Designing Feedback Visualizations for Anti-Hypertensive Medication Adherence for Older Adults.

Adhering to anti-hypertensive medications contributes to control of blood pressure and improved health outcomes. However, adherence rates among older adults are low. Patient monitoring of medication taking helps increase adherence and technology has great potential to support self-monitoring, in part by providing visual feedback about medication taking performance. However, little attention has been paid to designing feedback visualizations in medication-monitoring technology for older adults. In this research, we identified guidelines for designing understandable and effective adherence visualizations for older adults from existing theories and literature. With the guidelines in mind, we designed, refined, and evaluated visualizations that provided adherence feedback for a smartphone application with 17 older participants. Based on theory and evidence, we identified design guidelines for feedback visualizations. These guidelines can support design of useful feedback visualizations that may improve medication adherence among older adults.

Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR.

The ubiquity of EHRs in healthcare means that small EHR inefficiencies can have a major impact on clinician workload. We conducted a sequential explanatory mixed methods study to: 1) identify EHR-associated workload and usability effects for clinicians following an EHR change over time, 2) determine workload and usability differences for providers (MD and Advance Practice Nurses) versus nurses (RNs and MAs), 3) determine if usability predicts workload, 4) identify potential sources of EHR design flaws. Workload (NASA-Task Load Index) and usability (System Usability Scale) measures were administered pre, 6-8 month and 30-32 months post-implementation. We found significant increase in perceived workload post-implementation that persisted for 2.5 years (p < .001). The workload increase was associated with usability ratings, which in turn may relate to EHR interface design violations identified by a heuristic evaluation. Our findings suggest further innovation and attention to interface design flaws are needed to improve EHR usability and reduce clinician workload.

Health Literacy, Processing Capacity, Illness Knowledge, and Actionable Memory for Medication Taking in Type 2 Diabetes: Cross-Sectional Analysis.

BACKGROUND: Patient knowledge about the purpose of medications is crucial to ensure safe and correct use, so it is an important index of adherence in patients with chronic illness. OBJECTIVE: We examined how health literacy and its components (processing capacity and knowledge about illness) influence memory for medication purposes. DESIGN: We conducted a cross-sectional study to examine memory for medication purposes in relation to health literacy, processing capacity, and illness knowledge among patients with diabetes in outpatient clinics. PARTICIPANTS: Six hundred seventy-four adults who were diagnosed with type II diabetes mellitus, age 40 years or older, taking 5 or more current medications, native speakers of English, and with glycosylated hemoglobin (HbA1c) of 6.0 or more, were recruited to the study. MAIN MEASURES: We included measures of processing capacity, illness knowledge, health literacy, and actionable memory for medication taking (memory for medication purpose). KEY RESULTS: Results suggested an association between health literacy and both processing capacity and health knowledge, with some evidence that knowledge can compensate for limited processing capacity in order to maintain health literacy. Furthermore, health literacy was associated with memory for medication purposes, with processing capacity and health knowledge partly mediating this association. This pattern of results supports the process-knowledge model of health literacy. CONCLUSIONS: Our findings establish the role of health literacy in medication taking, in relation to broader cognitive abilities and knowledge. Implications for improving the learning of medication purpose among diverse older adults with chronic illness are discussed. TRIAL REGISTRATION: NIH trial registry number: NCT01296633.

Risk perception, decision-making, and risk communication in the time of COVID-19.

After first being declared a pandemic by the World Health Organization [WHO], (2020) in March 2020, coronavirus disease (COVID-19) spread rapidly and in the process altered our very way of life. At the same time, it became increasingly clear that a wide range of new behavioral science research was necessary to understand fully how people comprehend and respond to such an unprecedented and long lasting health threat as COVID-19. One of the primary aims for this Special Issue was to gather and publish that research. The studies contained in this Special Issue, conducted between April 2020 and March 2021, were selected to represent experimental research that is relevant to this unique situation and that also inform and extend existing theory. These studies investigate three broad topics: Risk perception, decision-making under risk, and risk communication in the context of COVID-19. Collectively, they advance our knowledge of risk calibration, health communication interventions, and decisions about behaviors that address risk in the context of a global health threat. Perhaps most importantly they also make a practical contribution to how we approach these issues going forward. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Framework for Design of Conversational Agents to Support Health Self-Care for Older Adults.

OBJECTIVE: We examined the potential of conversational agents (CAs) to support older adults' self-care related to chronic illness in light of lessons learned from decades of pedagogical agent research, which investigates the impact and efficacy of CAs for a wide range of learners. BACKGROUND: The role of CAs in education (i.e., pedagogical agents) has been long studied, but their potential for supporting self-care has received less attention, especially for older adults. METHODS: We reviewed work on pedagogical agents and considered how it informs the design of CAs for older adults. We propose a framework for designing CAs to support older adult self-care, which organizes a review of work in this area and integration with the pedagogical agent literature. RESULTS: Our review of the pedagogical agent literature revealed an evolution from teaching machines to interactive, social systems that influence student motivational as well as learning outcomes. To integrate this review with work on CAs and self-care, we developed a framework that specifies how self-care goals evolve with stages of an illness, communication goals that support self-care at each stage, patient needs, and requirements for CAs to support these needs. The review identified an agenda for future research on CA functions and features that help older adults accept need for self-care, establish self-care, and sustain self-care over time. CONCLUSIONS: Integrating insights from the pedagogical agent literature with research on developing CAs for self-care defines an agenda for developing and evaluating CAs to help older adults manage illness.

Stress Measurement of a Pressurized Vessel Using Ultrasonic Subsurface Longitudinal Wave With 1-3 Composite Transducers.

This article aims to develop a stress-sensing method for a pressurized vessel based on subsurface longitudinal (SSL) waves confined in a specific waveform by using 1-3 composite transducers. Although ultrasonic SSL waves have been commonly utilized for stress sensing, wave excitation under the predefined function using the composite-type transmitter is not well studied. In this article, composite-type transducers having a wide frequency bandwidth (> 60%) and a predominant thickness mode are utilized to enhance the signal intensity of the SSL wave and the accuracy of the sensor by incorporating a specific toneburst waveform. Finite element analysis demonstrates that the signal intensity of the composite-type transducer is up to 45.3% higher than that of a single-phase transducer. Pulse-echo tests reveal that the frequency bandwidth of the developed transducer reaches up to 60.7% and is, therefore, sufficient (> 57.0%) to transmit and receive Hanning-windowed toneburst signals. Results of stress sensing affirm a linear relationship between the time delay of SSL wave and the mechanical stress of a pressurized vessel (0.335 ns/MPa). Accordingly, the regression model is constructed via principal component regression (PCR) under temperature-varying condition. PCR has a less significant degree of error (0.62 MPa) compared to that of a typical least square regression (9.49 MPa).

Preliminary evaluation of a self-guided fall risk assessment tool for older adults.

Falls are a major health problem for older adults with significant physical and psychological consequences. The first step of successful fall prevention is to identify those at risk of falling. Recent technology advancement offers the possibility of objective, lowcost and self-guided fall risk assessment. The present work evaluated the preliminary validity and usability of a Kinect camera-based selfinitiated fall risk assessment system in a hospital setting. A convenience sample of 29 female participants (77.5 ± 7.9 years old) enrolled in this study. This low-cost self-guided system included a Kinect depth-sensing camera, a PC-based computer, and custom-built software. An onscreen Fall Risk Assessment Avatar (FRAAn) utilizing visual and verbal instructions led participants through a fall risk assessment consisting of self-report measures and clinically validated balance and mobility tests. Participants also completed clinical fall risk evaluation (Timed-Up and Go, and Berg Balance Scale) led by a researcher. User experience was evaluated by the System Usability Scale (SUS). Results indicate that FRAAn-based outcome measures (postural sway metrics, and sit-to-stand speed) were highly correlated with clinical fall risk measures, and were able to differentiate individuals with increased fall risk. Additionally, 83% participants reported high usability (SUS > 80), indicating the system is well received among older users. Overall, our results indicate that the FRAAn system has promise for providing a self-guided fall risk assessment, and is well received by older users. This affordable, portable and self-guided system has potential to facilitate objective fall risk assessment in older adults in various settings.

Contextualizing numeric clinical test results for gist comprehension: Implications for EHR patient portals.

Patient portals to Electronic Health Record (EHR) systems are underused by older adults because of limited system usability and usefulness, including difficulty understanding numeric information. We investigated whether enhanced context for portal messages about test results improved responses to these messages, comparing verbally, graphically, and video-enhanced formats. Older adults viewed scenarios with fictitious patient profiles and messages describing results for these patients from cholesterol or diabetes screening tests indicating lower, borderline, or higher risk levels. These messages were conveyed by standard format (table of numerical test scores) or one of the enhanced formats. Verbatim and gist memory for test results, risk perception, affective response, attitude toward and intention to perform self-care behaviors, and satisfaction were measured. Verbally and video enhanced context improved older adults' gist but not verbatim memory compared to the standard format, suggesting we were successful in designing messages that highlight gist-based information. Little evidence was found for benefits related to the graphically enhanced format. Although verbally and video enhanced formats improved gist memory and message satisfaction, they had less impact on the other responses to the messages. However, these responses reflected level of risk: As risk associated with test results increased, positive affect decreased whereas negative affect, perceived risk, behavioral attitudes, and intentions increased, as predicted by behavioral change theories. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pharmacy-Based Approach to Improving Heart Failure Medication Use by Older Adults with Limited Health Literacy: Learning from Interdisciplinary Experience.

Heart failure is a chronic disease requiring careful attention to self-care. Patients must follow instructions for diet and medication use to prevent or delay a decline in functional status, quality of life, and expensive care. However, there is considerable heterogeneity in heart failure patients' knowledge of important care routines, their cognition, and their health literacy, which predict the ability to implement self-care. Our interdisciplinary team of cognitive scientists with health literacy expertise, pharmacists, and physicians spent 18 years designing and testing protocols and materials to assist ambulatory heart failure patients with their care. Our approach is theory- as well as problem-driven, guided by our process-knowledge model of health literacy as it relates to self-care among older adult outpatients with either heart failure or hypertension. We used what we had learned from this model to develop a pharmacy-based protocol and tailored patient instruction materials that were the central component of a randomized clinical trial. Our results showed improved adherence to cardiovascular medications, improved health outcomes and patient satisfaction, and direct cost reductions. These results demonstrate the value of our interdisciplinary efforts for developing strategies to improve instruction and communication with attention to health literacy, which are core components of pharmacy and other ambulatory healthcare services. We believe attention to health literacy with medication use will result in improved health outcomes for older adult patients with heart failure and other complex chronic diseases.

Publishing papers that matter.

Daniel G. Morrow introduces himself as the fifth editor of the Journal of Experimental Psychology: Applied (JEPA). The journal is the premier outlet for "use-inspired basic research" (Stokes, 2011) in the psychological sciences. (PsycINFO Database Record

A Multi-faceted Approach to Promote Comprehension of Online Health Information Among Older Adults.

Purpose of the Study: Older adults' self-care often depends on understanding and utilizing health information. Inadequate health literacy among older adults poses a barrier to self-care because it hampers comprehension of this information, particularly when the information is not well-designed. Our goal was to improve comprehension of online health information among older adults with hypertension who varied in health literacy abilities. Design and Methods: We identified passages about hypertension self-care from credible websites (typical passages). We used a multi-faceted approach to redesign these passages, revising their content, language, organization and format (revised passages). Older participants read both versions of the passages at their own pace. After each passage, they summarized the passage and then answered questions about the passage. Results: Participants better remembered the revised than the typical passages, summarizing the passages more accurately and uptaking information more efficiently (less reading time needed per unit of information remembered). The benefits for reading efficiency were greater for older adults with more health knowledge, suggesting knowledge facilitated comprehension of information in the revised passages. Implications: A systematic, multi-faceted approach to designing health documents can promote online learning among older adults with diverse health literacy abilities.

A multidisciplinary approach to designing and evaluating Electronic Medical Record portal messages that support patient self-care.

We describe a project intended to improve the use of Electronic Medical Record (EMR) patient portal information by older adults with diverse numeracy and literacy abilities, so that portals can better support patient-centered care. Patient portals are intended to bridge patients and providers by ensuring patients have continuous access to their health information and services. However, they are underutilized, especially by older adults with low health literacy, because they often function more as information repositories than as tools to engage patients. We outline an interdisciplinary approach to designing and evaluating portal-based messages that convey clinical test results so as to support patient-centered care. We first describe a theory-based framework for designing effective messages for patients. This involves analyzing shortcomings of the standard portal message format (presenting numerical test results with little context to guide comprehension) and developing verbally, graphically, video- and computer agent-based formats that enhance context. The framework encompasses theories from cognitive and behavioral science (health literacy, fuzzy trace memory, behavior change) as well as computational/engineering approaches (e.g., image and speech processing models). We then describe an approach to evaluating whether the formats improve comprehension of and responses to the messages about test results, focusing on our methods. The approach combines quantitative (e.g., response accuracy, Likert scale responses) and qualitative (interview) measures, as well as experimental and individual difference methods in order to investigate which formats are more effective, and whether some formats benefit some types of patients more than others. We also report the results of two pilot studies conducted as part of developing the message formats.

Cognition and Health Literacy in Older Adults' Recall of Self-Care Information.

Purpose of the Study: Health literacy is associated with health outcomes presumably because it influences the understanding of information needed for self-care. However, little is known about the language comprehension mechanisms that underpin health literacy. Design and Methods: We explored the relationship between a commonly used measure of health literacy (Short Test of Functional Health Literacy in Adults [STOFHLA]) and comprehension of health information among 145 older adults. Results: Results showed that performance on the STOFHLA was associated with recall of health information. Consistent with the Process-Knowledge Model of Health Literacy, mediation analysis showed that both processing capacity and knowledge mediated the association between health literacy and recall of health information. In addition, knowledge moderated the effects of processing capacity limits, such that processing capacity was less likely to be associated with recall for older adults with higher levels of knowledge. Implications: These findings suggest that knowledge contributes to health literacy and can compensate for deficits in processing capacity to support comprehension of health information among older adults. The implications of these findings for improving patient education materials for older adults with inadequate health literacy are discussed.

Effects of a Patient-Provider, Collaborative, Medication-Planning Tool: A Randomized, Controlled Trial.

Among patients with various levels of health literacy, the effects of collaborative, patient-provider, medication-planning tools on outcomes relevant to self-management are uncertain. Objective. Among adult patients with type II diabetes mellitus, we tested the effectiveness of a medication-planning tool (Medtable™) implemented via an electronic medical record to improve patients' medication knowledge, adherence, and glycemic control compared to usual care. Design. A multicenter, randomized controlled trial in outpatient primary care clinics. 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months. Results. Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications. Patients' knowledge of drug indication improved with Medtable regardless of their literacy status. However, Medtable did not improve patients' demonstrated medication use, regimen adherence, or glycemic control (HbA1c). Conclusion. The Medtable tool supported provider/patient collaboration related to medication use, as reflected in patient satisfaction with communication, but had limited impact on patient medication knowledge, adherence, and HbA1c outcomes. This trial is registered with ClinicalTrials.gov NCT01296633.

Adult age differences in information foraging in an interactive reading environment.

When learning about a single topic in natural reading environments, readers are confronted with multiple sources varying in the type and amount of information. In this situation, readers are free to adaptively respond to the constraints of the environment (e.g., through selection of resources and time allocation for study), but there may be costs of exploring and switching between sources (e.g., disruption of attention, opportunity costs for study). From an ecological perspective, such properties of the environment are expected to influence learning strategies. In the current study, we used a novel reading paradigm to investigate age differences in the effects of information richness (i.e., sentence elaboration) and costs of switching between texts (i.e., time delay) on selection of sources and study time allocation. Consistent with the ecological view, participants progressed from less informative to more informative texts. Furthermore, increased switch cost led to a tendency to allocate more effort to easier materials and to greater persistence in reading, which in turn, led to better memory in both immediate and delayed recall. Older adults showed larger effects of switch cost, such that the age difference in delayed recall was eliminated in the high switch cost condition. Based on an ecological paradigm of reading that affords choice and self-regulation, our study provided evidence for preservation with age in the ability to adapt to changing learning environments so as to improve performance. (PsycINFO Database Record

Multifaceted Prospective Memory Intervention to Improve Medication Adherence.

OBJECTIVES: To test whether a multifaceted prospective memory intervention improved adherence to antihypertensive medications and to assess whether executive function and working memory processes moderated the intervention effects. DESIGN: Two-group longitudinal randomized control trial. SETTING: Community. PARTICIPANTS: Individuals aged 65 and older without signs of dementia or symptoms of severe depression who were self-managing prescribed medication. MEASUREMENTS: After 4 weeks of initial adherence monitoring using a medication event monitoring system, individuals with 90% or less adherence were randomly assigned to groups. INTERVENTION: The prospective memory intervention was designed to provide strategies that switch older adults from relying on executive function and working memory processes (that show effects of cognitive aging) to mostly automatic associative processes (that are relatively spared with normal aging) for remembering to take medications. Strategies included establishing a routine, establishing cues strongly associated with medication taking actions, performing the action immediately upon thinking about it, using a medication organizer, and imagining medication taking to enhance encoding and improve cuing. RESULTS: There was significant improvement in adherence in the intervention group (57% at baseline to 78% after the intervention), but most of these gains were lost after 5 months. The control condition started at 68% and was stable during the intervention, but dropped to 62%. Executive function and working memory moderated the intervention effect, with the intervention producing greater benefit for those with lower executive function and working memory. CONCLUSION: The intervention improved adherence, but the benefits were not sustained. Further research is needed to determine how to sustain the substantial initial benefits.

Information Foraging Across the Life Span: Search and Switch in Unknown Patches.

In this study, we used a word search puzzle paradigm to investigate age differences in the rate of information gain (RG; i.e., word gain as a function of time) and the cues used to make patch-departure decisions in information foraging. The likelihood of patch departure increased as the profitability of the patch decreased generally. Both younger and older adults persisted past the point of optimality as defined by the marginal value theorem (Charnov, 1976), which assumes perfect knowledge of the foraging ecology. Nevertheless, there was evidence that adults were rational in terms of being sensitive to the change in RG for making the patch-departure decisions. However, given the limitations in cognitive resources and knowledge about the ecology, the estimation of RG may not be accurate. Younger adults were more likely to leave the puzzle as the long-term RG incrementally decreased, whereas older adults were more likely to leave the puzzle as the local RG decreased. However, older adults with better executive control were more likely to adjust their likelihood of patch-departure decisions to the long-term change in RG. Thus, age-dependent reliance on the long-term or local change in RG to make patch-departure decisions might be due to individual differences in executive control.

Exploring relationships of human-automation interaction consequences on pilots: uncovering subsystems.

OBJECTIVE: We attempted to understand the latent structure underlying the systems pilots use to operate in situations involving human-automation interaction (HAI). BACKGROUND: HAI is an important characteristic of many modern work situations. Of course, the cognitive subsystems are not immediately apparent by observing a functioning system, but correlations between variables may reveal important relations. METHOD: The current report examined pilot judgments of 11 HAI dimensions (e.g., Workload, Task Management, Stress/Nervousness, Monitoring Automation, and Cross-Checking Automation) across 48 scenarios that required airline pilots to interact with automation on the flight deck. RESULTS: We found three major clusters of the dimensions identifying subsystems on the flight deck: a workload subsystem, a management subsystem, and an awareness subsystem. DISCUSSION: Relationships characterized by simple correlations cohered in ways that suggested underlying subsystems consistent with those that had previously been theorized. APPLICATION: Understanding the relationship among dimensions affecting HAI is an important aspect in determining how a new piece of automation designed to affect one dimension will affect other dimensions as well.

Response to bronchodilators in very preterm infants with evolving bronchopulmonary dysplasia.

BACKGROUND: There are few effective and safe medications to treat very low birth weight (VLBW) infants with evolving BPD. Bronchodilators are often given to patients who have clinical signs of reactive airway disease, but there is not enough information regarding their effectiveness within this population. OBJECTIVE: To quantify the pulmonary function response to bronchodilator therapy in a population of VLBW infants with evolving BPD. DESIGN/METHODS: This is a retrospective analysis of an ongoing large database of pulmonary function tests (PFTs) in premature infants. We reviewed pre and post bronchodilator PFTs ordered by a physician due to concern for reactive airway disease. Inclusion criteria: BW< 1500 grams; > 14 days of age; admission diagnosis of respiratory distress syndrome; requiring ongoing oxygen, CPAP or ventilator support at the time of PFT. PFTs were done prior to albuterol therapy and repeated 30 minutes after the therapy was given. PFTs included the measurement of passive respiratory mechanics with the single breath occlusion technique, including passive respiratory compliance (Crs), resistance (Rrs) and tidal volume (Vt). RESULTS: 40 VLBW infants (mean gestation of 27.4 weeks; mean birth weight (BW) of 848 grams) were identified as having PFTs. 29 of these patients had a BW of ≤ 1000 grams. Patients were studied at a mean corrected gestational age of 34.9 weeks. 29 of 40 were extubated at the time of the PFT. Of these patients, 21 (52.5%) had a decrease in Rrs of ≥10%. From the other 19 patients, 5 (12.5%) had a decrease of 0 to < 10% in Rrs, 14 (35%) showed no response to therapy. There was no significant difference in Crs between groups.

Recruitment of Older Adults: Success May Be in the Details.

PURPOSE: Describe recruitment strategies used in a randomized clinical trial of a behavioral prospective memory intervention to improve medication adherence for older adults taking antihypertensive medication. RESULTS: Recruitment strategies represent 4 themes: accessing an appropriate population, communication and trust-building, providing comfort and security, and expressing gratitude. Recruitment activities resulted in 276 participants with a mean age of 76.32 years, and study enrollment included 207 women, 69 men, and 54 persons representing ethnic minorities. Recruitment success was linked to cultivating relationships with community-based organizations, face-to-face contact with potential study participants, and providing service (e.g., blood pressure checks) as an access point to eligible participants. Seventy-two percent of potential participants who completed a follow-up call and met eligibility criteria were enrolled in the study. The attrition rate was 14.34%. IMPLICATIONS: The projected increase in the number of older adults intensifies the need to study interventions that improve health outcomes. The challenge is to recruit sufficient numbers of participants who are also representative of older adults to test these interventions. Failing to recruit a sufficient and representative sample can compromise statistical power and the generalizability of study findings.