Use of a virtual environment to promote self-management and lifestyle changes in persons with bipolar disorder.

PURPOSE: Self-management and lifestyle interventions are a key factor in treatment outcomes for persons with bipolar disorder (BD). A virtual environment (VE), due to it's ability to provide flexibility of involvement in its platform, may be an alternative to face-to-face treatment to provide support for self-management. The purpose of this study is to explore how a VE, developed for chronic illness self-management, may be modified to promote self-management and lifestyle changes in those with BD. METHOD: This study used a qualitative description design with focus groups. Data were collected via minimally structured interviews and analyzed using thematic content analysis. A total of seven focus groups were conducted, and the sample consisted of 30 adults with BD. Age range was 21-77 years with 21 females, seven males, and two non-binary individuals. RESULTS: Five themes emerged from the findings: Self-management and lifestyle interventions with regards to (1) mental health; (2) holistic health; (3) role of peers; (4) involvement of the family; (5) technological aspects of the VE. CONCLUSIONS: Focus group participants suggested that the VE may be an efficacious way to enhance self-management and promote lifestyle interventions in those with BD. Research is needed to adapt such platforms to the need of the patients and examine its' effect on health outcomes.

Listening to Remotely Monitored Home-based Preferred Music for Pain in Older Black Adults with Low Back Pain: A Pilot Study of Feasibility and Acceptability.

BACKGROUND: Low back pain (LBP) is a complex condition that is widespread among older Black adults. Nonpharmacologic interventions are recommended as first-line therapy, but their use in practice is limited, possibly due to misunderstanding of their analgesic characteristics. AIM: To determine the feasibility and acceptability of listening to preferred music at home to relieve pain in older Black adults aged 65 years or older with LBP. METHOD: We recruited 20 community-dwelling older adults (≥65 years) with LBP to use noise-isolating headphones to listen to their preferred music for 20 minutes twice daily for four days via the MUSIC CARE® app. Feasibility was determined using enrollment, adherence, and attrition rates, and acceptability was determined using the Treatment Acceptance and Preference (TAP) scale. Average pain scores were self-reported using the Numeric Rating Scale (NRS) after the second intervention of the day. Pain scores were evaluated using paired sample t test and repeated-measures ANOVA. RESULTS: Enrollment, adherence, and attrition rates were 95.25%, 100.00%, and 0.00%, respectively. Most participants rated the TAP scale at ≥3, indicating acceptance. Pain scores decreased significantly from baseline (M = 46.90, SD = 21.47) to post-intervention (M = 35.70, SD = 16.57), t (19) = 2.29, p = .03. Repeated measures ANOVA showed a significant decrease in mean pain scores over time [F (2.36, 44.88) = 5.61, p = .004, η2 = .23]. CONCLUSIONS: Listening to preferred music for 20 minutes twice a day is a feasible and acceptable intervention that can considerably reduce pain in older Black adults with LBP.

Learning in a Virtual Environment to Improve Type 2 Diabetes Outcomes: Randomized Controlled Trial.

BACKGROUND: Given the importance of self-management in type 2 diabetes mellitus (T2DM), a major aspect of health is providing diabetes self-management education and support. Known barriers include access, availability, and the lack of follow through on referral to education programs. Virtual education and support have increased in use over the last few years. OBJECTIVE: The purpose of the Diabetes Learning in a Virtual Environment (LIVE) study was to compare the effects of the LIVE intervention (educational 3D world) to a diabetes self-management education and support control website on diet and physical activity behaviors and behavioral and metabolic outcomes in adults with T2DM over 12 months. METHODS: The LIVE study was a 52-week multisite randomized controlled trial with longitudinal repeated measures. Participants were randomized to LIVE (n=102) or a control website (n=109). Both contained the same educational materials, but the virtual environment was synchronous and interactive, whereas the control was a flat website. Data were collected at baseline and 3, 6, and 12 months using surveys and clinical, laboratory, and Fitbit measures. Descriptive statistics included baseline characteristics and demographics. The effects of the intervention were initially examined by comparing the means and SDs of the outcomes across the 4 time points between study arms, followed by multilevel modeling on trajectories of the outcomes over the 12 months. RESULTS: This trial included 211 participants who consented. The mean age was 58.85 (SD 10.1) years, and a majority were White (127/211, 60.2%), non-Hispanic (198/211, 93.8%), married (107/190, 56.3%), and female (125/211, 59.2%). Mean hemoglobin A1c (HbA1c) level at baseline was 7.64% (SD 1.79%) and mean BMI was 33.51 (SD 7.25). We examined weight loss status versus randomized group, where data with no weight change were eliminated, and the LIVE group experienced significantly more weight loss than the control group (P=.04). There were no significant differences between groups in changes in physical activity and dietary outcomes (all P>.05), but each group showed an increase in physical activity. Both groups experienced a decrease in mean HbA1c level, systolic and diastolic blood pressure, cholesterol, and triglycerides over the course of 12 months of study participation, including those participants whose baseline HbA1c level was 8.6% or higher. CONCLUSIONS: This study confirmed that there were minor positive changes on glycemic targets in both groups over the 12-month study period; however, the majority of the participants began with optimal HbA1c levels. We did find clinically relevant metabolic changes in those who began with an HbA1c level >8.6% in both groups. This study provided a variety of resources to our participants in both study groups, and we conclude that a toolkit with a variety of services would be helpful to improving self-care in the future for persons with T2DM. TRIAL REGISTRATION: ClinicalTrials.gov NCT02040038; https://clinicaltrials.gov/ct2/show/NCT02040038.

Unpacking Peer Conversations in a Virtual Communitiy for Diabetes Self-Management Education and Support: Behavior Science and Linguistics Perspective.

Diabetes is a chronic disease that can be effectively managed and controlled using strategies such as self-management education and ongoing support. Virtual environments offer innovative and realistic settings where patients can achieve self-management education and obtain ongoing self-management support from peers and healthcare professionals. Transcribed real-time conversations in an innovative virtual community were analyzed using qualitative and linguistic analysis. These virtual interactions were manually coded to identify embedded behavior change techniques and linguistic features. Results showed 13 behavior change techniques were manifested. Further, language differences were observed between behavior change techniques and social support types. Our research can provide valuable insights into the design of effective digital health interventions that maximize sustained use of virtual environments, subsequently impacting self-management of chronic conditions such as diabetes.

Coping and healthcare utilization in LGBTQ older adults: A systematic review.

PURPOSE: This systematic review was conducted to identify, synthesize, and elucidate the coping mechanisms described by aging lesbian, gay, bisexual, transgender, and queer (LGBTQ) adults (60+) when utilizing healthcare. METHODS: A comprehensive literature search was conducted in Embase and Ovid databases to identify studies of aging LGBTQ adults using coping mechanisms during healthcare utilization. Qualitative and quantitative studies published in English between 1969 and 2020 were included and assessed with COREQ, STROBE Statement, and CASP instruments. RESULTS: Of 227 articles identified, six were included in the review. The final synthesis revealed that coping mechanisms were associated with social support, social network size, provider competency, and disclosure management. Frequency of appointments varied when seeking healthcare, and one study indicated delay in treatment. CONCLUSION: This systematic review highlights various coping mechanisms associated with healthcare utilization and supports the need to develop research uniquely focused on aging LGBTQ adults.

The Effect of Music Listening on Pain in Adults Undergoing Colonoscopy: A Systematic Review and Meta-Analysis.

PURPOSE: To investigate the role of music listening in reducing pain in adults undergoing colonoscopy. DESIGN: This is a systematic review and meta-analysis of randomized control trials (RCTs) that evaluated the effect of music in reducing pain in adults undergoing colonoscopy. METHODS: We searched CINAHL, Embase, MEDLINE, PsycINFO, and PubMed for RCTs that reported on the effects of music listening in reducing pain in adult patients undergoing colonoscopy from database inception to March 15, 2020, when the search was completed. Studies published in English with adult participants testing the efficacy of music during colonoscopy were eligible for inclusion. Studies reporting the results of combined nonpharmacological interventions were excluded. The methodological quality of each included RCT was assessed using the Cochrane Collaboration tool for assessing the risk of bias. Two authors independently abstracted data and assessed risks of bias. FINDINGS: Seven RCTs with a total of 622 adult participants fulfilled our inclusion criteria and were, therefore, included. A random-effects model estimated the summary effect of the 7 included studies as -1.83 ± 0.98, P = 0.06. CONCLUSIONS: Although our meta-analysis demonstrated a small treatment effect, this effect was clinically not statistically significant. Substantial heterogeneity among the included trials limits the certainty of our findings. Additional trials investigating the effects of listening to music on pain in adults undergoing colonoscopy are needed to generate further evidence to establish the analgesic effect of music in adults undergoing colonoscopy.

Exchanges in a Virtual Environment for Diabetes Self-Management Education and Support: Social Network Analysis.

BACKGROUND: Diabetes remains a major health problem in the United States, affecting an estimated 10.5% of the population. Diabetes self-management interventions improve diabetes knowledge, self-management behaviors, and clinical outcomes. Widespread internet connectivity facilitates the use of eHealth interventions, which positively impacts knowledge, social support, and clinical and behavioral outcomes. In particular, diabetes interventions based on virtual environments have the potential to improve diabetes self-efficacy and support, while being highly feasible and usable. However, little is known about the patterns of social interactions and support taking place within type 2 diabetes-specific virtual communities. OBJECTIVE: The objective of this study was to examine social support exchanges from a type 2 diabetes self-management education and support intervention that was delivered via a virtual environment. METHODS: Data comprised virtual environment-mediated synchronous interactions among participants and between participants and providers from an intervention for type 2 diabetes self-management education and support. Network data derived from such social interactions were used to create networks to analyze patterns of social support exchange with the lens of social network analysis. Additionally, network correlations were used to explore associations between social support networks. RESULTS: The findings revealed structural differences between support networks, as well as key network characteristics of supportive interactions facilitated by the intervention. Emotional and appraisal support networks are the larger, most centralized, and most active networks, suggesting that virtual communities can be good sources for these types of support. In addition, appraisal and instrumental support networks are more connected, suggesting that members of virtual communities are more likely to engage in larger group interactions where these types of support can be exchanged. Lastly, network correlations suggest that participants who exchange emotional support are likely to exchange appraisal or instrumental support, and participants who exchange appraisal support are likely to exchange instrumental support. CONCLUSIONS: Social interaction patterns from disease-specific virtual environments can be studied using a social network analysis approach to better understand the exchange of social support. Network data can provide valuable insights into the design of novel and effective eHealth interventions given the unique opportunity virtual environments have facilitating realistic environments that are effective and sustainable, where social interactions can be leveraged to achieve diverse health goals.

Developing Methods That Facilitate Coding and Analysis of Synchronous Conversations via Virtual Environments.

Programs via the Internet are uniquely positioned to capture qualitative data. One reason is because the Internet facilitates the creation of a community of similar individuals who can exchange information and support related to living with a chronic illness. Synchronous conversations via the Internet can provide insight into real-time social interaction and the exchange of social support. One way to analyze interactions among individuals is by using qualitative methods such as content, conversation, or discourse analysis. This manuscript describes how we used content analysis with aspects from conversation and discourse analysis to analyze synchronous conversations via the Internet to describe what individuals talk about and how individuals talk in an Internet-mediated interaction. With the increase in Internet interventions that facilitate collection of real-time conversational data, this article provides insight into how combining qualitative methods can facilitate the coding and analysis of these complex data.

Type 2 Diabetes Education and Support in a Virtual Environment: A Secondary Analysis of Synchronously Exchanged Social Interaction and Support.

BACKGROUND: Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE interactions remain unknown. OBJECTIVE: The objective of this study was to describe social interaction and support among individuals with type 2 diabetes (T2D) who interacted in a VE. METHODS: Data included VE-mediated synchronous conversations and text-chat and asynchronous emails and discussion board posts from a study that facilitated interaction among individuals with T2D and diabetes educators (N=24) in 2 types of sessions: education and support. RESULTS: VE interactions consisted of communication techniques (how individuals interact in the VE), expressions of self-management (T2D-related topics), depth (personalization of topics), and breadth (number of topics discussed). Individuals exchanged support more often in the education (723/1170, 61.79%) than in the support (406/1170, 34.70%) sessions or outside session time (41/1170, 3.50%). Of all support exchanges, 535/1170 (45.73%) were informational, 377/1170 (32.22%) were emotional, 217/1170 (18.55%) were appraisal, and 41/1170 (3.50%) were instrumental. When comparing session types, education sessions predominately provided informational support (357/723, 49.4%), and the support sessions predominately provided emotional (159/406, 39.2%) and informational (159/406, 39.2%) support. CONCLUSIONS: VE-mediated interactions resemble those in face-to-face environments, as individuals in VEs engage in bidirectional exchanges with others to obtain self-management education and support. Similar to face-to-face environments, individuals in the VE revealed personal information, sought information, and exchanged support during the moderated education sessions and unstructured support sessions. With this versatility, VEs are able to contribute substantially to support for those with diabetes and, very likely, other chronic diseases.

Participation of Racial and Ethnic Minorities in Technology-Based Interventions to Self-Manage Type 2 Diabetes: A Scoping Review.

PURPOSE: Strategies to decrease societal and cultural barriers for ethnic minorities to participate in health research are well established. However, limited data are available regarding participation of ethnic minorities in mobile and Internet technology-based interventions to self-manage type 2 diabetes where health disparities are predominant. Thus, the purpose was to understand the participation of ethnic minorities in technology-based intervention programs to manage type 2 diabetes. DESIGN/METHOD: A scoping review was used to review a total of 21 intervention studies containing participant information about ethnic minorities and one qualitative study discussing participation of ethnic minorities. FINDINGS: There was limited enrollment and participation of ethnic minorities. Technological barriers in addition to existing societal and cultural barriers were identified. Strategies to decrease the barriers were recommended. CONCLUSIONS: Technological barriers were identified on top of the societal and cultural barriers in traditional interventions. Further research to reduce the barriers is warranted.

Reactions to online colorectal cancer risk estimates among a nationally representative sample of adults who have never been screened.

Data on the public's reactions to online tailored colorectal cancer (CRC) risk estimates are sparse. We assessed among 560 men and women aged 50-75 with no CRC screening history reactions to online tailored CRC estimated comparative risk (i.e., self vs. other their age and sex). Assessed were reactions to estimate (i.e., repeating back estimate, match between perceived comparative risk and estimate, accuracy and usefulness of estimate, emotional reactions), risk appraisals and screening intentions. 73% of the sample accurately repeated back their estimate; the match between perceived comparative risk and the estimate was lowest among those informed of being at higher risk. Higher estimates were viewed as less useful and evoked more negative emotions. Viewing the estimate as more useful and experiencing more negative emotions were related with higher risk appraisals and, in turn, screening intentions. These data indicate that adults at higher comparative risk resist accepting a higher risk status.

Creating a sustainable collaborative consumer health application for chronic disease self-management.

As the prevalence of chronic diseases increase, there is a need for consumer-centric health informatics applications that assist individuals with disease self-management skills. However, due to the cost of development of these applications, there is also a need to build a disease agnostic architecture so that they could be reused for any chronic disease. This paper describes the architecture of a collaborative virtual environment (VE) platform, LIVE©, that was developed to teach self-management skills and provide social support to those individuals with type 2 diabetes. However, a backend database allows for the application to be easily reused for any chronic disease. We tested its usability in the context of a larger randomized controlled trial of its efficacy. The usability was scored as 'good' by half of the participants in the evaluation. Common errors in the testing and solutions to address initial usability issues are discussed. Overall, LIVE© represents a usable and generalizable platform that will be adapted to other chronic diseases and health needs in future research and applications.

Analyzing Unstructured Communication in a Computer-Mediated Environment for Adults With Type 2 Diabetes: A Research Protocol.

BACKGROUND: Individuals with type 2 diabetes have an increased risk for comorbidities such as heart disease, lower limb amputations, stroke, and renal failure. Multiple factors influence development of complications in a person living with type 2 diabetes; however, an individual's self-management behaviors may delay the onset of, or lessen the severity of, these complications. Social support provides personal, informal advice and knowledge that helps individuals initiate and sustain self-management and adherence. OBJECTIVE: Our aim was to gain an understanding of type 2 diabetes social interaction in a virtual environment, one type of computer-mediated environment (CME), and the social support characteristics that increase and sustain self-management in adults living with chronic illness. METHODS: This study is a secondary analysis of longitudinal data collected in a CME study, Second Life Impacts Diabetes Education & Self-Management (1R21-LM010727-01). This virtual environment replicated a real-life community where 6 months of naturalistic synchronous voice conversations, emails, and text chats were recorded among participants and providers. This analysis uses a mixed-methods approach to explore and compare qualitative and quantitative findings. This analysis is guided by two theories: Strong/Weak Ties Theory and Social Penetration Theory. Qualitative data will be analyzed using content analysis, and we will complete descriptive statistics on the quantified variables (eg, average number of ties). Institutional review board approval was obtained in June 2016. RESULTS: This study is in progress. CONCLUSIONS: Interventions provided through virtual environments are a promising solution to increasing self-management practices. However, little is known of the depth, breadth, and quality of social support that is exchanged and how interaction supports self-management and relates to health outcomes. This study will provide knowledge that will help guide clinical practice and policy to enhance social support for chronic illness via the Internet.

Increasing EHR system usability through standards: Conformance criteria in the HL7 EHR-system functional model.

Though substantial work has been done on the usability of health information technology, improvements in electronic health record system (EHR) usability have been slow, creating frustration, distrust of EHRs and the use of potentially unsafe work-arounds. Usability standards could be part of the solution for improving EHR usability. EHR system functional requirements and standards have been used successfully in the past to specify system behavior, the criteria of which have been gradually implemented in EHR systems through certification programs and other national health IT strategies. Similarly, functional requirements and standards for usability can help address the multitude of sequelae associated with poor usability. This paper describes the evidence-based functional requirements for usability contained in the Health Level Seven (HL7) EHR System Functional Model, and the benefits of open and voluntary EHR system usability standards.

Facilitating palliative care referrals in the intensive care unit: a pilot project.

BACKGROUND: Palliative care in intensive care units (ICUs) reduces costs and improves outcomes yet is consistently underused; studies suggest that screening tools increase the use of palliative services. AIMS: This project piloted the use of the Palliative Performance Scale, version 2 (PPSv2), as a trigger for palliative care referrals in a 12-bed medical ICU. METHODS: Using a preintervention-postintervention design, the authors measured the effect of the intervention on nurses' comfort and knowledge in assessing palliative care needs, number of palliative care referrals, and number of days between ICU admission and palliative care referral. The authors also measured uptake of the scale over 12 weeks of implementation and asked nurses to share their thoughts about using the PPSv2. RESULTS: Over 610 observations, the rate of uptake increased over time and use of the scale ranged from 24.2% to 85.6%. The nurses' (n = 26) comfort with palliative care issues increased from preintervention to postintervention, albeit not significantly. Knowledge items did not change. There was a 110% increase in the number of palliative care referrals between preintervention and postintervention and a nearly 1-day decrease in the number of days between medical ICU admission and palliative care referral; this reduction was not statistically significant. A majority of nurses (n = 22 [84.5%]) voted to retain the PPSv2 as an official process of care, stating that the tool facilitated assessment of patient needs that might have been previously overlooked. CONCLUSION: Data suggest that the PPSv2 was well received by the bedside nurses and changed practice patterns with regard to facilitating palliative care services.

Diabetes Learning in Virtual Environments: Testing the Efficacy of Self-Management Training and Support in Virtual Environments (Randomized Controlled Trial Protocol).

BACKGROUND: Ongoing self-management improves outcomes for those with Type 2 diabetes (T2D); however, there are many barriers to patients receiving assistance in this from the healthcare system and peers. Findings from our pilot study showed that a virtual diabetes community on the Internet with real-time interaction among peers with T2D-and with healthcare professionals-is feasible and has the potential to influence clinical and psychosocial outcomes. OBJECTIVE: The purpose of this article is to present the protocol for the Diabetes Learning in Virtual Environments (LIVE) trial. PROTOCOL: Diabetes LIVE is a two-group, randomized controlled trial to compare effects of a virtual environment and traditional Web site on diet and physical activity. Our secondary aims will determine the effects on metabolic outcomes; effects of level of engagement and social network formation in LIVE on behavioral outcomes; potential mediating effects of changes in self-efficacy; and diabetes knowledge, diabetes-related distress, and social support on behavior change and metabolic outcomes. We will enroll 300 subjects at two sites (Duke University/Raleigh-Durham, NC and New York University/New York, NY) who have T2D and do not have serious complications or comorbidities. Those randomly assigned to the intervention group have access to the LIVE site where they can find information, synchronous classes with diabetes educators, and peer support to enhance self-management. Those in the control group have access to the same informational and educational content in a traditional asynchronous Web format. Measures of self-management, clinical outcomes, and psychosocial outcomes are assessed at baseline and 3, 6, 12, and 18 months. DISCUSSION: Should LIVE prove effective in improved self-management of diabetes, similar interventions could be applied to other prevalent chronic diseases. Innovative programs such as LIVE have potential for improving healthcare access in an easily disseminated alternative model of care that potentially improves the reach of self-management training and support.

Factors Affecting Accuracy of Data Abstracted from Medical Records.

OBJECTIVE: Medical record abstraction (MRA) is often cited as a significant source of error in research data, yet MRA methodology has rarely been the subject of investigation. Lack of a common framework has hindered application of the extant literature in practice, and, until now, there were no evidence-based guidelines for ensuring data quality in MRA. We aimed to identify the factors affecting the accuracy of data abstracted from medical records and to generate a framework for data quality assurance and control in MRA. METHODS: Candidate factors were identified from published reports of MRA. Content validity of the top candidate factors was assessed via a four-round two-group Delphi process with expert abstractors with experience in clinical research, registries, and quality improvement. The resulting coded factors were categorized into a control theory-based framework of MRA. Coverage of the framework was evaluated using the recent published literature. RESULTS: Analysis of the identified articles yielded 292 unique factors that affect the accuracy of abstracted data. Delphi processes overall refuted three of the top factors identified from the literature based on importance and five based on reliability (six total factors refuted). Four new factors were identified by the Delphi. The generated framework demonstrated comprehensive coverage. Significant underreporting of MRA methodology in recent studies was discovered. CONCLUSION: The framework generated from this research provides a guide for planning data quality assurance and control for studies using MRA. The large number and variability of factors indicate that while prospective quality assurance likely increases the accuracy of abstracted data, monitoring the accuracy during the abstraction process is also required. Recent studies reporting research results based on MRA rarely reported data quality assurance or control measures, and even less frequently reported data quality metrics with research results. Given the demonstrated variability, these methods and measures should be reported with research results.

Utilization of electronic modified early warning score to engage rapid response team early in clinical deterioration.

After implementation of electronic modified early warning score to engage the rapid response team as a clinical decision support tool, we assessed the knowledge level about and usage of the tool by core staff. We identified a knowledge deficit, planned and implemented an educational intervention, and measured the outcome of the intervention. The outcome measurement indicated improved use of the clinical decision support tool by core staff and improved patient rescue strategies.

mHealth interventions for weight loss: a guide for achieving treatment fidelity.

UNLABELLED: mHealth interventions have shown promise for helping people sustain healthy behaviors such as weight loss. However, few have assessed treatment fidelity, that is, the accurate delivery, receipt, and enactment of the intervention. Treatment fidelity is critical because the valid interpretation and translation of intervention studies depend on treatment fidelity assessments. We describe strategies used to assess treatment fidelity in mobile health (mHealth) interventions aimed at sustaining healthy behaviors in weight loss. We reviewed treatment fidelity recommendations for mHealth-based behavioral interventions and described how these recommendations were applied in three recent weight loss studies. We illustrate how treatment fidelity can be supported during study design, training of providers, treatment delivery, receipt of treatment, and enactment of treatment skills. Pre-planned strategies to ensure the treatment fidelity of mHealth interventions will help counter doubts concerning valid conclusions about their effectiveness and allow investigators and clinicians to implement robustly efficacious mobile health programs. TRIAL REGISTRATION NUMBER: 1F31 NR012599.

A theoretical framework for a virtual diabetes self-management community intervention.

Due to its high prevalence, chronic nature, potential complications, and self-management challenges for patients, diabetes presents significant health education and support issues. We developed and pilot-tested a virtual community for adults with type 2 diabetes to promote self-management education and provide social support. Although digital-based programs such as virtual environments can address significant barriers to reaching patients (i.e., child care, transportation, location), they must be strongly grounded in a theoretical basis to be well-developed and effective. In this article, we discuss how we synthesized behavioral and virtual environment theoretical frameworks to guide the development of SLIDES (Second Life Impacts Diabetes Education and Support).