The mental health workforce is insufficient to meet the current needs of service utilization, particularly with regards to geographic distribution and ethnoracial diversity. Technology-enabled services (TESs) have the potential to increase access by overcoming barriers related to clinician availability and geography. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a single-site six-month pilot implementation of myStrength, a digital cognitive-behavioral therapy platform, to explore its potential to reduce loneliness amongst isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. English and Spanish-speaking isolated older adults (N = 30) received a digital literacy course followed by eight weeks of myStrength access and human support from a nurse intern, promotore, or in- house county staff (N = 20). We evaluated factors related to reach, effectiveness, adoption, and implementation using self-report measures of platform users and pilot staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon Signed-Rank were used to examine pilot effectiveness. Results are as follows. Reach: Compared to overall county demographics, platform users were majority female (93.1% v. 50.5%), ethnoracialized (62.1% v. 24.2%) and of lower socioeconomic status (Md = $35,000 v. $131,008). Effectiveness: Users experienced a significant decrease in loneliness (z = −2.62, p < .001). Adoption: Users logged into myStrength an average of 10 times (SD = 11.7) and completed 33 activities (SD = 53.5) during the eight weeks of myStrength use. Implementation: Each pilot staff member spent an average of 19.8 hours (SD = 16.51), over the course of the six-month pilot, supporting several aspects of myStrength use, including accessing technology, onboarding, and gaining digital literacy skills. Furthermore, in presenting, discussing, and delivering myStrength, pilot staff made several adaptations to meet the needs of platform users. Our results revealed several challenges and opportunities. Successes included reaching the target population, reducing loneliness, and gaining adoption by platform users. However, pilot staff had to invest significant time in various activities to support those with lower digital literacy skills. Thus, although TESs hold the potential to address access needs, their use with underserved populations, may require upfront and ongoing support provided by the settings where they are implemented.

The COVID-19 pandemic has propelled patient-facing research to shift to digital and telehealth strategies. If these strategies are not adapted for minority patients of lower socioeconomic status, health inequality will further increase. Patient-centered models of care can successfully improve access and experience for minority patients.

This study aims to present the development process and preliminary acceptability of altering in-person onboarding procedures into internet-based, remote procedures for a mobile health (mHealth) intervention in a population with limited digital literacy.

We actively recruited safety-net patients (English- and Spanish-speaking adults with diabetes and depression who were receiving care at a public health care delivery system in San Francisco, United States) into a randomized controlled trial of text messaging support for physical activity. Because of the COVID-19 pandemic, we modified the in-person recruitment and onboarding procedures to internet-based, remote processes with human support. We conducted a preliminary evaluation of how the composition of the recruited cohort might have changed from the pre–COVID-19 period to the COVID-19 enrollment period. First, we analyzed the digital profiles of patients (n=32) who had participated in previous in-person onboarding sessions prior to the COVID-19 pandemic. Next, we documented all changes made to our onboarding processes to account for remote recruitment, especially those needed to support patients who were not very familiar with downloading apps onto their mobile phones on their own. Finally, we used the new study procedures to recruit patients (n=11) during the COVID-19 social distancing period. These patients were also asked about their experience enrolling into a fully digitized mHealth intervention.

Recruitment across both pre–COVID-19 and COVID-19 periods (N=43) demonstrated relatively high rates of smartphone ownership but lower self-reported digital literacy, with 32.6% (14/43) of all patients reporting they needed help with using their smartphone and installing apps. Significant changes were made to the onboarding procedures, including facilitating app download via Zoom video call and/or a standard phone call and implementing brief, one-on-one staff-patient interactions to provide technical assistance personalized to each patient’s digital literacy skills. Comparing recruitment during pre–COVID-19 and COVID-19 periods, the proportion of patients with digital literacy barriers reduced from 34.4% (11/32) in the pre–COVID-19 cohort to 27.3% (3/11) in the COVID-19 cohort. Differences in digital literacy scores between both cohorts were not significant (P=.49).

Patients of lower socioeconomic status have high interest in using digital platforms to manage their health, but they may require additional upfront human support to gain access. One-on-one staff-patient partnerships allowed us to provide unique technical assistance personalized to each patient’s digital literacy skills, with simple strategies to troubleshoot patient barriers upfront. These additional remote onboarding strategies can mitigate but not eliminate digital barriers for patients without extensive technology experience.

Clinicaltrials.gov NCT0349025, https://clinicaltrials.gov/ct2/show/NCT03490253

Background

Objective

Methods

Results

Conclusions

Trial registration

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.

Background

Objective

Methods

Results

Conclusions

Text messaging interventions can be an effective and efficient way to improve health behavioral changes. However, most texting interventions are neither tested nor designed with diverse end users, which could reduce their impact, and there is limited evidence regarding the optimal design methodology of health text messages tailored to low-income, low–health literacy populations and non-English speakers.

This study aims to combine participant feedback, crowdsourced data, and researcher expertise to develop motivational text messages in English and Spanish that will be used in a smartphone app–based texting intervention that seeks to encourage physical activity in low-income minority patients with diabetes diagnoses and depression symptoms.

The design process consisted of 5 phases and was iterative in nature, given that the findings from each step informed the subsequent steps. First, we designed messages to increase physical activity based on the behavior change theory and knowledge from the available evidence. Second, using user-centered design methods, we refined these messages after a card sorting task and semistructured interviews (N=10) and evaluated their likeability during a usability testing phase of the app prototype (N=8). Third, the messages were tested by English- and Spanish-speaking participants on the Amazon Mechanical Turk (MTurk) crowdsourcing platform (N=134). Participants on MTurk were asked to categorize the messages into overarching theoretical categories based on the capability, opportunity, motivation, and behavior framework. Finally, each coauthor rated the messages for their overall quality from 1 to 5. All messages were written at a sixth-grade or lower reading level and culturally adapted and translated into neutral Spanish by bilingual research staff.

A total of 200 messages were iteratively refined according to the feedback from target users gathered through user-centered design methods, crowdsourced results of a categorization test, and an expert review. User feedback was leveraged to discard unappealing messages and edit the thematic aspects of messages that did not resonate well with the target users. Overall, 54 messages were sorted into the correct theoretical categories at least 50% of the time in the MTurk categorization tasks and were rated 3.5 or higher by the research team members. These were included in the final text message bank, resulting in 18 messages per motivational category.

By using an iterative process of expert opinion, feedback from participants that were reflective of our target study population, crowdsourcing, and feedback from the research team, we were able to acquire valuable inputs for the design of motivational text messages developed in English and Spanish with a low literacy level to increase physical activity. We describe the design considerations and lessons learned for the text messaging development process and provide a novel, integrative framework for future developers of health text messaging interventions.