about SRH care. This paper focuses on the recruitment and social media marketing methods used to recruit young, heterosexual African American male individuals aged 18-24 years for the Stay Safe Project, a larger study that aims to promote SRH services among this population in Detroit, Michigan. We investigate the use of TinyURL, a URL shortener and customized tool, and culturally informed social media marketing strategies to promote electronic engagement within this population., Methods: Participants were recruited between December 2021 and February 2022 through various modes, including email listserves, Mailchimp, the UMHealthResearch website, X (formerly Twitter), Facebook, and Instagram. Images and vector graphics of African American male individuals were used to create social media advertisements that directed participants to click on a TinyURL that led to a recruitment survey for the study., Results: TinyURL metrics were used to monitor demographic and user data, analyzing the top countries, browsers, operating systems, and devices of individuals who engaged with the customized TinyURL links and the total human and unique clicks from various social media platforms. Mailchimp was the most successful platform for electronic engagement with human and unique clicks on the custom TinyURL link, followed by Instagram and Facebook. In contrast, X, traditional email, and research recruiting websites had the least engagement among our population. Success was determined based on the type of user and follower for each platform, whether gained in the community through sign-ups or promoted at peak user time and embedded and spotlighted on nontraditional media (eg, social media sites, blogs, and podcasts) for the user. Low engagement (eg, traditional email) from the target population, limited visibility, and fewer followers contributed to decreased engagement., Conclusions: This study provides insight into leveraging customized, shortened URLs, TinyURL metrics, and social media platforms to improve electronic engagement with young African American male individuals seeking information and resources about SRH care. The results of this study have been used to develop a pilot intervention for this population that will contribute to strategies for encouraging sexual well-being, clinic use, and appropriate linkage to SRH care services among young, heterosexual African American male individuals., (©Sandy Arena, Mackenzie Adams, Jade Burns. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.04.2024.)

Background: Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health., Objective: This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence-directed research., Methods: Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health's self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022., Results: Arm 3 had significantly younger members (F 2,4564 =40.97; P<.001) and significantly more female members (χ 2 =92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001).4 =92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001)., Conclusions: Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field., International Registered Report Identifier (irrid): RR2-10.2196/37231., (©Trevor van Mierlo, Renante Rondina, Rachel Fournier. Originally published in JMIR Formative Research (https://formative.jmir.org), 09.04.2024.)

Background: Since June 2021, patients with hemophilia A with antifactor VIII inhibitors and those with severe hemophilia A without antifactor VIII inhibitors treated with Hemlibra have had to choose between a community or hospital pharmacy. The French reference center for hemophilia developed the HEMOPHAR e-learning program for community pharmacists for dispensing emicizumab., Objective: This study aims to evaluate the efficiency and safety of this new care pathway by assessing the HEMOPHAR e-learning program., Methods: The methodology is based on Kirkpatrick's model for evaluating the immediate reaction of trained community pharmacists (level 1), their level of acquired knowledge (level 2), and their professional practice after 3 months of dispensation (level 3)., Results: The HEMOPHAR e-learning program reached a large audience, with 67% (337/502) of the eligible community pharmacists following it. The immediate reaction was overall satisfying. High rates of engagement were reported with 63.5% (214/337) to 73.3% (247/337) of completed training modules, along with high rates of success with quizzes of 61.5% (174/337) to 95.7% (244/337). We observed that 83.9% (193/230) of the community pharmacists needed less than 2 attempts to pass the quiz of the module related to professional practice, while the other quizzes required more attempts. Advice on compliance and drug interactions were most frequently provided to patients by the community pharmacists., Conclusions: This study suggests ways to improve the training of community pharmacists and to optimize coordination with treatment centers. This study also reports on the feasibility of switching to a community pharmacy in a secure pharmaceutical circuit, including in the context of a rare bleeding disease., Trial Registration: ClinicalTrials.gov NCT05449197; https://clinicaltrials.gov/study/NCT05449197., International Registered Report Identifier (irrid): RR2-10.2196/43091., (©Valérie Chamouard, Julie Freyssenge, Béatrice Clairaz-Mahiou, Felicia Ferrera Bibas, Laurie Fraticelli. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.04.2024.)

Background: Digital screening and intervention tools have shown promise in the identification and reduction of substance use in health care settings. However, research in this area is impeded by challenges in integrating recruitment efforts into ongoing clinical workflows or staffing multiple study clinics with full-time research assistants, as well as by the underreporting of substance use., Objective: The aim of the study is to evaluate pragmatic methods for facilitating study recruitment in health care settings by examining recruitment rates and participant characteristics using in-person-based versus flyer approaches., Methods: This study compared recruitment rates at a Women's Health clinic in the Midwest under 2 different recruitment strategies: in person versus via a flyer with a QR code. We also examined the disclosure of substance use and risk screener positivity for the 2 strategies. We also obtained information about the current use of technology and willingness to use it for study participation., Results: A greater percentage of patients recruited in person participated than those recruited via flyers (57/63, 91% vs 64/377, 17%). However, the final number recruited in each group was roughly equal (n=57 vs n=64). Additionally, participants recruited via flyers were more likely to screen positive for alcohol use risk on the Tolerance, Annoyed, Cut Down, Eye-Opener alcohol screen than those recruited at the clinic (24/64, 38% vs 11/57, 19%; χ 2 1 =4.9; P=.03). Participants recruited via flyers were also more likely to screen positive for drug use risk on the Wayne Indirect Drug Use Screener than those recruited at the clinic (20/64, 31% vs 9/57, 16%; χ 2 1 =4.0; P=.05). Furthermore, of the 121 pregnant women, 117 (96.7%) reported owning a smartphone, 111 (91.7%) had an SMS text message plan on their phone, and 94 (77.7%) reported being willing to receive SMS text messages or participate in a study if sent a link to their phone., Conclusions: The distribution of flyers with a QR code by medical staff appears to be an efficient and cost-effective method of recruitment that also facilitates disclosure while reducing the impact on clinic workflows. This method of recruitment can be useful for data collection at multiple locations and lead to larger samples across and between health systems. Participant recruitment via technology in perinatal health care appears to facilitate disclosure, particularly when participants can learn about the research and complete screening using their own device at a place and time convenient for them. Pregnant women in an urban Midwestern hospital had access to and were comfortable using technology., (©Jessica R Beatty, Logan Zelenak, Spencer Gillon, Lucy McGoron, Gregory Goyert, Steven J Ondersma. Originally published in JMIR Formative Research (https://formative.jmir.org), 04.03.2024.)

Background: The prevalence of gestational diabetes mellitus (GDM) has drastically risen in recent years. For some, self-management includes the use of GDM online communities on Facebook. Such communities can fill gaps in information and support that participants are not able to access elsewhere to address unmet needs. Given the popularity of sharing information about pregnancy on Facebook and the documented benefits of diabetes online communities, the same may be true of GDM online communities., Objective: This study aimed to categorize and quantify what is being discussed in GDM Facebook groups, including informational and emotional help-seeking behavior, and how this support and engagement may be demonstrated by peers through comments and reactions., Methods: We sourced the data from the 2 largest Facebook groups focused on GDM in Australia. A summative content analysis was conducted on original posts across the 2 groups and coded for topics as well as help-seeking types. The coding scheme was based on the previous work of Liang and Scammon. Visible indicators of engagement, including the number of comments and "reactions," were tabled and manually evaluated., Results: There were 388 original posts, and the analysis produced 6 topics: GDM self-management (199/388, 51.3%), GDM clinical management (120/388, 30.9%), preparing for birth (40/388, 10.3%), mental distress (35/388, 9%), birth announcement (29/388, 7.5%), and GDM journey reflections (21/388, 5.4%). Secondary coding of help-seeking type revealed more than half of the posts were informational help-seeking (224/388, 57.7%), while a small proportion were both informational and emotional help-seeking (44/388, 11.3%), and some (12/388, 3.1%) were emotional help-seeking only. Self-disclosure was identified as a fourth category, comprising almost a quarter of all posts (90/388, 23.2%). A total of 6022 comments were posted in response to the original posts, and there were 4452 reactions across all posts. Emotional help-seeking attracted the most comments per thread (mean 21.5, SD 19.8), followed by informational and emotional help-seeking (mean 20.2, SD 14.7), informational help-seeking (mean 15.6, SD 14.6), and self-disclosure (mean 14.3, SD 21.8). Across all help-seeking categories, few reactions occurred compared to comments; in contrast, self-disclosure attracted a large number of reactions (mean 9.4, SD 45.3)., Conclusions: This is one of the first studies to examine peer support in a GDM online community on Facebook. Our findings suggest that active participants' needs around information and support in relation to GDM are being somewhat met by peer-led online communities. Given the practical limitations of formal health care, including the provision of ongoing social support, it is important to recognize how GDM online communities can complement formal health care and help address unmet needs., (©Sheila Pham, Kate Churruca, Louise A Ellis, Jeffrey Braithwaite. Originally published in JMIR Formative Research (https://formative.jmir.org), 26.02.2024.)

Background: Research is needed on how faith and prayer apps fit within the values of racial and ethnic minority (REM) groups, as well as whether such apps are effective in promoting mental health and well-being., Objective: This study aims to determine the feasibility and preliminary effectiveness of using the mobile app Pray.com on mental health and well-being among REM participants., Methods: This study was a single-group (N=77), 4-week feasibility trial in REM groups (65/77, 84% Black or African American). Participants were asked to use the Pray.com app at no cost for at least 5 times per week for 5 minutes per day. Participants completed questionnaires at the baseline and postintervention time points. Feasibility questionnaires were only completed at the postintervention time point, including qualitative interviews (n=15). The feasibility questions included acceptability (ie, satisfaction, intent to continue use, perceived appropriateness, and fit within culture), demand (ie, self-reported app use, expressed interest, and perceived demand), and practicality (ie, ease or difficulty of use, ability to use the app, and cost-effectiveness). Frequency and descriptive statistics were used to analyze feasibility outcomes. Changes in dependent variables were analyzed using paired-sample 2-tailed t tests. Partial correlations were conducted to explore the association between app use and outcomes, controlling for baseline scores., Results: Participants reported (54/72, 75% responded with "very likely" or "likely" to the feasibility questions) that they perceived the Pray.com app as acceptable. These findings were supported by qualitative interviews (n=15). Most participants (62/72, 86%) did not meet the app use prescription but expressed interest in using the app in the future and perceived demand for it in their communities. In addition, participants reported that the app was easy to use and perceived it to be inexpensive (US $7.99). Participants reported improved mental health (ie, stress and depressive and anxiety symptoms) and well-being (ie, satisfaction with life, spiritual well-being, religious commitment, and racial or ethnic identity development) at postintervention despite relatively low average levels and high variability of app use (average total of 45.83, SD 111.90 min over the course of the study). Greater app use was significantly associated with improvements in mental health and spiritual well-being. However, app use and study methodology limitations suggest that the study results may not accurately capture the full impact of Pray.com use., Conclusions: This is the first study to assess the feasibility of a faith and prayer app for mental health and well-being in a sample of REM individuals. Our findings suggest that the use of a faith and prayer app (ie, Pray.com) could be feasible and significantly impactful for the improvement of mental health symptoms and well-being in REM individuals and their communities, especially Black and African American individuals with a Christian affiliation. Further research is warranted., (©Breanne Laird, Sabrina Zuniga, Joshua N Hook, Daryl R Van Tongeren, Lynda Joeman, Jennifer Huberty. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.02.2024.)

Background: Maintaining good communication and engagement between people with dementia and their caregivers is a major challenge in dementia care. Cognitive stimulation is a psychosocial intervention that supports communication and engagement, and several digital applications for cognitive stimulation have been developed. Personalization is an important factor for obtaining sustainable benefits, but the time and effort required to personalize and optimize applications often makes them difficult for routine use by nonspecialist caregivers and families. Although artificial intelligence (AI) has great potential to support automation of the personalization process, its use is largely unexplored because of the lack of suitable data from which to develop and train machine learning models., Objective: This pilot study aims to evaluate a digital application called Aikomi in Japanese care homes for its potential to (1) create and deliver personalized cognitive stimulation programs to promote communication and engagement between people with dementia and usual care staff and (2) capture meaningful personalized data suitable for the development of AI systems., Methods: A modular technology platform was developed and used to create personalized programs for 15 people with dementia living in 4 residential care facilities in Japan with the cooperation of a family member or care staff. A single intervention with the program was conducted with the person with dementia together with a care staff member, and for some participants, smell stimulation was provided using selected smell sticks in conjunction with the digital program. All sessions were recorded using a video camera, and the combined personalized data obtained by the platform were analyzed., Results: Most people with dementia (10/15, 67%) showed high levels of engagement (>40 on Engagement of a Person with Dementia Scale), and there were no incidences of negative reactions toward the programs. Care staff reported that some participants showed extended concentration and spontaneous communication while using Aikomi, which was not their usual behavior. Smell stimulation promoted engagement for some participants even when they were unable to identify the smell. No changes in well-being were observed following the intervention according to the Mental Function Impairment Scale. The level of response to each type of content in the stimulation program varied greatly according to the person with dementia, and personalized data captured by the Aikomi platform enabled understanding of correlations between stimulation content and responses for each participant., Conclusions: This study suggests that the Aikomi digital application is acceptable for use by persons with dementia and care staff and may have the potential to promote communication and engagement. The platform captures personalized data, which can provide suitable input for machine learning. Further investigation of Aikomi will be conducted to develop AI systems and create personalized digital cognitive stimulation applications that can be easily used by nonspecialist caregivers., (©Nick Hird, Tohmi Osaki, Samik Ghosh, Sucheendra K Palaniappan, Kiyoshi Maeda. Originally published in JMIR Formative Research (https://formative.jmir.org), 16.01.2024.)

Public deliberation, or deliberative democracy, is a method used to elicit informed perspectives and justifiable solutions to ethically fraught or contentious issues that affect multiple stakeholder groups with conflicting interests. Deliberative events bring together stakeholders (deliberants) who are provided with empirical evidence on the central issue or concern and then asked to discuss the evidence, consider the issue from a societal perspective, and collectively work toward a justifiable resolution. There is increasing interest in this method, which warrants clear guidance for evaluating the quality of its use in research. Most of the existing literature on measuring deliberation quality emphasizes the quality of deliberants' inputs (eg, engagement and evidence of compromise) during deliberative sessions. Fewer researchers have framed quality in terms of facilitator inputs, and these researchers tend to examine inputs that are consistent with generic group processes. The theory, process, and purpose of public deliberation, however, are distinct from those of focus groups or other group-based discussions and warrant a mechanism for measuring quality in terms of facilitator fidelity to the principles and processes of deliberative democracy. In our public deliberation on ethical conflicts in minor consent for biomedical HIV prevention research, we assessed facilitator fidelity to these principles and processes because we believe that such assessments serve as a component of a comprehensive evaluation of overall deliberation quality. We examined verbatim facilitator remarks in the deliberation transcripts and determined whether they aligned with the 6 principles of public deliberation: equal participation, respect for the opinions of others, adoption of a societal perspective, reasoned justification of ideas, expression of diverse opinions, and compromise or movement toward consensus. In this tutorial, we describe the development of a blueprint to guide researchers in assessing facilitator fidelity, share 3 templates that will assist them in the task, and describe the results of our assessment of facilitator fidelity in 1 of the 4 sites in which we conducted deliberations., (©Claire Draucker, Andrés Carrión, Mary A Ott, Amelia Knopf. Originally published in JMIR Formative Research (https://formative.jmir.org), 13.12.2023.)

Background: The prevention of oral health diseases is a key public health issue and a major challenge for racial and ethnic minority groups, who often face barriers in accessing dental care. Daily toothbrushing is an important self-care behavior necessary for sustaining good oral health, yet engagement in regular brushing remains a challenge. Identifying strategies to promote engagement in regular oral self-care behaviors among populations at risk of poor oral health is critical., Objective: The formative research described here focused on creating messages for a digital oral self-care intervention targeting a racially and ethnically diverse population. Theoretically grounded strategies (reciprocity, reciprocity-by-proxy, and curiosity) were used to promote engagement in 3 aspects: oral self-care behaviors, an oral care smartphone app, and digital messages. A web-based participatory co-design approach was used to develop messages that are resource efficient, appealing, and novel; this approach involved dental experts, individuals from the general population, and individuals from the target population-dental patients from predominantly low-income racial and ethnic minority groups. Given that many individuals from racially and ethnically diverse populations face anonymity and confidentiality concerns when participating in research, we used an approach to message development that aimed to mitigate these concerns., Methods: Messages were initially developed with feedback from dental experts and Amazon Mechanical Turk workers. Dental patients were then recruited for 2 facilitator-mediated group webinar sessions held over Zoom (Zoom Video Communications; session 1: n=13; session 2: n=7), in which they provided both quantitative ratings and qualitative feedback on the messages. Participants interacted with the facilitator through Zoom polls and a chat window that was anonymous to other participants. Participants did not directly interact with each other, and the facilitator mediated sessions by verbally asking for message feedback and sharing key suggestions with the group for additional feedback. This approach plausibly enhanced participant anonymity and confidentiality during the sessions., Results: Participants rated messages highly in terms of liking (overall rating: mean 2.63, SD 0.58; reciprocity: mean 2.65, SD 0.52; reciprocity-by-proxy: mean 2.58, SD 0.53; curiosity involving interactive oral health questions and answers: mean 2.45, SD 0.69; curiosity involving tailored brushing feedback: mean 2.77, SD 0.48) on a scale ranging from 1 (do not like it) to 3 (like it). Qualitative feedback indicated that the participants preferred messages that were straightforward, enthusiastic, conversational, relatable, and authentic., Conclusions: This formative research has the potential to guide the design of messages for future digital health behavioral interventions targeting individuals from diverse racial and ethnic populations. Insights emphasize the importance of identifying key stimuli and tasks that require engagement, gathering multiple perspectives during message development, and using new approaches for collecting both quantitative and qualitative data while mitigating anonymity and confidentiality concerns., (©Stephanie M Carpenter, Zara M Greer, Rebecca Newman, Susan A Murphy, Vivek Shetty, Inbal Nahum-Shani. Originally published in JMIR Formative Research (https://formative.jmir.org), 11.12.2023.)

Background: Patients with chronic respiratory diseases and those in the postdischarge period following hospitalization because of COVID-19 are particularly vulnerable, and little is known about the changes in their symptoms and physiological parameters. Continuous remote monitoring of physiological parameters and symptom changes offers the potential for timely intervention, improved patient outcomes, and reduced health care costs., Objective: This study investigated whether a real-time multimodal program using commercially available wearable technology, home-based Bluetooth-enabled spirometers, finger pulse oximeters, and smartphone apps is feasible and acceptable for patients with chronic respiratory diseases, as well as the value of low-burden, long-term passive data collection., Methods: In a 3-arm prospective observational cohort feasibility study, we recruited 60 patients from the Royal Free Hospital and University College Hospital. These patients had been diagnosed with interstitial lung disease, chronic obstructive pulmonary disease, or post-COVID-19 condition (n=20 per group) and were followed for 180 days. This study used a comprehensive remote monitoring system designed to provide real-time and relevant data for both patients and clinicians. Data were collected using REDCap (Research Electronic Data Capture; Vanderbilt University) periodic surveys, Remote Assessment of Disease and Relapses-base active app questionnaires, wearables, finger pulse oximeters, smartphone apps, and Bluetooth home-based spirometry. The feasibility of remote monitoring was measured through adherence to the protocol, engagement during the follow-up period, retention rate, acceptability, and data integrity., Results: Lowest-burden passive data collection methods, via wearables, demonstrated superior adherence, engagement, and retention compared with active data collection methods, with an average wearable use of 18.66 (SD 4.69) hours daily (77.8% of the day), 123.91 (SD 33.73) hours weekly (72.6% of the week), and 463.82 (SD 156.70) hours monthly (64.4% of the month). Highest-burden spirometry tasks and high-burden active app tasks had the lowest adherence, engagement, and retention, followed by low-burden questionnaires. Spirometry and active questionnaires had the lowest retention at 0.5 survival probability, indicating that they were the most burdensome. Adherence to and quality of home spirometry were analyzed; of the 7200 sessions requested, 4248 (59%) were performed. Of these, 90.3% (3836/4248) were of acceptable quality according to American Thoracic Society grading. Inclusion of protocol holidays improved retention measures. The technologies used were generally well received., Conclusions: Our findings provide evidence supporting the feasibility and acceptability of remote monitoring for capturing both subjective and objective data from various sources for respiratory diseases. The high engagement level observed with passively collected data suggests the potential of wearables for long-term, user-friendly remote monitoring in respiratory disease management. The unique piloting of certain features such as protocol holidays, alert notifications for missing data, and flexible support from the study team provides a reference for future studies in this field., International Registered Report Identifier (irrid): RR2-10.2196/28873., (©Malik A Althobiani, Yatharth Ranjan, Joseph Jacob, Michele Orini, Richard James Butler Dobson, Joanna C Porter, John R Hurst, Amos A Folarin. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.11.2023.)

Background: The COVID-19 pandemic has brought to light the prevalence of mental health issues among nurses. Work engagement (WE) is a concept that describes work-related positive psychological states and is of importance within mental health measures. There is, however, a lack of research on factors associated with the WE of nurses during the COVID-19 pandemic., Objective: We aimed to determine which factors are associated with WE among nurses during the COVID-19 pandemic using the job demands-resources (JD-R) model as a framework., Methods: A web-based cross-sectional survey was conducted among nurses working in acute care and psychiatric institutions in the prefectures of Chiba and Tokyo in Japan. The survey period occurred between August 8 and September 30, 2021, during a time when the number of patients with a positive COVID-19 infection increased. The 3-item version of the Utrecht Work Engagement Scale (UWES-3) was used to measure WE. Factors such as age, gender, years of experience, affiliated ward, COVID-19-related stress, financial rewards from the government and hospital, encouragement from the government and patients, and workplace social capital were assessed. A total of 187 participants were included in the final analysis. Multiple regression analysis was performed to examine the factors related to WE. Partial regression coefficients (B), 95% CI, and P values were calculated., Results: The mean overall score for the UWES-3 was 3.19 (SD 1.21). Factors negatively associated with UWES-3 were COVID-19-related stress on work motivation and escape behavior (Β -0.16, 95% CI -0.24 to -0.090; P<.001), and factors positively associated with UWES-3 were affiliation of intensive care units (Β 0.76, 95% CI 0.020-1.50; P=.045) and financial rewards from the government and hospital (Β 0.40, 95% CI 0.040-0.76; P=.03)., Conclusions: This study examined factors related to WE among nurses during the COVID-19 pandemic using the JD-R model. When compared with findings from previous studies, our results suggest that nurses' WE was lower than before the COVID-19 pandemic. Negative motivation and escape behaviors related to COVID-19 were negatively associated with WE, while there were positive associations with financial rewards from the government and hospital and affiliation with an intensive care unit. Further research into larger populations is needed to confirm these findings., (©Kei Muroi, Mami Ishitsuka, Tomoko Hachisuka, Itsuka Shibata, Tomohiko Ikeda, Daisuke Hori, Shotaro Doki, Tsukasa Takahashi, Shin-ichiro Sasahara, Ichiyo Matsuzaki. Originally published in JMIR Formative Research (https://formative.jmir.org), 03.11.2023.)

Background: Generation Z (Gen Z) and young millennials (GenZennials) (ages 18-35 years) are unique in that they either have no memory of or were born shortly after the internet "explosion." They are constantly on the internet, face significant challenges with their mental health and sleep, and are frequent users of digital wellness apps. GenZennials also uniquely identify with and practice spirituality, which has been linked to better mental health and sleep in adult populations. Research has not examined digital approaches to spiritual self-care and its relationship to mental health and sleep in GenZennials., Objective: The purpose of this study was to describe a sample of adult GenZennials who use a spiritual self-care app (ie, Skylight), describe how users engage with and perceive the app, and assess the relationship between frequency of using the app with mental health, sleep, and spiritual well-being., Methods: Participants were 475 adult Gen Z (ages 18-28 years) and young millennial (ages 29-35 years) Skylight app users who responded to an anonymous survey on the web. The survey asked about demographics, spiritual self-care and practice, and user engagement and perceptions of the app. Outcome measures included 4 validated surveys for mental health (ie, depression, anxiety, and stress) and sleep disturbance, and one validated survey on spiritual well-being. Mean scores were calculated for all measures, and linear regressions were conducted to examine the relationship between the frequency of app use and mental health, sleep, and spiritual well-being outcomes., Results: Participants were predominantly White (324/475, 68.2%) and female (255/475, 53.7%), and approximately half Gen Z (260/475, 54.5%) and half young millennials (215/475, 45.3%). Most users engaged in spiritual self-care (399/475, 84%) and said it was important or very important to them (437/475, 92%). Users downloaded the app for spiritual well-being (130/475, 30%) and overall health (125/475, 26.3%). Users had normal, average depressive symptoms (6.9/21), borderline abnormal anxiety levels (7.7/21), slightly elevated stress (6.7/16), and nonclinically significant sleep disturbance (5.3/28). Frequency of app use was significantly associated with lower anxiety (Moderate use: β=-2.01; P=.02; high use: β=-2.58; P<.001). There were no significant relationships between the frequency of app use and mental health, sleep, and spiritual well-being outcomes except for the personal domain of spiritual well-being., Conclusions: This is the first study to describe a sample of adult GenZennials who use a spiritual self-care app and examine how the frequency of app use is related to their mental health, sleep, and spiritual well-being. Spiritual self-care apps like Skylight may be useful in addressing anxiety among GenZennials and be a resource to spiritually connect to their personal spiritual well-being. Future research is needed to determine how a spiritual self-care app may benefit mental health, sleep, and spiritual well-being in adult GenZennials., (©Susanna Y Park, Jennifer Huberty, Jacqlyn Yourell, Kelsey L McAlister, Clare C Beatty. Originally published in JMIR Formative Research (https://formative.jmir.org), 27.09.2023.)

Background: Machine learning (ML)-driven clinical decision support (CDS) continues to draw wide interest and investment as a means of improving care quality and value, despite mixed real-world implementation outcomes., Objective: This study aimed to explore the factors that influence the integration of a peripheral arterial disease (PAD) identification algorithm to implement timely guideline-based care., Methods: A total of 12 semistructured interviews were conducted with individuals from 3 stakeholder groups during the first 4 weeks of integration of an ML-driven CDS. The stakeholder groups included technical, administrative, and clinical members of the team interacting with the ML-driven CDS. The ML-driven CDS identified patients with a high probability of having PAD, and these patients were then reviewed by an interdisciplinary team that developed a recommended action plan and sent recommendations to the patient's primary care provider. Pseudonymized transcripts were coded, and thematic analysis was conducted by a multidisciplinary research team., Results: Three themes were identified: positive factors translating in silico performance to real-world efficacy, organizational factors and data structure factors affecting clinical impact, and potential challenges to advancing equity. Our study found that the factors that led to successful translation of in silico algorithm performance to real-world impact were largely nontechnical, given adequate efficacy in retrospective validation, including strong clinical leadership, trustworthy workflows, early consideration of end-user needs, and ensuring that the CDS addresses an actionable problem. Negative factors of integration included failure to incorporate the on-the-ground context, the lack of feedback loops, and data silos limiting the ML-driven CDS. The success criteria for each stakeholder group were also characterized to better understand how teams work together to integrate ML-driven CDS and to understand the varying needs across stakeholder groups., Conclusions: Longitudinal and multidisciplinary stakeholder engagement in the development and integration of ML-driven CDS underpins its effective translation into real-world care. Although previous studies have focused on the technical elements of ML-driven CDS, our study demonstrates the importance of including administrative and operational leaders as well as an early consideration of clinicians' needs. Seeing how different stakeholder groups have this more holistic perspective also permits more effective detection of context-driven health care inequities, which are uncovered or exacerbated via ML-driven CDS integration through structural and organizational challenges. Many of the solutions to these inequities lie outside the scope of ML and require coordinated systematic solutions for mitigation to help reduce disparities in the care of patients with PAD., (©Sabrina M Wang, H D Jeffry Hogg, Devdutta Sangvai, Manesh R Patel, E Hope Weissler, Katherine C Kellogg, William Ratliff, Suresh Balu, Mark Sendak. Originally published in JMIR Formative Research (https://formative.jmir.org), 21.09.2023.)

Background: Although evidence suggests that digital mental health interventions (DMHIs) are effective alternatives to traditional mental health care, participant engagement continues to be an issue, especially for pediatric DMHIs. Extant studies of DMHIs among adults suggest that participants' satisfaction, perceived usefulness, and therapeutic alliance are closely tied to engagement. However, these associations have not been investigated among children and adolescents involved in DMHIs., Objective: To address these gaps in extant DMHI research, the purpose of this study was to (1) develop and implement a measure to assess satisfaction, perceived usefulness, and therapeutic alliance among children and adolescents participating in a DMHI and (2) investigate satisfaction, perceived usefulness, and therapeutic alliance as correlates of children's and adolescents' engagement in the DMHI., Methods: Members (children and adolescents) of a pediatric DMHI who had completed at least one session with a care provider (eg, coach or therapist) were eligible for inclusion in the study. Adolescent members and caregivers of children completed a survey assessing satisfaction with service, perceived usefulness of care, and therapeutic alliance with care team members., Results: This study provides evidence for the reliability and validity of an adolescent- and caregiver-reported user experience assessment in a pediatric DMHI. Moreover, our findings suggest that adolescents' and caregivers' satisfaction and perceived usefulness are salient correlates of youths' engagement with a DMHI., Conclusions: This study provides valuable preliminary evidence that caregivers' satisfaction and perceived usefulness are salient correlates of youths' engagement with a DMHI. Although further research is required, these findings offer preliminary evidence that caregivers play a critical role in effectively increasing engagement among children and adolescents involved in DMHIs., (©Landry Huffman, Darian Lawrence-Sidebottom, Jennifer Huberty, Clare Beatty, Monika Roots, Kurt Roots, Amit Parikh, Rachael Guerra. Originally published in JMIR Formative Research (https://formative.jmir.org), 06.09.2023.)

Background: Substance use disorders are prevalent and undertreated among people with HIV. Computer-delivered interventions (CDIs) show promise in expanding reach, delivering evidence-based care, and offering anonymity. Use in HIV clinic settings may overcome access barriers. Incorporating digital counselors may increase CDI engagement, and thereby improve health outcomes., Objective: We aim to develop and pilot a digital counselor-delivered brief intervention for people with HIV who use drugs, called "C-Raven," which is theory grounded and uses evidence-based practices for behavior change., Methods: Intervention mapping was used to develop the CDI including a review of the behavior change research in substance use, HIV, and digital counselors. We conducted in-depth interviews applying the situated-information, motivation, and behavior skills model and culturally adapting the content for local use with people with HIV. With a user interaction designer, we created various digital counselors and CDI interfaces. Finally, a mixed methods approach using in-depth interviews and quantitative assessments was used to assess the usability, acceptability, and cultural relevance of the intervention content and the digital counselor., Results: Participants found CDI easy to use, useful, relevant, and motivating. A consistent suggestion was to provide more information about the negative impacts of drug use and the interaction of drug use with HIV. Participants also reported that they learned new information about drug use and its health effects. The CDI was delivered by a "Raven," digital counselor, programmed to interact in a motivational interviewing style. The Raven was perceived to be nonjudgmental, understanding, and emotionally responsive. The appearance and images in the intervention were perceived as relevant and acceptable. Participants noted that they could be more truthful with a digital counselor, however, it was not unanimously endorsed as a replacement for a human counselor. The C-Raven Satisfaction Scale showed that all participants rated their satisfaction at either a 4 (n=2) or a 5 (n=8) on a 5-point Likert scale and all endorsed using the C-Raven program again., Conclusions: CDIs show promise in extending access to care and improving health outcomes but their development necessarily requires integration from multiple disciplines including behavioral medicine and computer science. We developed a cross-platform compatible CDI led by a digital counselor that interacts in a motivational interviewing style and (1) uses evidence-based behavioral change methods, (2) is culturally adapted to people with HIV who use drugs, (3) has an engaging and interactive user interface, and (4) presents personalized content based on participants' ongoing responses to a series of menu-driven conversations. To advance the continued development of this and other CDIs, we recommend expanded testing, standardized measures to evaluate user experience, integration with clinician-delivered substance use treatment, and if effective, implementation into HIV clinical care., (©Heidi E Hutton, Saavitri Aggarwal, Afroza Gillani, Geetanjali Chander. Originally published in JMIR Formative Research (https://formative.jmir.org), 28.08.2023.)