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Digital health innovations, such as telehealth and remote monitoring, have shown promise in addressing patient barriers to accessing evidence-based programs and providing a scalable path for tailored behavioral interventions that support self-management skills, knowledge acquisition and promotion of relevant behavioral change. However, significant attrition continues to plague internet-based studies, a result we believe can be attributed to characteristics of the intervention, or individual user characteristics. In this paper, we provide the first analysis of determinants of non usage attrition in a randomized control trial of a technology-based intervention for improving self-management behaviors among Black adults who face increased cardiovascular risk factors. We introduce a different way to measure nonusage attrition that considers usage over a specific period of time and estimate a cox proportional hazards model of the impact of intervention factors and participant demographics on the risk of a nonusage event. Our results indicated that not having a coach (compared to having a coach) decreases the risk of becoming an inactive user by 36% (HR = .63, P = 0.04). We also found that several demographic factors can influence Non-usage attrition: The risk of nonusage attrition amongst those who completed some college or technical school (HR = 2.91, P = 0.04) or graduated college (HR = 2.98, P = 0.047) is significantly higher when compared to participants who did not graduate high school. Finally, we found that the risk of nonsage attrition among participants with poor cardiovascular from “at-risk” neighborhoods with higher morbidity and mortality rates related to CVD is significantly higher when compared to participants from “resilient” neighborhoods (HR = 1.99, P = 0.03). Our results underscore the importance of understanding challenges to the use of mhealth technologies for cardiovascular health in underserved communities. Addressing these unique barriers is essential, because a lack of diffusion of digital health innovations exacerbates health disparities. Author summary Mobile-health (mHealth) technologies continue to serve immensely valuable roles in current healthcare systems by bridging several accessibility gaps and facilitating patient-provider interactions. However, and ironically, they also present several accessibility gaps due to design features and/or individual characteristics. In this study, we explore the effects of having an adjunct health coach with a behavior-modification mHealth app, Health360x (H360x) in promoting user-interface interaction in a population of African American patients with significant cardiovascular (CV) risk factors. While we saw an improvement in CV risk factors, we also identified an interesting attrition in app usage in patients assigned a health coach; and observed similar effects in those with higher socioeconomic status. These findings may be due to a higher (baseline or acquired) self-efficacy in these patients, and suggests that longitudinal assessments of app engagement in this population should be approached with careful consideration of attrition.

BackgroundA critical unmet need for underserved patients with diabetes is regular access to sufficient support for diabetes self-management. Although advances in digital technologies have made way for eHealth applications that provide a scalable path for tailored interventions for self-management of chronic conditions, health and digital literacy has remained an obstacle to leveraging these technologies for effective diabetes self-management education. Studies have shown that the availability of coaches helps to maintain engagement in internet-based studies and improves self-efficacy for behavior change. However, little is known about the substances involved in these interactions. ObjectiveThis study aims to compare the content of conversations between patient–coach pairs that achieved their self-management goals and those that did not. The context is a clinical implementation study of diabetes self-management behavior change using Health360x within the practices of the Morehouse Choice Accountable Care Organization in the Atlanta metro area. Health360x is a coach-assisted consumer health information technology designed to support self-management skills acquisition and behavior among underserved, high-risk patients with diabetes. MethodsWe provide a novel analysis of the discursive emphasis on patients and coaches. We examined transcripts of visits using a structural topic model to estimate topic content and prevalence as a function of patient and coach characteristics. We compared topics between patient–coach pairs that achieved diabetes-related self-management goals and those who did not. We also estimated a regression in which utterances are the units, the dependent variable is the proportion of an utterance that is about a given topic, and the independent variables are speaker types and explored other themes. ResultsTranscripts from 50 patients who were recruited and consented, starting in February 2015, were analyzed. A total of 44 topics were estimated for patient–coach pairs that achieved their intended health goals and 50 topics for those who did not. Analysis of the structural topic model results indicated that coaches in patient–coach pairs that were able to achieve self-management goals provided more contextual feedback and probed into patients’ experience with technology and trust in consumer information technologies. We also found that discussions around problem areas and stress, support (βCoach=.015; P