Linguistic analysis of Latinx patients' responses to a text messaging adjunct during cognitive behavioral therapy for depression.

Cognitive behavioral therapy (CBT) is efficacious to treat depression, however more research is needed to understand its functions among Latinxs. This study analyzed qualitative responses that were paired with a mood rating (1-9 scale) from daily ecological momentary assessments via text-messaging of 52 low-income, Spanish-speaking patients to assess the relationship between word use and changes in mood during group CBT. Based on previous research, we chose 11 linguistic dimensions from the Linguistic Inquiry and Word Count text analysis software that conceptually related to core CBT treatment elements and sociocultural factors of depression in Latinxs. Results showed that the use of words from the categories of Friends, Religion, Positive Emotions, and Leisure (proxy for behavioral activation) were significantly associated with a significant increase in mood. The use of Negative Emotions and Health words were significantly associated with a significant decrease in mood. Post-hoc analysis revealed that Certainty (proxy for cognitive inflexibility) words were related to a significant decrease in mood when Negative Emotional words were present. Findings contribute to our understanding of the role of sociocultural factors and core CBT elements in changes in mood among Latinxs. Lastly, this paper demonstrates the potential for analyzing language content during a digital health intervention to better understand user experiences.

Assessing Mobile Phone Digital Literacy and Engagement in User-Centered Design in a Diverse, Safety-Net Population: Mixed Methods Study.

BACKGROUND: Health care systems are rapidly deploying digital tools for disease management; however, few studies have evaluated their usability by vulnerable populations. To understand the barriers to app usage among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app. OBJECTIVE: The study aimed to describe variations in patients' engagement in the app design process, focusing on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL). METHODS: We conducted 20 in-depth semistructured interviews with primary care patients at a public health care system, used open-ended discussions and card sorting tasks to seek input about mobile phones and text messaging, and used open coding to categorize the patterns of mobile phone usage and to evaluate engagement in the card sorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content and calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy. RESULTS: The average age of the 20 participants was 59 (SD 8) years; 13 (65%) were female, 18 (90%) were nonwhite, 16 (80%) had LHL, and 13 (65%) had LEP. All had depression, and 14 (70%) had diabetes. Most participants had smartphones (18/20, 90%) and regularly used text messaging (15/20, 75%), but 14 (70%) of them reported having difficulty texting because of inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP, and all 10 had LHL. Half of the participants required a modification of the card sorting activity owing to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (4/13, 30% vs 5/7, 71%), limited versus adequate health literacy (7/16, 44% vs 3/4, 75%), and limited versus adequate digital literacy (4/10, 40% vs 6/10, 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (8/16, 50% vs 4/4, 100%); there were no statistical differences by any subgroup. CONCLUSIONS: Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the card sorting activity varied among participants and appeared to be lower among those with LHL, LEP, and LDL. Researchers employing traditional UCD methods should routinely measure these communication domains among their end-user samples. Future work is needed to replicate our findings in larger samples, but augmentation of card sorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.

Engaging users in the design of an mHealth, text message-based intervention to increase physical activity at a safety-net health care system.

OBJECTIVES: Text-messaging interventions are a promising approach to increasing physical activity in vulnerable populations. To better inform the development of a text-messaging intervention, we sought to identify barriers and facilitators to using text messaging and engaging in physical activity among patients with diabetes and comorbid depression. MATERIALS AND METHODS: We conducted interviews with primary care patients at a safety-net health care system (N = 26). Data were collected at 3 stages, including a focus group (stage 1), and individual interviews (stage 2 and 3). Patients in stage 1 and 2 previously participated in a text-messaging intervention as part of depression treatment. Discussions focused on participant experience of previously using a text-messaging intervention, influences and perceptions of physical activity, and mobile phone use. We analyzed all transcripts for emerging themes. RESULTS: Participants were 56.2 years (±9.7); 69.2% were female, 65.4% identified as Hispanic/Latino(a), and 46.2% reported having less than a high school education. All had depression and 61.5% had diabetes. Specific barriers that emerged included low literacy and only basic use of mobile phones in everyday life, in combination with a high prevalence of comorbid health conditions and limited mobility. These were each addressed with a specific content or intervention delivery change in the overall intervention design. CONCLUSIONS: Conducting a focus group and individual interviews with end users of an mHealth intervention under development has implications for tailoring and modifying components of the content and format to ensure that the final intervention will engage end users most effectively.