Developing a User-centered Mobile Application for Stroke Caregivers: A Pilot National Survey
Jonathan Singera,*, Sarah Weingastb, Nadege Gillesb, Mohammad Fayseld, Dimitre G. Stefanovc, Shirley Girouarde, Alyssa Conigliarof,g, Marilyn Fraser Whiteh,i, Amy Jensenj, Dee Burtonk, Steven R. Levineb,l,m
aDepartment of Psychology, University of Nevada, Reno, NV, USA; bDepartment of Neurology, SUNY Downstate Medical Center, Brooklyn, NY, USA; cAcademic Computing, SUNY Downstate Medical Center, Brooklyn, NY, USA; dMedical Informatics Program, SUNY Downstate Medical Center, Brooklyn, NY, USA; eCollege of Nursing, SUNY Downstate Medical Center, Brooklyn, NY, USA; fDepartment of Emergency Medicine, Kings County Hospital Center, Brooklyn, NY, USA; gDepartment of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA; hArthur Ashe Institute for Urban Health, Brooklyn, NY, USA; iBrooklyn Health Disparities Center, Brooklyn, NY, USA; jNational Stroke Association, Centennial, CO, USA; kCenter for Health, Media and Policy, Hunter College, NY, USA; lStroke Center, SUNY Downstate Medical Center, Brooklyn, NY USA; mDepartment of Neurology, Kings County Hospital Center, Brooklyn, NY, USA and The Mobile Applications for Stroke (MAPPS) Investigative Team
Corresponding Author: firstname.lastname@example.org
Journal MTM 7:2:35–45, 2018
Abstract: Inadequate support, along with the stroke patient’s level of disability, can have a negative impact on informal caregivers’ quality of life and well-being. Yet, there is a lack of research and interventions focused on improving the health and well-being of informal caregivers. To determine the most salient potential resources and features for stroke patient caregivers regarding the use of mobile apps to improve caregiver’s health. A nationwide survey of caregivers was mailed to stroke survivors through the National Stroke Association, which included questions on demographics, cell phone/smartphone ownership, and caregiver’s opinion about mobile app resources– specifically 1) scheduling multiple tasks, 2) finding resource information, 3) finding local resources, 4) tracking fitness and diet, and 5) communication with the stroke survivor. 396 stroke caregivers [(299 (76%) female, 96 (24%) African-American, 42 (11%) Hispanic/Latino, and 210 (53%) Caucasian], aged 20-99 years (mean 58.2 ± 11.30), returned surveys; 96% owned a cell phone and 60% owned a smartphone. Most caregivers reported aspects of the app to be useful, including, doctor/rehab appointments [80% (95% CI 76-84%)], links to reliable medical information [84% (95% CI 80-87%)], local stroke support groups [81% (95% CI 77-85%)], exercises [76% (95% CI 71-80%)], and touch screen with useful phrases [76% (95% CI 71-80%)]. Latino (88%-74%) and African-American (84%-77%) caregivers reported the highest rate of usefulness. Implementation of a mobile app unique to stroke caregivers with multiple resources is desired by this diverse, national sample of informal caregivers. Such a mobile app holds potential to reduce the disparities gap for resource use.
Keywords: Stroke, Caregiver, Rehabilitation, Stroke mHealth, Mobile health
Stroke is one of the leading causes of long-term disability in the United States and is a substantial burden on informal caregivers1. These individuals play a vital role in the health and well-being of stroke survivors. Usually, informal caregivers are family members who have little to no training on how to care for a stroke patient. This training deficit creates additional physical, psychological, and economic strain on both the caregiver and patient1–4.
Inadequate support, along with the stroke patient’s level of disability, can have a major negative impact on informal caregivers’ quality of life (QoL) and well-being5. Yet, there is a lack of research focused on the health and well-being of informal caregivers1,2,5,6. New approaches have been reported as possible avenues to improve caregiver QoL including patient and caregiver-centered models5 and mobile health (mHealth) technology7. In 2015, smartphone ownership rates in America were reported as 64%; while 90% owned any type of cell phone, 32% owned an e-reader and 42% owned a tablet computer8. Also in 2015, 64% of Latinos and 68% of African Americans owned a cell phone8. Numerous studies have shown that Latinos and African Americans have disparate access to healthcare9,10. These populations have some of the highest rates of obesity, diabetes, and hypertension – all major risk factors for stroke10. New mobile-based technologies may narrow the gap in access to care and health related resources for minority populations11–13. To our knowledge, there is no medical app specifically dedicated to stroke patient caregivers to help improve the caregiver’s quality of life.
Many resources can be implemented in a mobile app for stroke patient caregivers, which could help both the caregiver and the stroke survivor (e.g. managing task scheduling, finding resources, exercise routines, fitness and diet/nutrition tracking, etc.). In order to design and develop a useful mobile app for stroke patient caregivers, identification of appropriate resources and features for inclusion is critical. A caregiver-centered survey regarding the use of mobile apps was designed to determine the most salient potential resources and features for stroke patient caregivers taking race/ethnicity, age, and gender into account.
Materials and Methods
Design: A nationwide, observational survey. Participants: Using a national database of stroke survivors maintained by the National Stroke Association (NSA), stroke survivors were mailed a cover letter and a 17-question survey (Appendix B). The 17 questions were designed by the stroke experts on this manuscript from SUNY Downstate as well National Stroke Association. Stroke survivors were asked to give the survey to their informal caregiver, if applicable. The NSA database does not have a record of how many stroke survivors have caregivers and to our knowledge there are no studies that have determined a ratio of caregivers to stroke survivors. Therefore, it is impossible to conclude response rate. Caregivers were not provided compensation for participating in the study.
Measures: The study was approved by the SUNY Downstate Institutional Review Board. After consent was signed, the survey was administered. The Survey included demographic questions, as well as questions regarding the caregiver’s opinion on what features in a mobile app (if any) would be most useful to include, specifically: 1) scheduling multiple tasks, 2) finding information and resources about stroke care on the Internet, 3) local stroke-related resources, 4) tracking fitness and diet, and 5) communication tools for stroke survivors. The caregivers were also surveyed on their ownership of a cell phone and/or smartphone on which the app could be used. Data Analysis: Multiple logistic regressions were performed to analyze the data. In the five logistic regression models, the independent variables were age (computed into tertiles 20-53, 54-62, 63-91), race (African American, White, Hispanic/Latino, and responses of Asian, Native American and mixed were grouped as Other), and gender. The dependent variable was overall caregiver rating of the potential usefulness of the app, with regard to the five possible resources, dichotomized as useful or not useful. Responses were coded as “not useful” if they reported, “this app would not be useful” and coded as “useful” if they reported one of the aspects of the mobile app would be useful to help with the given task. Statistical significance was set at .05 and SAS 9.4 (SAS Institute, Inc Cary, NC) was used for statistical analysis.
A sample of 396 informal stroke patient caregivers (299 females) ranging from 20 to 91 years of age participated in this study. The mean age of the caregivers was 58.2 (SD = 11.30) years. Of the 396 caregivers, 210 (53%) were White/Caucasian, 96 (24%) were African-American, 42 (11%) were Hispanic/Latino, and the remainder (12%) self-identified as Asian, Native American, Mixed and Other. Ninety percent of the caregivers reported owning a cell phone, and 60% of all caregivers reported owning a smartphone.
After examining the five questions to see which resources caregivers want implemented to improve both their and their stroke survivors’ lives, high rates of usefulness were found between all races and genders (Tables 1–5). As age increased, caregivers’ reports of each resource’s potential utility in a mobile app decreased ( p < .05). However, even in the oldest group (63+), the majority of caregivers reported that each of the five types of resources could be useful in a mobile app, ranging from the lowest at 67% to the highest at 79%. “Doctor or rehab appointments,” “Links to trustworthy medical information,” “stroke support groups in my or my stroke survivors area,” “app with exercises for stroke survivors,” and “a touch screen with useful phrases” were reported as potentially the most useful features in a mobile app regardless of race, age, or gender for the five questions.
High rates of potential usefulness were found for the minority caregivers in our sample for these five resources; consequently, each question was investigated further to examine racial differences for each of the five questions individually. Table 1 outlines gender, age, and racial differences for the caregivers’ opinions on mobile app features to schedule multiple tasks. Implementation of an app to help caregivers with scheduling multiple tasks for the stroke survivor was found to be useful to 80% (95% CI 76-84%) of the population, with no significant differences found between races when controlling for age and gender ( p = .073). Caregivers stated that “stroke rehab exercises” and “links to trustworthy medical information” are the most desired features for an app used to find resources about stroke. Table 2 outlines data (App most useful to find information and resources about stroke) based on race, gender, and age, and they were similar between all groups. An app for stroke resources was reported as useful to 84% (95% CI 80-87%) of the caregivers, and no racial differences were found when controlling for age and gender ( p = .89; Appendix A).
Table 1: App most useful when scheduling multiple tasks for stroke survivor
Table 2: App most useful to find information and resources about stroke
Eighty one percent (95% CI 77-85%) of caregivers believed a mobile app would be useful for finding local resources, and no racial differences were found when controlling for age and gender (p = .49; Appendix A). More specifically, caregivers indicated that access to “stroke support groups in my area” and “stroke physicians and rehab specialists in my area” would be most beneficial (Table 3).
Table 3: App most useful to find local resources
Caregivers reported that having a mobile app with “exercises for stroke survivors” and that “tracks stroke survivor’s diet” would be the most beneficial features in an app to track stroke survivors’ fitness and diet. However, 21% of the caregivers reported that having an app to track the survivors’ fitness and diet would not be useful (Table 4). Caregivers reported that this resource was useful at the lowest percentage of any of the five resources. Racial differences for caregivers’ reporting of potential usefulness of an app to track the stroke survivors’ fitness and diet, after controlling for age and gender, was not significant (p = .19; Appendix A).
Table 4: App most useful to track fitness and diet
The fifth question investigating the most useful features for an app focused on communication with the stroke survivor. Caregivers reported that having a touch screen with useful phrases such as “I am hungry” would be the most useful. However, 21% of the caregivers reported that an app to communicate with the stroke survivor would not be useful (Table 5). Racial and gender differences were not found when investigating caregivers’ opinions on usefulness of an app to help the caregiver communicate with stroke survivors (p =.67; Appendix A).
Table 5: App most useful for Stroke Survivor to communicate with you
To our knowledge, this study is the first to formally investigate a national sampling of informal stroke caregivers’ opinions on potential usefulness of features to be made available in a mobile stroke app. Despite the millions of informal caregivers who suffer economic, physical and emotional burdens14, there are limited resources that are both useful and cost effective. Forty percent of caregivers reported having an app for “doctor or rehab appointments” as potentially the most useful, which is consistent with stroke patients often having multiple health care providers, including neurologists, cardiologists, primary care physicians, physical therapists and/or speech therapists. Tracking numerous appointments and ensuring that these are kept can become challenging and increase stress, especially when coordinating with existing commitments. Therefore, implementing a mobile app that assists caregivers in organizing the stroke survivor’s schedule could alleviate some of the caretaker’s burden.
Caregivers’ QoL and well-being have been found to be associated with the disability level of the stroke survivors5, and providing a tool to help manage the severity of survivor’s disability may help improve the caregiver’s QoL and well-being. Moreover, by improving caregivers QoL, it may in turn improve the survivor’s QoL and well-being. Caregivers reported that an app which would provide “links to trustworthy medical information,” “exercises for stroke survivors,” “stroke support groups in my or survivor’s area,” and “stroke physicians and rehab specialists in my or survivor’s area,” would be the most useful. Creating an app that would provide caregivers with this information might not only improve stroke survivors’ QoL and well-being, but potentially improve the caregiver’s health by allowing the caregiver opportunities to exercise with the patient or bring the stroke survivor to support groups. In turn, these activities could reduce caregivers’ feelings of alienation and stress5. Also, many of these apps hold the potential to decrease economic burden if a caregiver is given resources that will improve recovery for the stroke patient, thereby reducing the number of practitioners or appointments required for future care. Evaluating resources for stroke patients and their caregivers is important following a stroke, and especially for minority groups who may have limited or no access to healthcare9,10.
One of the objectives of this study was to examine racial/ethnic differences in caregivers’ assessment of the potential utility of a mobile app, and to identify specific features caregivers would want in a mobile app. Despite not finding any significant differences among races/ethnicities for all five questions regarding desirable features, possibly due to an underpowered sample, Hispanic/Latino and African American respondents reported the highest rates of potential utility for all five-resource types. Minority populations also have highest rates of poverty and are often underserved15, so reducing the economic burden on these caregivers is critical. Therefore, implementation of a mobile app with the features desired by the minority informal caregivers in this sample may narrow the gap by providing resources that will improve health outcomes for minority populations.
Mobile technology was not available until later in the lives of older adults. As expected, the five resources of the mobile app were reported as potentially less useful for the older cohort, as compared to a younger sample16. However, in our oldest group of 63+ years of age, more than half of caregivers reported all five resources could be useful in a mobile app. The argument against mHealth technology for caregivers15,17 has been that older generations will not have access to, or benefit from, these resources in a mobile app. However, high rates of cellphone/smartphone ownership among older participants (63+; cell phone ownership= 86%, smartphone ownership= 43%) were reported, and this older cohort reported that the resources could be potentially useful. Despite arguments stating that older adults wouldn’t benefit from mHealth15, our data suggest that mHealth has the potential to be an innovative, universal resource accessible to all populations.
There were several limitations in this study. First, the study was survey-based from a national database and the respondents may not necessarily be representative of the general stroke caregiver population. Also, the response rate is impossible to identify due to the NSA not having records of how many stroke survivors had caregivers. Although the app resources and features selected for the survey were developed with input from two focus groups of stroke survivors18, the questionnaire did not allow for open-ended responses. Therefore, it could be argued that caregivers in the sample may desire alternative features built into a mobile app, which were not captured by the closed-ended questionnaire. Another potential weakness is that we do not know the symptoms of the caregivers’ stroke survivors’ strokes or their concurrent illnesses. These items could have impacted the responses of the respondents (e.g. survivors with/without aphasia may or may not need communication tools; survivors with diabetes or hypertension may need more diet tools than those without).
Despite these limitations, at least 80% of caregivers said they want these features in a mobile app, which provides a foundation for future app/studies to build upon. Future directions for research that may benefit the field and improve both stroke patient and caregivers health and well-being are, developing a mobile app for caregivers, and completing beta testing to make sure it meets the needs of the caregivers, is user friendly, and can be disseminated to all races, ethnicities and age groups.
Funding: This study was supported by The Patient-Centered Outcomes Research Institute (PCORI) pilot award 1IP2PI000781.
Conflict of interest
There is no conflict of interest in this research.
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Table 1a: App most useful when scheduling multiple tasks for stroke survivor (Dichotomized)
Table 2a: App most useful to find information and resources about stroke (Dichotomized)
Table 3a: App most useful to find local resources (Dichotomized)
Table 4a: App most useful to track fitness and diet (Dichotomized)
Table 5a: App most useful for Stroke Survivor to communicate with you (Dichotomized)
Ten questions mailed to stroke caregivers and analyzed in this study
1. Which of these mobile apps would be the MOST useful to you when scheduling your stroke survivor’s multiple tasks? (Please check only one)
a. Doctor or rehab appointments
b. A medication reminder
c. Coordinating meals with medication schedule
d. Scheduling social activities
e. Blood pressure tracking
f. This type of app would not be useful
2. Which of these mobile apps would be the MOST useful to help you find how-to information about stroke care on the Internet? (Please check only one)
a. A medication resource guide
b. Suggested stroke rehab exercises
c. Links to trustworthy medical information
d. This type of app would not be useful
3. Which of these mobile apps would be the MOST useful to help you find LOCAL stroke-related resources? (Please check only one)
a. Stroke support groups in my or my stroke survivor’s area
b. Stroke physicians and rehab specialists in my or my stroke survivor’s area
c. Reviews of stroke physicians and rehab specialists in my or my stroke survivor’s area
d. Locations of certified stroke centers in my or my stroke survivor’s area
e. This type of app would not be useful
4. Which of these mobile apps would be the MOST useful to you to track your stroke survivor’s fitness and diet? (Please check only one)
a. An app that tracks distance when I or my stroke survivor exercise
b. An app that tracks how much time I or my stroke survivor exercise
c. An app with exercises for stroke survivors
d. An app that offers healthy meal suggestions for stroke survivors
e. An app that tracks my stroke survivor’s diet, including calories, sodium, fat, etc.
f. This type of app would not be useful
5. Which of these mobile apps would be the MOST useful to your stroke survivor to communicate with you and/or others? (Please check one)
a. A touch screen with useful phrases (e.g., I want to go to the park; I am hungry)
b. An app that translates your stroke survivor’s typed text into spoken words
c. An app that translates a text message your stroke survivor receives into spoken words
d. An app that my stroke survivor can show people to let them know they have had a stroke
e. An app that uses GPS to show my stroke survivor’s location
f. This type of app would not be useful
6. Please check if you are:
___ female ___ male
7. What is your age? _______
8. Please check the ethnicity that best describes you:
___ Black or African-American
___ White or Caucasian
___ Hispanic or Latino
___ Native American
9. Do you have a cell phone?
___ Yes ___ No
10. If Yes, is your cell phone a smartphone (i.e., you can use it to connect to the Internet or web)?
___ Yes ___ No
Expanding The Use of Telemedicine in Neurology: A Pilot Study
Melissa M. Reider-Demer1, D.N.P, MN, CNP and Dawn Eliashiv1, M.D.
1Department of Neurology, University of California, Los Angeles
Corresponding Author: email@example.com
Journal MTM 7:2:46–50, 2018
Background: Telemedicine enables providers to connect with patients and consultants remotely in a cost-effective, convenient manner. Telemedicine in various forms—from store-and-forward technology to real-time videoconferencing—has demonstrated good outcomes in specialties including neurosurgery, general neurology, stroke, and epilepsy.
Aim: To demonstrate the feasibility of telemedicine in an outpatient university-based neurology clinic, and assess patient and provider satisfaction with telemedicine.
Methods: Forty neurologically stable adult patients were recruited. We excluded patients who were non-English speaking, had intellectual disability, lacked caregiver availability, or had unstable neurological conditions. After each telemedicine visit a patient standardized satisfaction survey was completed, comprising 11 questions assessing patient willingness to participate, technical issues, and satisfaction with the clinic experience and medical provider. A provider satisfaction survey was obtained at the end of the study.
Results: Forty of fifty patients meeting criteria consented to a telemedicine visit in lieu of a routine visit, and 15 of these responded to survey. All felt confident when meeting with their provider met their needs. Ninety percent of participants agreed that the technical process of joining the on-line session was easy. All patients agreed that they were satisfied with their telemedicine session and would choose telemedicine over face-to-face visits in the future. Cost analysis demonstrated a UCLA healthcare system saving of $28.00 for each telemedicine replacing an in-person clinic visit. Patients saved the cost of auto fuel, missed work, and parking when using the telemedicine option.
Conclusions: Telemedicine in neurology patients is feasible and satisfies patients and providers.
Traditional ways of providing health care are constantly being improved as evidenced by the increasing use of telemedicine. This option enables providers to connect with patients and consultants across challenging geographic distances in a cost-effective, convenient manner (Reider-Demer, 2017). In neurology and neurosurgery populations, telemedicine in various forms—from store-and-forward technology to real-time videoconferencing—has demonstrated good outcomes. (Reixeira-Poit, 2017). In an effort to maximize resource efficiency, continuity of care and patient access, the Veterans Health Administration has tested workflows using allied health professionals to conduct telemedicine follow-up care in lieu of in person clinical visits to maximize response efficiency and patient access (Dadlani, 2014).
Further studies have shown that the use of telemedicine in neurology is an alternative to traditional health care (Hwa, 2013). In major urban centers, increased patient demands can cause neurology practices to struggle, resulting in patients having to travel within large catchment areas for follow-up care. This is especially true for subspecialty care where a significant shortage of neurologists limits the number of patients who can be seen (Reixeira-Poit, 2017). Many patients have to travel long distances, take days off work without pay, and absorb the costs of motor fuel and parking fees. Many have disabilities that hinder travel mobility, and many have restricted driving privileges, so travel to appointments places a burden on them and their caregivers. While the use of telemedicine may not be feasible for patients with complex neurological conditions, it is a viable alternative for stable patients (Pulley, 2015). Neurology visits are typically carried out face-to-face by trained allied health professionals, and have shown good patient satisfaction and high-quality care. We performed a prospective feasibility pilot study to determine if real-time videoconferencing (telemedicine sessions) with allied health professionals can successfully substitute for in-person clinic visits and still maintain patient/provider satisfaction in neurology (Govindarajan, 2017).
The study was prospectively approved by our local institutional review board, and included random, stable neurology patients who accepted the use of telemedicine for their routine follow-up appointments, or results review sessions, among patients with ataxia, epilepsy, stroke, genetic disorders, dementia, multiple sclerosis, Parkinson’s disease and neuro rehabilitation. This project began in September 2017 and ended in December 2017. When established neurology patients required a follow-up clinic visit and/or a results review session, they were offered a telemedicine session as an option. Patients were required to have a stable neurology disorder, be over the age of 18 years, and be able to verbally consent to the study. Patients were offered this alternative provided they had internet access via a smart phone, tablet, or laptop equipped with a video camera, similar to that of the participating medical providers. Patients lacking one of these devices could not participate. Exclusion criteria were inability to speak the English language, inability to consent, or an unstable neurological condition. If the patient selected a telemedicine session, the clinic coordinators sent an invitation to the patient. To ensure that the telemedicine consult was feasible, a technology support designee contacted the patient prior to the visit and offered to test the internet connection and assist to download the application program “ZOOM.” The telemedicine consult was performed utilizing ZOOM, a secure web-based, HIPPA compliant software application (https://twitter.com/zoom_us).
Verbal consent was obtained and documented within the clinic note at each clinic encounter with patients willing to participate in the telemedicine study. If the telemedicine visit resulted in an unexpected assessment, an in-person visit was arranged. Otherwise at the end of the session the patient was offered a future telemedicine follow up visit or a result summary session as appropriate.
After each telemedicine session, patients were queried about their satisfaction with the telemedicine session via an automatically generated electronic patient satisfaction survey. At the end of the study the provider satisfaction survey was electronically sent to the participating providers. The patient survey instrument is provided as Survey 1(Figure 1), and the provider survey as Survey 2 (Figure 2).
Figure 1: Survey One: Patient Satisfaction
Figure 2: Survey Two Provider Satisfaction
Outcome measures were used to evaluate patient/provider satisfaction and the feasibility of using telemedicine.
Forty of 55 identified eligible patients accepted telemedicine sessions. Twenty-five participants used tablet computers, ten used laptop computers, and five used smartphones. All patient survey responders indicated that they wanted to participate in the patient satisfaction survey. All participants either agreed or strongly agreed that the telemedicine session was clearly explained to them. Ninety percent of the participants underwent a follow-up appointment. Ninety percent did not require a session prior to the actual clinic visit, and ninety percent agreed or strongly agreed that the technical process of joining the on-line session was easy. All participants either agreed or strongly agreed that they felt confident when meeting with the provider, could clearly visually see their provider on the device screen, and that the telemedicine session met their expectations. All patients agreed or strongly agreed that they were satisfied overall with their telemedicine session and would choose telemedicine over face-to-face visits in the future.
Only one provider had previously used a form of telemedicine prior to this study. Among the nine participating providers, six responded to the questionnaire. All were satisfied that the telemedicine session met both their provider expectations as well as their medical needs for examining the patient, and were either satisfied or strongly satisfied with audio-visual quality. All were very satisfied with the overall quality of the care provided and would participate in telemedicine in the future.
This prospective feasibility pilot study supports the effective use of videoconferencing by allied health professionals for established neurology follow-up clinic visits that may include a review of previously obtained tests. The clinical setting of this study supported using telemedicine as a tool in evaluating patients with follow-up clinic visits in a multi subspecialty outpatient neurology clinic with a varied diagnoses including epilepsy, genetic disorders, stroke, ataxia, dementia, neurorehabilitation, and other general neurology disorders.
Telemedicine technology can bridge care gaps and help meet the increasing demands for neurologists. Twenty-one small studies within the United States were published between 2010 and 2015 and review telemedicine intervention outcomes for follow up care. These studies demonstrated showed a high level satisfaction in a majority of patients and providers who used telemedicine, and noted reductions in travel time and cost (Snyder, 2018). Telemedicine has proven to be an increasingly viable supplement to traditional health care delivery, enabling providers to connect with patients and consultants across distances in a cost effective and convenient manner (Armstrong, 2014).
Telemedicine is an innovative tool for improving access to care reducing burden in clinics, and providing cost savings to patients, their families and the healthcare system. Telemedicine is convenient for patients who routinely use cellular phones, tablets, or laptop computers. Patients are willing and ready to utilize telemedicine as indicated by 40 out of 55 eligible patients opting to participate in this study. The post visit survey showed favorable patient and provider satisfaction. Telemedicine allowed patients to reduce driving time, fuel usage, and parking costs. Although total costs were not assessed, some specific cost savings were noted throughout the feasibility study. Typically, patients and families that drove to and from the medical center often missed work (Reider-Demer, 2017). Costs for fuel in the state of California averaged $0.54/mile. Parking at our institute was $12.00 daily. As this was a pilot study a health economics analysis including administrative, pre and post visit functions were not assessed. Note, telemedicine visits did not incur clerical cost for registering patients or medical assistant costs to obtain vital signs which saved the department $28.00 per visit in our department. The reduction in clinic load would allow to schedule more patients as well as decrease wait time for new or established clinic visits, decompressing clinics.
The use of telemedicine, employing technological devices such as cellular phones, tablets and laptops, can improve access to healthcare providers. It can provide medical care providers an equivalent alternative to in-person clinic visits, ultimately providing better service to patients and their families. As hospitals acquire electronic health-record systems, wireless telephones, and other technological devices, telemedicine will likely become an integral part of the institutional infrastructure. The limitations of this study are the relatively small number of patients, the lack of access for patient without acceptable devices, lack of internet connection in some households, and language barriers. As this as a pilot study the applicability of telemedicine to unstable patients was not assessed.
Presently the use of telemedicine can only be used within the state in which a practitioner is licensed to practice. Additionally, Medicare does not reimburse for telemedicine. Both are limiting factors that could be surmounted in the future.
Telemedicine is an increasingly viable, cost-effective, convenient alternative to traditional neurological care delivery, enabling providers to connect with patients and consultants across distances (Reider-Demer, 2017). This pilot study supports telemedicine as an option for neurological patients with favorable patient/provider satisfaction. Further studies should be performed in additional patient populations at other institutions.
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Pulley M, Berger A, Hodges W, Brittain R, Feasibility study of the use of telemedicine in the care of ALS patients. Neurology. 2015;84:127.
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Reixeira-Poit S, Halper M, Kane H, Keating M, Olmsted M, Factors influencing professional life satisfaction among neurologists. Research BMC. 2017;17:409. https://doi.org/10.1186/s12913-017-2343-8
Snyder S, Editorial: Telemedicine for elective neurosurgical routine follow up care: A promising patient-centered and cost effective alternative to in-person clinic visits. Neurosurgical Focus. May 2018;44:5:18.
Patients’ Attitudes Towards Text Messages about HIV and Hepatitis C Screening
Julika Kaplan, MD1, Haley Marek, BS2, Monisha Arya, MD, MPH1,3
1 Department of Medicine, Baylor College of Medicine, Houston, TX, USA
2 School of Medicine, Baylor College of Medicine, Houston, TX, USA
3 Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
Corresponding author: firstname.lastname@example.org
Journal MTM 7:2:51–54, 2018
Background: Despite the prevalence of HIV and hepatitis C virus (HCV), many people in the United States have never been screened for these infections. Mobile phones could educate patients about screening recommendations and “nudge” them to request screening from their physicians. There is a need for studies to understand patients’ perspectives on this campaign strategy.
Aims: The purpose of this pilot study is to describe patients’ attitudes towards text messages that educated them about HIV and HCV and “nudged” them to discuss screening recommendations with their physicians.
Methods: In 2016 and 2017, patients in primary care clinics in Houston, Texas were recruited to participate in text message studies promoting HIV and HCV screening. Participants were sent either HIV, HCV, or control text messages prior to their individual primary care appointments. After the appointment, research staff called the participants and conducted evaluation surveys to determine whether they enjoyed receiving health-related text messages and to elicit their opinions about the specific content of the messages.
Results: The majority of our participants appreciated the text messages, specifically because they provided valuable health information that was unfamiliar to the patients and prompted them to discuss HIV and HCV screening with their physicians.
Conclusion: Our pilot study demonstrated that the majority of patients enjoyed receiving text message-based “nudges” because they helped them overcome barriers to healthy behavior and may have improved patient-physician communication. These findings are important because this strategy can improve screening rates in primary care for infections such as HIV and HCV.
Keywords: Text Messaging, Hepatitis C, HIV Infections, Mobile Health, Pilot Projects
Despite the prevalence of HIV and hepatitis C virus (HCV), many people in the United States have never been screened for these infections.1,2 This is partially due to a lack of physician awareness of national screening recommendations.3,4,5 Screening and early detection are critical to improving health outcomes for HIV and HCV, so strategies to increase routine screening in healthcare are necessary.6,7 While improving physician awareness of screening recommendations could be one approach, a patient-focused strategy may be to use mobile health (mHealth) technology to provide targeted health information directly to patients. Mobile phones, specifically, could educate patients about screening recommendations and “nudge” them to actively engage in their healthcare.8 In the case of health, “nudging” involves using interventions to help people overcome the barriers that may be limiting their ability to obtain optimal healthcare.9 We developed text message campaigns in which we educated patients about HIV and HCV and “nudged” them to discuss screening with their physicians. The purpose of this pilot study is to describe patients’ attitudes towards these HIV and HCV text messages.
In 2016 and 2017, patients in primary care clinics in Houston, Texas were recruited to participate in mHealth text message studies promoting HIV and HCV screening. During the consent process, patients were informed that they would receive a message either about HIV, HCV, or a different health topic. Patients who participated had mobile phones, used text messaging, and provided informed consent. Participants in the HIV study were sent an HIV text message or a control text message, and participants in the HCV study were sent an HCV text message or a control text message. Each message included a one-sentence fact about HIV or HCV and a prompt encouraging participants to talk to their physicians about screening. The messages were sent within the hour prior to their individual primary care appointments. After the appointment, research staff called the participants and conducted evaluation surveys to determine whether they enjoyed receiving health-related text messages and to elicit their opinions about the specific content of the messages. The Baylor College of Medicine Institutional Review Board approved these studies.
For both our HIV and HCV campaigns, we found that the majority of participants enjoyed receiving text messages with health information. Our post-text evaluation surveys provided insight into why our participants did or did not enjoy receiving health-related messages before their appointments with their physicians.
Out of our 12 HIV text message recipients, 11 (92%) enjoyed receiving a health-related text message, while one (8%) did not. Those who enjoyed receiving the message cited the following reasons: seven (64%) appreciated a health reminder, two (18%) felt that the message provided valuable information relevant to their health, and one (9%) believed that texting was more effective than calling as a communication method. A participant who benefitted from the reminder about HIV testing stated, “I liked it because it reminded me to ask my doctor about the HIV test.” Another acknowledged that the text instructed her “to do something that [she] otherwise wouldn’t have asked.” One of the participants who valued the information he received said the message “[kept him] on point” and let him know that he could get an HIV test “without setting a special appointment.” Another participant expressed her belief that “[HIV] is a disease that everyone should be on top of.” Finally, there were several participants who found the text message useful but still confessed that it was “alarming” or “a little disturbing” because people do not normally “send a text message out of the blue about something like [HIV].” On the other hand, the single participant who did not enjoy receiving our HIV text message was concerned that her confidentiality could be breached if a friend saw her phone: “It was a personal message but it was to my phone. I’m okay with it… but it could be a problem… someone snooping could cause a problem.”
Out of the 25 participants who received text messages about HCV, 22 (88%) enjoyed receiving a health-related text message, while two (8%) did not and one (4%) felt neutral. Those who enjoyed receiving the message cited the following reasons: 14 (64%) felt that the message provided valuable information relevant to their health, seven (32%) appreciated a health reminder, and one (5%) believed that receiving the text message was easy and convenient. One participant who was grateful that the text message prompted her to discuss HCV with her physician stated: “At appointments, it’s hard to remember what you want to bring up with your doctor. This text can function as a jumping off point for initial discussion.” Two other participants felt that the text message provided valuable information about their health; one said the message “pertained to an issue most people don’t know about,” and another said he “never thought about a hepatitis C test at [his] age.” One participant who did not enjoy receiving the text message said he “didn’t understand the purpose” of the text message.
In this pilot study, we encouraged participants to discuss HIV and HCV screening with their physicians by sending them informative text messages with cues to action prior to their appointments. We learned that participants appreciated our text messages because they provided valuable health information and prompted them to discuss HIV and HCV screening with their physicians. However, despite the consent process, we also found that one patient had concerns about receiving health information on her cell phone that she considered alarming and another patient did not understand the purpose of the text message campaign.
The limitations of this study include a small sample size, which may hinder generalizability. However, this pilot study provides proof of concept for using text messages as an intervention to promote HIV and HCV screening. Another potential limitation is social desirability bias, or participants’ tendency to give responses that will satisfy the research staff. We attempted to mitigate this limitation by emphasizing before participants completed the evaluation survey that there were no correct answers and that their participation would not impact their medical care.
People face many barriers that may negatively impact their ability to make decisions that are good for their health. Examples of these barriers include limited awareness of medical topics, difficulty remembering to ask their providers certain questions, or fear of receiving an unwanted diagnosis, particularly in the case of chronic infections such as HIV and HCV. A “nudge” is a policy change or intervention that helps people overcome these barriers, thereby making it easier for people to act in their own best interest and make healthy decisions. Our study demonstrates that the majority of patients enjoyed receiving a text message-based “nudge” because it helped them overcome two of their most significant barriers: lack of information about screening recommendations and difficulty remembering health information. These findings are important because they can improve screening rates for asymptomatic yet treatable diseases such as HIV and HCV in primary care. Larger studies are needed to confirm our findings and determine the impact on screening rates.
The authors would like to thank John Benjamin Kellogg, Jessica Lee, Sharon Joy, and Stephen Manning for their contributions to data collection. The HIV-related work was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number K23MH094235 (Principal Investigator: Arya). This work was also supported in part by the Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413) of the Michael E. DeBakey Veterans Affairs Medical Center in Houston. The views expressed in this article are those of the authors and do not necessarily represent the views of the National Institutes of Health or of the US Department of Veterans Affairs.
1. Dailey AF, Hoots BE, Hall HI, Song R, Hayes D, Fulton Jr P, Prejean J, Hernandez AL, Koenig LJ, Valleroy LA. Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays—United States. Morbidity and Mortality Weekly Report. 2017 Dec 1;66(47):1300–1306.
2. Smith BD, Morgan RL, Beckett GA, Falck-Ytter Y, Holtzman D, Teo CG, Jewett A, Baack B, Rein DB, Patel N, Alter M. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. Morbidity and Mortality Weekly Report: Recommendations and Reports. 2012 Aug 17;61(4):1–32.
3. Zheng MY, Suneja A, Chou AL, Arya M. Physician Barriers to Successful Implementation of US Preventive Services Task Force Routine HIV Testing Recommendations. Journal of the International Association of Providers of AIDS Care. 2014 May;13(3):200–205.
4. Falade-Nwulia O, McAdams-Mahmoud A, Irvin R, Niculescu A, Page KR, Mix M, Thomas DL, Sulkowski MS, Mehta SH. Primary Care Providers Knowledge, Attitude and Practices Related to Hepatitis C Screening and Treatment in the Oral Direct Acting Antiviral Agents Era. Journal of Community Medicine & Health Education. 2016 Oct;6(5).
5. Thomson M, Konerman MA, Choxi H, Lok AS. Primary Care Physician Perspectives on Hepatitis C Management in the Era of Direct-Acting Antiviral Therapy. Digestive Diseases and Sciences. 2016 Dec 1;61(12):3460–3468.
6. Moyer VA. Screening for HIV: US Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2013 Jul 2;159(1):51–60.
7. Younossi Z, Blissett D, Blissett R, Henry L, Younossi Y, Beckerman R, Hunt S. In an Era of Highly Effective Treatment, Hepatitis C Screening of the General Population of the United States for Hepatitis C Should be Considered. Liver International. 2017 Jul 18:38(2):258–265.
8. Arya M, Kumar D, Patel S, Street Jr RL, Giordano TP, Viswanath K. Mitigating HIV Health Disparities: The Promise of Mobile Health for a Patient-Initiated Solution. American Journal of Public Health. 2014 Dec;104(12):2251–2255.
9. Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven, CT. Yale University Press; 1999.
The Role of Text Messages in Patient-Physician Communication about the Influenza Vaccine
Disha Kumar1, BS, BA, Vagish Hemmige2,3, MD, MS, Michael A. Kallen4, PhD, MPH, Richard L. Street Jr.2,5,6, PhD, Thomas P. Giordano2,5, MD, MPH, Monisha Arya2,5, MD, MPH
1School of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, U.S.A.; 2Department of Medicine, Baylor College of Medicine, Houston, TX, U.S.A.; 3Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, 3411 Wayne Avenue, Suite 4H, Bronx, NY 10467, U.S.A.; 4Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611 U.S.A.; 5Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd (Mailstop 152), Houston, TX 77030, U.S.A.; 6Department of Communication, Texas A&M University, 4234 TAMU, College Station, TX 77843, U.S.A.
Corresponding author: email@example.com
Journal MTM 7:2:55–59, 2018
Background: Racial and ethnic minorities face disparities in receiving the influenza vaccination. A text message intervention could deliver personalized and timely messages to counsel patients on asking their physician for the vaccination.
Aims: We assessed whether patients would be receptive to influenza vaccination text messages.
Methods: Participants were recruited from a sample of low-income, racial and ethnic minority primary care patients. Participants completed a self-administered survey. Descriptive statistics were used to analyze the data.
Results: There were 274 patients who participated and answered the questions of interest, of whom 70% were racial and ethnic minorities and 85% owned a cell phone. Thirty-six percent reported they had never received an influenza vaccination recommendation from their physician. However, 84% would be comfortable asking their physician for the influenza vaccination. Of cell phone-owning participants who would be comfortable asking their physician about the influenza vaccination, 80% would also be comfortable receiving a text message reminder.
Conclusion: Text messages may be an acceptable channel to prompt patients to discuss the annual influenza vaccination with their physicians. Text messaging is a feasible tool to engage patients in their health and improve annual influenza vaccination rates among low-income, racial and ethnic minority patients.
Key words: minority health, healthcare disparities, telemedicine, mHealth, text messaging, influenza vaccination, health communication
Text messages may be an effective solution for improving unacceptably low influenza vaccination rates.1 In the U.S. 2017 early-influenza season, only 38% of adults received the influenza vaccine, with 36% of Hispanic adults, 40% of non-Hispanic Black adults, and 38% of non-Hispanic White adults receiving the vaccine.2 In comparison, 41% of adults received the influenza vaccine during the 2016 early-influenza season.2 As recommended by the U.S. Advisory Committee on Immunization Practices, all adults should receive annual influenza vaccination3 to prevent against the life-threatening effects of influenza. The low vaccination rate during the 2017 early-influenza season may in part have led to the relatively high incidence of influenza illness. During the recent 2017-2018 influenza season (1 Oct 2017 to 03 Feb 2018), the weekly percentage of outpatients visits for influenza-like illness ranged from 1.3% to 7.7%, well above the 2.2% national baseline for the prior three seasons.4
The push-pull capacity model5,6 could be adapted to improve influenza vaccination communication between patients and physicians. In this context, an intervention “pushing” the patient to ask their physician about the influenza vaccination may then “pull” the physician into talking about or recommending the vaccine. Arya et al. have illustrated how the push-pull model using text messages could improve communication about and demand for preventive health services.7 As racial and ethnic minorities are more likely to have poorer communication with their physicians,8 adapting the push-pull model using text messages may help improve this communication especially among these groups. Text messaging-based health campaigns have been successful at engaging patients in preventive health behaviors.9 Despite this success, text messages are underutilized in pushing health information to patients to engage them in managing their own health and in particular, improving patient-physician communication. Due to the ubiquity of text messaging, a text message campaign could help reduce the digital divide, which has left certain groups – such as racial and ethnic minorities – with less access to health information.10
Studies have demonstrated that text messages can help improve influenza vaccination rates; however, these studies have focused on improving childhood vaccination (by texting parents) or improving vaccination among pregnant women.11,12 To date, there has been limited research among low-income racial and ethnic minority adults on using text messages to improve patient-physician communication about vaccination. The purpose of this study was to determine if racial and ethnic minority adult patients who had not received an influenza vaccination recommendation would be comfortable 1) receiving a cell phone text message reminder about the vaccination and 2) asking their physicians for the vaccination.
This study was conducted June 2014 – February 2015 in a primary care clinic that serves low-income, mostly uninsured racial and ethnic minority patients. We recruited a convenience sample of patients to participate in a self-administered survey developed by the research team. Before study initiation, 38 patients pilot-tested the questions to ensure survey comprehensibility. In addition to survey questions on demographics and cell phone ownership, the primary questions were: 1) “Has your doctor at this clinic ever recommended that you get a flu shot?” 2) “How comfortable would you be asking your doctor for the flu shot?” and 3) “Would you be comfortable receiving a text message reminder about the flu shot?” Participants were given a $10 gift card for participating. The Baylor College of Medicine Institutional Review Board approved the study.
Descriptive statistics were used for data analysis. The responses “no” and “did not remember” for question one were combined into the single response category “no.” The responses “comfortable” and “very comfortable” for question two were combined into the single response category “comfortable.” Similarly, the responses “somewhat comfortable” and “not at all comfortable” for question two were combined into the single response category “not comfortable.”
We report data from the 274 participants who answered all three primary questions. Not all 274 participants answered all demographic questions. Of those who answered, the majority were female, had less than a college education, were racial and ethnic minorities, had an income under $20,000/year, and owned a cell phone. Of the 272 participants who responded to age, the median age was 54 years old (Interquartile range: 46-59 years old). See Table 1 for demographic characteristics of study participants.
Table 1: Demographic characteristics of the study population (N=274)
Overall, 98 (36%) had never received an influenza vaccination recommendation from their physician, 230 (84%) would be comfortable asking their physician for the vaccination, and 176 of 234 (75%) cell-phone owning participants would be comfortable receiving a vaccination text message reminder. See Table 2. Of the 98 (36%) participants who indicated they had never received an influenza vaccination recommendation, 77 (79%) would be comfortable asking their physician for the vaccination. Of these 77 participants, 64 (83%) owned a cell phone. Fifty-one (80%) of these 64 participants would be comfortable receiving an influenza vaccination text message reminder. Thus, overall 51 of 98 (52%) participants who had never received an influenza vaccination recommendation would be comfortable asking their physician for the vaccination and may be prompted by a text message to do so. See Figure 1.
Table 2: Results of survey questions pertaining to receiving the influenza vaccination (N=274)
Figure 1: Acceptability of an influenza vaccination text message among participants who have never received a vaccination recommendation from their physician.
Interventions are needed to improve vaccination rates, particularly among racial and ethnic minority populations who are traditionally underserved in healthcare. In our study of mostly racial and ethnic minority adults, over one-third of patients did not receive or did not remember receiving an influenza vaccination recommendation from their physician. This highlights the need for strategies to improve vaccination communication between these patients and their physicians. Notably, over three-fourths of patients who had never received an influenza vaccination recommendation from their physician and would be comfortable asking their physician for the vaccination, would also be comfortable receiving the corresponding text message reminder.
Text messages may be particularly suitable for delivering vaccine information in healthcare settings. Texts can be tailored and delivered at a highly pertinent time, such as immediately before a patient enters the examination room. An example of a personalized text message could be: “John, even healthy adults can get the flu and spread it to loved ones. Remind Dr. Jones at your appointment today to talk to you about your yearly flu shot.” This personalized and timely campaign may be more influential at prompting patients to ask for the influenza vaccination than static and non-personalized campaigns. Static campaigns, epitomized by posters in a clinic, may simply go unnoticed among a sea of signs, may not be relatable to the specific patient, or may fail to convince patients who have not already received their annual influenza vaccination. Another benefit of a text message campaign is that it can be integrated into the existing electronic medical record (EMR). Many EMR systems have the capability to send text messages. EMRs are able to extract patient name, physician name, appointment date and time, patient phone number, and lack of receipt of influenza vaccination – all of which can be used to personalize the text message. Thus, the EMR could both personalize and automate text message delivery to patients before a scheduled appointment. For healthcare systems that already use the EMR for appointment reminders, an influenza vaccination campaign could complement the existing reminder. In sum, text messages offer significant opportunity to cost-effectively improve influenza vaccination rates.
While this study offers insight into a strategy to improve influenza vaccination, there are limitations to our findings. Limitations to this study include a relatively small sample size consisting of predominately racial and ethnic minorities and collection of data from one study site. Thus our findings may not be generalizable to other populations. However, our findings may be salient for improving influenza vaccination rates among racial and ethnic adults. An additional limitation is our method of convenience sampling. This may have resulted in a response bias from participants already more inclined to engage in their health; our study sample may therefore be overrepresented by participants willing to talk to their physicians and to receive text message reminders. Our proposed intervention of using text messaging to encourage patient-physician communication about vaccination may therefore be most useful for patients who already actively participate in their health.
Our findings suggest a text message could “push” patients to “pull” their physicians into an influenza vaccination discussion, a step needed to improve vaccination rates among adults. This type of text message campaign could help achieve Healthy People 2020 goals of increased patient-physician communication, greater use of health communication technologies, and increased influenza immunization rates.13 Research is still needed to determine the optimal text message content to best persuade patients about their need for annual influenza vaccination and cue them to engage in an influenza vaccination conversation with their physicians. Physician ordering of the vaccination after a patient prompt would also need to be assessed to provide empirical evidence supporting the push-pull model for influenza vaccination.
The authors would like to thank Alexandra Trenary, Sajani Patel, and Ashley Phillips for their contributions to data collection. We would also like to thank Haley Marek for her thoughtful contributions to the manuscript draft.
D. Kumar contributed to literature reviews, study design, data collection and analysis, and the writing of all sections. V. Hemmige contributed to data analysis and the writing of the methods and results sections. M.A. Kallen and R.L. Street contributed to study design. T.P. Giordano contributed to study design and data analysis. M. Arya planned the thematic content and study design, and contributed to data analysis and the writing and editing of all sections. All authors contributed to draft versions of the manuscript and provided editorial suggestions for important intellectual content. All authors read and approved the final version of the manuscript.
Some of the results presented in this manuscript were presented in a poster at the March 10, 2016 Henry J.N. Taub/James K. Alexander Medical Student Research Symposium at the Baylor College of Medicine.
Funding: This work was supported by the National Institute of Mental Health of the National Institutes of Health under Award Number K23MH094235 (PI: Arya). This work was supported in part by the Center for Innovations in Quality, Effectiveness and Safety (#CIN 13-413).
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the National Institutes of Health, or Baylor College of Medicine.
Financial Disclosures: No financial disclosures were reported by the authors of this paper.
Research Involving Human Participants: This study was conducted under approval of Baylor College of Medicine Institutional Review Board Protocol H-30232. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
1. Phillips AL, Kumar D, Patel S, Arya M. Using text messages to improve patient–doctor communication among racial and ethnic minority adults: An innovative solution to increase influenza vaccinations. Prev Med. 2014;69:117–119. doi:10.1016/j.ypmed.2014.09.009
2. U.S. Centers for Disease Control and Prevention. National Early-Season Flu Vaccination Coverage, United States, November 2017. https://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2017.htm. Accessed March 17, 2017.
3. U.S. Centers for Disease Control and Prevention. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season.; 2017:1–20. https://www.cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm. Accessed March 17, 2018.
4. U.S. Centers for Disease Control and Prevention. Update: Influenza Activity — United States, October 1, 2017–February 3, 2018.; 2018:169–179. https://www.cdc.gov/mmwr/volumes/67/wr/mm6706a1.htm?s_cid=mm6706a1_w. Accessed March 17, 2018.
5. Curry SJ. Organizational interventions to encourage guideline implementation. Chest. 2000;118(2 Suppl):40S-46S.
6. Orleans CT. Increasing the demand for and use of effective smoking-cessation treatments reaping the full health benefits of tobacco-control science and policy gains–in our lifetime. Am J Prev Med. 2007;33(6 Suppl):S340–348. doi:10.1016/j.amepre.2007.09.003
7. Arya, M., Kumar, D., Patel, S., Street, R.L., Giordano, T.P., Viswanath, K. Mitigating HIV Health Disparities: The Promise of Mobile Health for a Patient-Initiated Solution. Am J Public Health. 2014;104(12):2251–2255. doi:10.2105/AJPH.2014.302120
8. Ashton CM, Haidet P, Paterniti DA, et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18(2):146–152.
9. Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med. 2009;36(2):165–173. doi:10.1016/j.amepre.2008.09.040
10. Chang BL, Bakken S, Brown SS, et al. Bridging the digital divide: reaching vulnerable populations. J Am Med Inform Assoc. 2004;11(6):448–457. doi:10.1197/jamia.M1535
11. Hofstetter AM, Vargas CY, Camargo S, et al. Impacting delayed pediatric influenza vaccination: a randomized controlled trial of text message reminders. Am J Prev Med. 2015;48(4):392–401. doi:10.1016/j.amepre.2014.10.023
12. Stockwell MS, Westhoff C, Kharbanda EO, et al. Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial. Am J Public Health. 2014;104 Suppl 1:e7–12. doi:10.2105/AJPH.2013.301620
13. U.S. Department of Health and Human Services. Healthy People 2020 Topics and Objectives. http://www.healthypeople.gov/2020/topicsobjectives2020/default. Accessed March 17, 2018.
Recharging Smiles: Strategies for Using Mobile Phones in Dental Public Health
Dr. Aditi Hegde1, Dr. Gopikrishna V2, Dr. Smitha B Kulkarni3, Dr. Nithin N Bhaskar3, Dr. Sourabha K Gangadharappa4, Dr. Jeswin Jacob4
1BDS, Postgraduate student, Department of Public Health Dentistry, Dayananda Sagar College of Dental Sciences; 2MDS, Professor and Head of the Department, Department of Public Health Dentistry, Dayananda Sagar College of Dental Sciences; 3MDS, Reader, Department of Public Health Dentistry, Dayananda Sagar College of Dental Sciences; 4MDS, Senior Lecturer, Department of Public Health Dentistry, Dayananda Sagar College of Dental Sciences
Corresponding Author: firstname.lastname@example.org
Journal MTM 7:2:60–65, 2018
Abstract: Through the advent of smartphones, the previously elusive internet is now available to each person right in their hands, with lightning fast speeds available at rather nominal charges. Mobile phones offer numerous solutions to dentists and health workers alike and can be applied in a variety of ways in a public health setting. This paper discusses the application of mobile phones in primary, as well as secondary and tertiary levels of intervention from a dental public health perspective. Indeed, the described strategies can be employed by professionals, alone or combined with other interventions, to enhance the oral health of their patients.
Keywords: cell phones, dental public health, health promotion, oral health, prevention.
The role of communication in the human health care sector is inescapable. It helps to convey the patient’s own experiences, values and preferences to the health care professional, all of which greatly influences a patient’s perception of the service, can create motivation for change, as well as augment subsequent compliance and adherence.1 This has led health care providers to constantly seek new, effective ways to reach “consumers” and promote their health through education, ultimately helping them manage their ailments. Overall, mobile phones have revolutionized the face of communication, and there is great potential for their use in health sectors. Patients and providers can now communicate from anywhere in order to follow-up on test results, ask questions, collect information, schedule appointments, send reminders and renew prescriptions.
Previously, text-messaging based health education campaigns have been used by administrations to control infectious diseases, to educate people regarding health policies, care of the pregnant and the elderly, and to dispel rumors.2 In scarcely resourced countries, mobile technologies can be used in a three-fold manner – to educate health workers, to establish a surveillance system, and to provide information to the general public.3
Dental Public Health has been defined as “the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts. It is that form of dental practice that serves the community as a patient rather than the individual. It is concerned with the dental health education of the public, with applied dental research, and with the administration of group dental care programs, as well as the prevention and control of dental diseases on a community basis.”4 In this new, complex world, dental public health is seen as a means to address the disparities in oral health outcomes that exist both within and between nations.5
In a country like India, where the dentist population ratio is so skewed in favor of urban areas, many remote villages and localities severely lack dental health services.6 The absence of private dentists can only be countered by providing adequate oral health services at a primary health center or community health center. Deprofessionalization of dentistry has been regarded as a necessary evolution to combat the burgeoning morbidity due to oral diseases in rural areas, a problem that is only magnified by the ever-increasing population.7 Developing a system to remotely educate and aid health extension workers will greatly improve the quality of oral health care. Where other conventional delivery mechanisms fall short, mHealth is already being used to provide underserved populations with access to information and services.
Mobile devices can easily be applied in a dental health setting to enhance patient outcomes.8 As practitioners of dental public health in a developing nation where there is both lack of oral health awareness and lack of services, the authors realized the need for alternative methods of oral health care delivery. It was observed that most patients possessed a mobile phone with internet capabilities, and were also interested in innovative technologies that could enhance their health. This inspired a search for mobile phone interventions in dental public health. A comprehensive knowledge of the purposes for which mobile phones have been used in healthcare in the past and an idea about their future utilization is necessary. Understanding the ‘Why?’, ‘What?’ and ‘How?’ of these interventions will enable public health workers to incorporate mHealth, an essential tool in this technology-oriented era, into dental public health practice.
Applying Mobile Phones In Dental Public Health
Researchers from all fields of science have attempted to incorporate the myriad features and technologies of mobile phones into health-care interventions. In the field of oral health, such interventions can be used in a variety of ways to enhance health outcomes. Dentists too are getting involved in this technological revolution. In a descriptive study by Jasti et el.,9 approximately 68% of the surveyed dentists from Khammam, Andhra Pradesh reported using healthcare apps on their smartphones for either personal knowledge or patient education purposes. In a Dental Public Health setting, mobile phones can be used for primordial, primary, secondary, as well as tertiary prevention.
In primordial prevention
One way to help patients is by giving them the information about how to avoid dental problems by means of text messaging or apps. A mass oral health education campaign can be carried out using text messages and multimedia messages (MMS) even before the appearance of risk factors in the population. For example, text messages discussing the importance of avoiding tobacco can be sent to all cell phone users, irrespective of their usage status. The reach of such a campaign will be massive because even in a developing country like India, there are approximately 74 mobile subscriptions per 100 people.10
An attempt can also be made to bolster the oral health of the community by taking advantage of the Digital India Initiative by the Government of India. ‘Kilkari’ is one such scheme for information regarding maternal and child health, where pregnant women receive voice calls on a range of relevant topics.11 Integrating oral health education into this scheme will not just expand the latitude of the existing programme, but will also allow access to a key target population.
In primary prevention
Using SMS and mobile phone applications, oral health education can be provided at an individual and community level. When selecting apps for oral health education, it is necessary to select one that dispenses accurate information based on evidence. Software developed for this purpose usually allows patients learn about their disease, its prevention and necessary treatment, however, requires active participation.
Smartphones can also utilize entertainment to dispense health education, such as Molarcropolis, a mobile persuasive to raise oral health and dental hygiene awareness for adolescents and young adults. Soler et al.12 evaluated the game and found that most of the participants found the game to be both entertaining and informative. Mobile social media platforms such as Facebook and Twitter can also be used to leverage social influence and bring attention to the importance of oral health.
Schluter et al.13 successfully utilized motivational text messaging to promote brushing among young adults receiving Work and Income support in New Zealand. By making use of the communication capabilities of mobile phones, a discernible improvement in oral hygiene was obtained. Researchers have also reported that sharing anonymous photographs (“selfies”) in a WhatsApp or other such chat-room leads to significant improvements in oral hygiene of participants.14,15
The Brush DJ app was developed to motivate patients to adopt an evidence-based oral hygiene behavior by playing music of the user’s choice. The app also reminds the user to spit and not rinse after brushing in order to maintain optimum local fluoride levels. Its competence was demonstrated by Underwood et al.16 who reported that 88% of app users were motivated to brush longer.
Dental caries is another common dental disease, closely associated with diet, as has been proven by innumerable researchers.17,18 Tracking a patient’s diet is a commonly used method for caries risk assessment and also for assessing one’s general health behavior in routine practice. Although unexplored, this pivotal step of diet history can be simplified by making use of journaling applications such as Wellness Diary, Calorific, My Food Diary, Nutritionist etc. This comprehensive overview of the patient’s diet history can be shared with the dentist who can then formulate an appropriate treatment plan.
To help patients quit harmful habits, public health dentists and primary care workers can provide habit counselling using mobile phones. An example of this is The Real E Quit Mobile smoking cessation application that helps people quit smoking with the aid of supportive audio clips and documents. Users can also make their own lists on reasons for quitting, benefits, and plans for challenging situations. Buller et al.19 found that 75% of users evaluated REQ-mobile to be user-friendly, and concluded that it was a feasible method for delivering cessation support to help people quit smoking.
In secondary prevention
Oral cancer screening is based on the rationale that self-examination or oral check-up by a professional reduces the mortality due to this disease, and also leads to recognition in earlier stages. Birur et al.20 describe the use of Oncogrid, a mobile phone based remote oral cancer surveillance tool, connecting primary care dental professionals with frontline health workers (FHW). This telemedicine program found that oral cancer screening and surveillance via mobile phones was feasible even in remote areas and low-resource settings. The authors suggest that such interventions can cause a paradigm shift in the practice of public health.
MySmileBuddy was developed by Levine et al.21 to reduce early childhood caries prevalence and its consequences amongst a high risk population. It allows community health workers or lay workers to conduct preliminary dietary screening assessment for high risk children and their mothers. After collecting information on the caries risk, the parents are informed of suitable behavior goals they can choose from so that the caries risk is diminished. The associated community health worker also follows up on the family to assess the progress towards behavior goals. With further research and adaptation, the use of mobile technology for dietary assessment may be applicable for widespread use in a variety of sites and programs that address the health needs of young children. The highly-advanced cameras available in current mobile phones also allow for remote screening for dental caries by mid-level dental providers, as demonstrated by Estai et al.22 They found that this method has a sensitivity ranging from 60-68%, and a specificity between 97-98%. This can help tackle some of the problems caused by the lack of dental services available to rural populations in countries like India.
Another problem created by inequitable distribution is the unavailability of emergency dental treatment. Oral and maxillofacial surgery (OMFS) is a particularly challenging field as it requires impeccable knowledge of both medicine and dentistry.23 There is potential for gaps in clinical knowledge when an untrained health worker has to manage acute OMFS cases. Mobile devices can be a means to access electronic educational resources during clinical activities and also improve clinical decision-making.24
Additionally, it is now possible to advise even those who are furthest from dental treatment during an emergency. Stein et al.25 developed an extremely useful application for the purpose of triaging dental emergency. Their study demonstrated that patients can use their smartphones to transmit relevant clinical data to their dentists, all within 4 minutes. The authors suggested using mobile applications to enhance routine and emergency dental care.
In Tertiary Prevention
In primary and community health centers, dentists are often posted on a rotational basis due to the paucity of professionals. Therefore, a dentist may not always be available for post-surgery consultation. In the case of full-mouth rehabilitation cases, it takes quite some time for patients to get used to their new appearance and occlusion. To help patients rehabilitate, dental professionals and health workers can consult and counsel via mobile phones. For instance, myDentist is an app through which patients may explain their problems to the oral health care provider by sending text, diagrams or photos. The dentist can respond to these messages with appropriate instructions to manage the problem, and can also arrange an appointment for the future.
Dental phobia is a crippling disorder causing an individual to avoid dental treatment because of an irrational fear, even if they are in pain. In the process of avoiding the dentist, the disease progresses and may lead to severe disability. To limit this disability caused by dental diseases, elimination of dental phobia is necessary, after which patients can utilize the services available to them. Applications like Dental Phobia claim to reduce a patient’s anxiety towards dental treatment through hypnosis. Such means of handling dental phobia must be critically reviewed before wider application; research must be conducted in this field in the future.
Shortcomings of Mobile Phone Health Care Interventions
One of the primary restraints of mHealth is that not all interventions can be readily applied to the myriad segments of the population. It must be kept in mind that the ability to read the information may be lacking in many mobile phone users due to low literacy rates; approximately 15% of the adult population was considered to be illiterate in 2010. Moreover, as per World Bank estimates, at least thirteen developing nations have a literacy rate of less than 50%.26 In such conditions, a text-based intervention may fail, while image-based interventions can succeed. Complicated and cumbersome technology may hinder, rather than assist the user, especially if the procedure involves too many steps.
Another limitation is that the cost-effectiveness of internet-based mobile phone interventions has not been established. Depending on the network carrier and data usage, charges can vary from user to user. One more feature that varies with network carrier is the range. Although there has been staggering growth, there are certain areas that are still untouched by this technology.
Table 1: Mobile phone interventions in Dental Public Health
Additionally, Tatum et al.27 have proposed that cortical processing in the human brain is uniquely activated by the use of personal electronic devices such as mobile phones. However, the practical and real-world implications are yet to be studied.
Finally, it is worth mentioning that there is a paucity of comparative studies regarding mobile phone interventions in dentistry. Therefore, it is not possible at this time to conclude on the relative value of each intervention. It is necessary to conduct rigorous investigation to assess the same.
Like fire and the wheel, the invention of mobile phones changed the lives of humans worldwide, and like most inventions, they are in a process of constant improvement. Healthcare professionals have recognized the impact this has had on the lives of their patients, and have adopted cellphones in a variety of ways. Oral health care providers can implement mHealth interventions in public health practice at all levels of prevention. Indeed, one, or a combination of these strategies can be employed by health workers to enhance the oral health of their patients. Moreover, mobile phones are an accessible, affordable, appropriate technology for interventions in a public health setting.
By focusing on prevention and involving the community in these programs, dental professionals can give a much-needed boost to the oral health status of people. There are unparalleled advantages to using mobile devices that cannot be matched by other technological media. However, the potential complications should be kept in mind. Dentists should take initiative and be involved in the planning of guidelines for these interventions.
Sources of support
Declaration: The matter presented in this paper or any part of it is has not been submitted elsewhere simultaneously. The authors certify that they have no potential conflict of interest, financial or otherwise, pertaining to the information discussed in this paper. All the matter presented in this paper has been read and approved by all the authors.
Criteria for inclusion in author’s list: Dr. Aditi Hegde was involved in the conception, literature review, compilation and writing of the paper. Dr. Gopikrishna V took part in the conception of the study and writing of the paper. Dr. Smitha B Kulkarni took part in writing the paper. Dr. Nithin N Bhaskar supervised the literature review, and took part in the writing of the paper. Dr. Sourabha K G participated in literature review and paper writing. Dr. Jeswin Jacob participated in the study conception and writing of the paper. All authors have provided valuable inputs to the manuscript, agree with its contents, and have approved the final manuscript.
The literature search was performed using an electronic database search of peer-reviewed bibliographic and non-bibliographic databases, as well as a review of websites of reliable institutions. Medical Subject Headings (MeSH terms) were used wherever possible to ensure a uniform search strategy. Each term was used as a single item or in combination by employing the Boolean operators “AND” and “OR”. The following terms were used: teledentistry, mHealth, mobile phone, mobile health, cell phone, texting, message, text message, mobile application, SMS, dentistry, dental health, dental public health, public health dentistry, oral health.
The studies that were not directed towards oral or dental health were excluded. All included studies focused on the prevention and control of oral diseases, collection and transmission of oral disease information, and training of health workers.
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Computer Literacy in the Elderly: A Survey Examining Real World Usability of Medical Software
Journal MTM 7:2:66–67, 2018
There is widespread evidence of an association between reduced health literacy and an increased risk of poor medical outcome. Patients with poor medical education experience significantly higher emergency room costs1 and up to double the hospital admission rates compared to patients with sufficient medical education.2–6 Lack of medical literacy is particularly important in the ageing population, due to increased burden of chronic illness and the increasingly complex management of progressive chronic conditions. To address this, various smartphone and tablet medical applications have been developed to improve patient health literacy and monitor chronic illnesses. We propose the need to examine the technological literacy of elderly patients, who are most likely to benefit from these applications.
The efficacy of self-monitoring medical applications hinges on a patient’s ability to access and use technology to track health progress. We suspect that computer literacy in elderly patients will not be adequate for effective technological monitoring of chronic illness at this time. It has been shown that amongst doctors there is often low familiarity with basic computer applications.7
We have designed a study to determine the technological literacy of patients who present to a large specialist Ophthalmology hospital. This population is one of the least likely to adequately operate advanced technology due to deteriorating vision and advanced age. There has also been recent development of patient health-monitoring applications for illnesses in this field. These include applications to monitor glaucoma and macular degeneration, which have significant correlation with clinical assessment in experimental settings.8,9
We will survey Ophthalmology patients and compare their ability to perform simple tasks on their smartphones and tablets as a screening measure for operating more advanced medical software for the purposes of health monitoring. The designed survey will enquire about the ability of patients to install, open and operate applications on a smartphone or tablet. The survey will also obtain information about the type of devices patients own and frequently use. Finally, the survey asks whether a patient has any previous experience with medical applications.
With the results of this research we aim to assess the computer literacy of an ageing patient population, and extrapolate from this data the reliability of personal medical software to accurately monitor chronic disease in this demographic. Due to potential limitations in patient language comprehension, participants will be limited to those fluent in English. While there are also potential study limitations due to visual or technological difficulties, these problems will reflect the issues in implementing personal medical applications in practice.
These findings will act as a benchmark to guide the feasibility of implementation of technology-based disease monitoring in the near future. We would expect, with time, that subsequent generations’ computer literacy will only improve from this benchmark.
1. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees. The American journal of medicine [Internet]. 2005;118(4):371–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15808134
2. Baker DW, Parker RM, Williams M V., Clark WS. Health literacy and the risk of hospital admission. Journal of General Internal Medicine. 1998;13(12):791–8.
3. Levin-Zamir D, Peterburg Y. Health literacy in health systems: Perspectives on patient self-management in Israel. Vol. 16, Health Promotion International. 2001. p. 87–94.
4. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. Journal of general internal medicine. United States; 2004 Dec;19(12):1228–39.
5. Williams M V, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Archives of internal medicine. United States; 1998 Jan;158(2):166–72.
6. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, et al. Association of health literacy with diabetes outcomes. JAMA. United States; 2002 Jul;288(4):475–82.
7. Debehnke DJ, Valley VT. Assessment of the current computer literacy and future computer needs of emergency medicine residents and faculty. American Journal of Emergency Medicine. 1993;11(4):371–3.
8. Anderson A, Bedggood A, Kong Y, Martin K, Vingrys A. Can Home Monitoring Allow Earlier Detection of Rapid Visual Field Progression in Glaucoma? American Academy of Ophthalmology. 2017;124(12):1735–42.
9. Winther C, Frisen L. Self-Testing of Vision in Age-Related Macula Degeneration: A Longitudinal Pilot Study Using a Smartphone-Based Rarebit Test. Journal of Opthalmology. 2015;2015:285463.