Chinese Immigrant Caregivers: Understanding Their Unmet Needs and the Co-Design of an mHealth App.

BACKGROUND: Immigrant caregivers support the aging population, yet their own needs are often neglected. Mobile technology-facilitated interventions can promote caregiver health by providing easy access to self-care materials. OBJECTIVE: This study employed a design thinking framework to examine Chinese immigrant caregivers' (CICs) unmet self-care needs and co-design an app for promoting self-care with CICs. METHODS: Nineteen semi-structured interviews were conducted in conceptual design and prototype co-design phases. FINDINGS: Participants reported unmet self-care needs influenced by psychological and social barriers, immigrant status, and caregiving tasks. They expressed the need to learn to keep healthy boundaries with the care recipient and respond to emergencies. Gaining knowledge was the main benefit that drew CICs' interest in using the self-care app. However, potential barriers to use included issues of curriculum design, technology anxiety, limited free time, and caregiving burdens. DISCUSSION: The co-design process appears to be beneficial in having participants voice both barriers and preferences.

Care Me Too, a Mobile App for Engaging Chinese Immigrant Caregivers in Self-Care: Qualitative Usability Study.

BACKGROUND: Caregiving and self-care are challenging for Chinese immigrants in the United States due to limited accessible support and resources. Few interventions exist to assist Chinese immigrant caregivers in better performing self-care. To address this gap in the literature, our team developed the Care Me Too app to engage Chinese immigrant caregivers in self-care and conducted a user experience test to assess its usability and acceptability. OBJECTIVE: This paper aims to report the results of the app's usability and acceptability testing with Chinese immigrant caregivers and to solicit participants' feedback of the app design and functions. METHODS: A total of 22 Mandarin-speaking Chinese caregivers participated in the study, which consisted of 2 parts: the in-lab testing and the 1-week at-home testing. In-depth face-to-face interviews and follow-up phone interviews were used to assess user experience of the app's usability and acceptability and to solicit feedback for app design and functions. Directed content analysis was used to analyze the qualitative data. RESULTS: Among the 22 participants, the average age was 60.5 (SD 8.1) years, ranging from 46 to 80 years; 17 (77%) participants were women and 14 (64%) had an associate degree or higher. Participants reported uniformly positive ratings of the usability and acceptability of the app and provided detailed suggestions for app improvement. We generated guidelines for mobile health (mHealth) app designs targeting immigrant caregivers, including weighing flexibility versus majority preferences, increasing text sizes, using colors effectively, providing engaging and playful visual designs and functions, simplifying navigation, simplifying the log-in process, improving access to and the content on the help document, designing functions to cater to the population's context, and ensuring offline access. CONCLUSIONS: The main contribution of this study is the improved understanding of Chinese caregivers' user experiences with a language-appropriate mHealth app for a population that lacks accessible caregiving and self-care resources and support. It is recommended that future researchers and app designers consider the proposed guidelines when developing mHealth apps for their population to enhance user experience and harness mHealth's value.

Peer influences: the impact of online and offline friendship networks on adolescent smoking and alcohol use.

PURPOSE: Online social networking sites (SNSs) have become a popular mode of communication among adolescents. However, little is known about the effects of social online activity on health behaviors. The authors examined the use of SNSs among friends and the degree to which SNS activities relate to face-to-face peer influences and adolescent risk behaviors. METHODS: Longitudinal egocentric friendship network data along with adolescent social media use and risk behaviors were collected from 1,563 10th-grade students across five Southern California high schools. Measures of online and offline peer influences were computed and assessed using fixed-effects models. RESULTS: The frequency of adolescent SNS use and the number of their closest friends on the same SNSs were not significantly associated with risk behaviors. However, exposure to friends' online pictures of partying or drinking was significantly associated with both smoking (ß = .11, p < .001) and alcohol use (ß = .06, p < .05). Whereas adolescents with drinking friends had higher risk levels for drinking, adolescents without drinking friends were more likely to be affected by higher exposure to risky online pictures (ß = -.10, p < .05). Myspace and Facebook had demographically distinct user characteristics and differential effects on risk behaviors. CONCLUSIONS: Exposure to risky online content had a direct impact on adolescents' risk behaviors and significantly interacted with risk behaviors of their friends. These results provide evidence that friends' online behaviors should be considered a viable source of peer influence and that increased efforts should focus on educating adolescents on the negative effects of risky online displays.

mHealth approaches to child obesity prevention: successes, unique challenges, and next directions.

Childhood obesity continues to be a significant public health issue. mHealth systems offer state-of-the-art approaches to intervention design, delivery, and diffusion of treatment and prevention efforts. Benefits include cost effectiveness, potential for real-time data collection, feedback capability, minimized participant burden, relevance to multiple types of populations, and increased dissemination capability. However, these advantages are coupled with unique challenges. This commentary discusses challenges with using mHealth strategies for child obesity prevention, such as lack of scientific evidence base describing effectiveness of commercially available applications; relatively slower speed of technology development in academic research settings as compared with industry; data security, and patient privacy; potentially adverse consequences of increased sedentary screen time, and decreased focused attention due to technology use. Implications for researchers include development of more nuanced measures of screen time and other technology-related activities, and partnering with industry for developing healthier technologies. Implications for health practitioners include monitoring, assessing, and providing feedback to child obesity program designers about users' data transfer issues, perceived security and privacy, sedentary behavior, focused attention, and maintenance of behavior change. Implications for policy makers include regulation of claims and quality of apps (especially those aimed at children), supporting standardized data encryption and secure open architecture, and resources for research-industry partnerships that improve the look and feel of technology. Partnerships between academia and industry may promote solutions, as discussed in this commentary.

Social media microblogs as an HPV vaccination forum.

The 2006 US FDA approval of the human papillomavirus (HPV) vaccine brought new hope for cancer prevention. Gardasil and Cervarix are widely available vaccines that can deter HPV infection, which causes 70% of cervical cancer. Acceptance of vaccination varies due to a lack of HPV awareness and HPV vaccine knowledge. Recent observations of the Chinese microblog "SinaWeibo" suggest a new approach to engage health professionals and consumer website bloggers. Websites that present the latest fashion, fitness or beauty news and ways to obtain "deals" have created informative blogs or online communities that appeal to female users. Some users raise health questions of their peers. Health professionals, as website bloggers, can introduce vaccine news or respond to conversations between bloggers and their followers. By transforming medical vocabulary into ordinary chat, microblogs may promote efficiency in vaccine education and communication. A web-based, interactive social media-microblog could offer an ideal platform to speed up information dissemination and increase targeted communication.

Wellness partners: design and evaluation of a web-based physical activity diary with social gaming features for adults.

BACKGROUND: The United States is currently in an age of obesity and inactivity despite increasing public awareness and scientific knowledge of detrimental long-term health effects of this lifestyle. Behavior-tracking diaries offer an effective strategy for physical activity adherence and weight management. Furthermore, Web-based physical activity diaries can engage meaningful partners in people's social networks through fun online gaming interactions and generate motivational mechanisms for effective behavioral change and positive health outcomes. OBJECTIVE: Wellness Partners (WP) is a Web-based intervention in the form of a physical activity diary with social networking and game features. Two versions were designed and developed for the purpose of this study-"Diary" only and "Diary+Game". The objectives of this study included pilot testing the research process of this intervention design, implementation, evaluation, and exploring the effectiveness of social gaming features on adult participants' physical activity and anthropometric measures. METHODS: We conducted a field experiment with randomized crossover design. Assessments occurred at baseline, first follow-up (FU, 5-8 weeks after using one version of WP), and second FU (5-8 weeks of using the other version of WP). In the control condition, participants started with the "Diary" version of WP while in the experimental condition, participants started with the "Diary+Game" version of WP. A total of 54 adults (egos) ages 44-88, and their family and friends (alters) ages 17-69 participated in the study in ego-network groups. Both egos and their alters completed online surveys about their exercise habits. In addition, egos completed anthropometric measurements of BMI, fat percentage, and fat mass by bioimpedance. RESULTS: From October 2009 to May 2010, flyers, emails, and Web advertisements yielded 335 volunteers who were screened. Rolling recruitment resulted in enrollment of 142 qualified participants in 54 ego-network groups, which were randomly assigned to a study condition. The final analytic sample included 87 individuals from 41 groups. Data were collected from December 2009 to August 2010, and data analysis was completed in 2011. Overall, the participants were given access to the intervention for 10-13 weeks. Statistical analysis suggested an increase in self-reported exercise frequency (mean days per week) from baseline (2.57, SD 1.92) to first FU (3.21, SD 1.74) in both conditions. Stronger effects were seen in the condition where Diary+Game was played first, especially in network groups with larger age variation between the alters and egos. Overall, the decrease in egos' BMI was statistically significant from baseline to first FU, with greater decrease for those in the Diary+Game first condition (-0.26 vs -0.16 in the Diary first condition). CONCLUSIONS: The Wellness Partners program increased physical activity among participants and resulted in health benefits among the egos. Web-based diary interventions designed with social gaming features hold potential to promote active lifestyles for middle-age adults and people in their social networks.

Tai chi and reduction of depressive symptoms for older adults: a meta-analysis of randomized trials.

The aim of the present article was to systematically review the effectiveness of tai chi for reducing depressive symptoms among older adults. Electronic databases were searched through January 2011. Reference lists of systematic reviews and identified studies from the search strategy were also screened. Randomized controlled trials of tai chi compared with waiting list controls in older adults with depressive symptoms measured by a self-report depression rating scale were included. Two authors independently identified eligible studies, extracted data and assessed the included studies for risk of bias. Estimates of depressive symptoms reduction used a random effects model, and the I(2) statistic was applied to examine heterogeneity. Four trials with a total of 253 participants met the inclusion criteria. Two studies were assessed as being of high quality; the remaining two studies were rated as moderate quality. All four studies compared tai chi with a waiting list control group. The pooled standard mean difference for these studies was -0.27 (95% CI -0.52 to -0.02, P=0.03). Tai chi appeared to have a significant impact on reducing depressive symptoms compared with the waiting list control groups. Further research is recommended with larger sample sizes, more clarity on trial design and the intervention, longer-term follow up, and concomitant economic evaluations.

Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised Controlled Trial.

BACKGROUND: Older people are at risk for health decline and loss of independence. Lifestyle interventions offer potential for reducing such negative outcomes. The aim of this study was to determine the effectiveness and cost-effectiveness of a preventive lifestyle-based occupational therapy intervention, administered in a variety of community-based sites, in improving mental and physical well-being and cognitive functioning in ethnically diverse older people. METHODS: A randomised controlled trial was conducted comparing an occupational therapy intervention and a no-treatment control condition over a 6-month experimental phase. Participants included 460 men and women aged 60-95 years (mean age 74.9 ± 7.7 years; 53% <$12000 annual income) recruited from 21 sites in the greater Los Angeles metropolitan area. RESULTS: Intervention participants, relative to untreated controls, showed more favourable change scores on indices of bodily pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and depressive symptomatology (ps<0.05). The intervention group had a significantly greater increment in quality-adjusted life years (p<0.02), which was achieved cost-effectively (US $41218/UK £24868 per unit). No intervention effect was found for cognitive functioning outcome measures. CONCLUSIONS: A lifestyle-oriented occupational therapy intervention has beneficial effects for ethnically diverse older people recruited from a wide array of community settings. Because the intervention is cost-effective and is applicable on a wide-scale basis, it has the potential to help reduce health decline and promote well-being in older people. Trial Registration clinicaltrials.gov identifier: NCT0078634.

Predictors of computer use in community-dwelling, ethnically diverse older adults.

OBJECTIVE: In this study, we analyzed self-reported computer use, demographic variables, psychosocial variables, and health and well-being variables collected from 460 ethnically diverse, community-dwelling elders to investigate the relationship computer use has with demographics, well-being, and other key psychosocial variables in older adults. BACKGROUND: Although younger elders with more education, those who employ active coping strategies, or those who are low in anxiety levels are thought to use computers at higher rates than do others, previous research has produced mixed or inconclusive results regarding ethnic, gender, and psychological factors or has concentrated on computer-specific psychological factors only (e.g., computer anxiety). Few such studies have employed large sample sizes or have focused on ethnically diverse populations of community-dwelling elders. METHOD: With a large number of overlapping predictors, zero-order analysis alone is poorly equipped to identify variables that are independently associated with computer use. Accordingly, both zero-order and stepwise logistic regression analyses were conducted to determine the correlates of two types of computer use: e-mail and general computer use. RESULTS: Results indicate that younger age, greater level of education, non-Hispanic ethnicity, behaviorally active coping style, general physical health, and role-related emotional health each independently predicted computer usage. CONCLUSION: Study findings highlight differences in computer usage, especially in regard to Hispanic ethnicity and specific health and well-being factors. APPLICATION: Potential applications of this research include future intervention studies, individualized computer-based activity programming, or customizable software and user interface design for older adults responsive to a variety of personal characteristics and capabilities.

Confronting challenges in intervention research with ethnically diverse older adults: the USC Well Elderly II Trial.

BACKGROUND: Community-dwelling older adults are at risk for declines in physical health, cognition, and psychosocial well-being. However, their enactment of active and health-promoting lifestyles can reduce such declines. PURPOSE: The purpose of this article is to describe the USC Well Elderly II study, a randomized clinical trial designed to test the effectiveness of a healthy lifestyle program for elders, and document how various methodological challenges were addressed during the course of the trial. METHODS: In the study, 460 ethnically diverse elders recruited from a variety of sites in the urban Los Angeles area were enrolled in a randomized experiment involving a crossover design component. Within either the first or second 6-month phase of their study involvement, each elder received a lifestyle intervention designed to improve a variety of aging outcomes. At 4-5 time points over an 18-24 month interval, the research participants were assessed on measures of healthy activity, coping, social support, perceived control, stress-related biomarkers, perceived physical health, psychosocial well-being, and cognitive functioning to test the effectiveness of the intervention and document the process mechanisms responsible for its effects. RESULTS: The study protocol was successfully implemented, including the enrollment of study sites, the recruitment of 460 older adults, administration of the intervention, adherence to the plan for assessment, and establishment of a large computerized data base. LIMITATIONS: Methodological challenges were encountered in the areas of site recruitment, participant recruitment, testing, and intervention delivery. CONCLUSIONS: The completion of clinical trials involving elders from numerous local sites requires careful oversight and anticipation of threats to the study design that stem from: (a) social situations that are particular to specific study sites; and (b) physical, functional, and social challenges pertaining to the elder population.

Fictive kin: friends as family supporting older adults as they age.

Assessing social support or social capital is receiving renewed attention in health care. A search of the nursing literature revealed limited attention to a potential resource in the care of older adults--fictive kin. Transdisciplinary searches indicated that "fictive kin" or "chosen kin" are increasingly important as family size shrinks and older adults live longer lives. Fictive kin are common across cultural groups and some have designated special names for these quasi-family members. The purpose of this article is to advance the concept of fictive kin as a resource for older adults and to provide strategies to promote engagement of fictive kin in health care planning by nurses.

The social ecology of changing pain management: do I have to cry?

OBJECTIVE: To improve acute pain management for children with systematic assessment and appropriate analgesia. DESIGN: An action research design was used; pre-post data were collected during a four-phase intervention. The intervention was a social ecological approach to changing pain assessment and prescription practices. SETTING: A university-affiliated public hospital in the greater Los Angeles area. PARTICIPANTS: An interdisciplinary team of clinicians and hospital administrators were engaged in implementing new pain management procedures for children with postoperative and procedural pain. INTERVENTIONS: We implemented the Poker Chip Tool as a standard pain assessment tool, changed policy to make morphine drug of choice for acute postoperative pain, provided extensive educational activities, and conducted weekly rounds with anesthesiologist/intensivist, nurses, pharmacist, and child life specialist. Role modeling by leaders was used to build skill in interdisciplinary collaboration for staff. We promoted the initiative as an activity of the medical center strategic plan. Efforts were linked to national shifts in pain management through guideline review and use of a visiting expert. OUTCOME MEASURES: Charts were audited for assessment of pain intensity. Doses dispensed by pharmacy were used as a proxy measure of analgesia administered to children to establish change in pattern of analgesic use. RESULTS: In Phase I: 54% of charts audited had documentation of pain intensity. This rate climbed to Phase II, 93% of the audited charts at full implementation and stabilized at 84% at the project conclusion. Record of doses of analgesia dispensed demonstrated a shift from reliance on meperidine to morphine and acetaminophen with codeine. The relative rates demonstrated a 100% increase in acetaminophen with codeine distributed from the beginning of the study to full implementation of the project (chi(2) = 9.01, df = 1, p < 0.002). The relative rate for meperidine demonstrated a 250% decrease (chi(2) = 12.26, df = 1, p < 0.0004), and the relative rate for morphine exhibited a 455% increase (chi(2) = 209.20, df = 1, p < 0.0001). By the final phase (IV: Evaluation), meperidine was only 1% of the analgesia dispensed. Morphine doses that were initially 35% climbed to 62% at the close of the study. Acetaminophen with codeine shifted correspondingly from 24% to 36%. Anecdotal reports suggested that skills in assessment and building collaboration generalized to other patient care situations. CONCLUSIONS: Using a social ecology approach that focused simultaneously on the environment (ward, medical center, and national scene) and relationships among the clinical team improved pain management practices. These changes took place over 2 years and were sustained 2 years after the intense intervention.

Culture & risk taking in adolescents' behaviors.

Adolescents constitute the only segment of the population in the United States that has not seen a decrease in its mortality and morbidity over the last 4 decades. The Centers for Disease Control and Prevention has identified six risk-taking behaviors that place adolescents at risk: unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors, and physical inactivity. This list is of particular concern for the increasingly diverse racial and ethnic youth of America who have been disproportionately affected by both morbidity and mortality from risk behaviors. To effectively care for this segment of the population, healthcare professionals need to become culturally competent. In so doing, it is also important to recognize traditional cultural values, and to acknowledge personal attributes of adolescents to promote healthy lifestyle choices and deter risk-taking behaviors.

Health-seeking behaviors of elderly Chinese Americans: shifts in expectations.

PURPOSE: This study reported a qualitative analysis of health-seeking behaviors of community-dwelling elderly Chinese Americans on the influences of family network, cultural values, and immigrant experience in their use of health resources. Barriers to health care, pathway of health care, and adaptation of health care by use of self-treatment and Eastern and Western medicines were also examined. DESIGN AND METHODS: The investigators used content analysis to obtain themes and key points of focus group interview data (N = 25) to explore the elderly participants' attitudes, values, and practices in their use of health resources. Survey questionnaires in Chinese were used to compile demographic data. RESULTS: Findings suggested a shift from traditional expectations of filial piety to more dependence on neighbors and friends, and a genuine adaptability to combining Eastern and Western health care modalities. Immigration was not proposed by these Chinese elders as an explanation of shifts in expectations for family support or values. IMPLICATIONS: This study has implications for research, service delivery, and policy making for health care of ethnic elderly persons, particularly in addressing structural and cultural issues in access and compliance.