@Article{info:doi/10.2196/19270,
author="Patel, Devika
and Berger, Allen Christopher
and Kityamuwesi, Alex
and Ggita, Joseph
and Kunihira Tinka, Lynn
and Turimumahoro, Patricia
and Feler, Joshua
and Chehab, Lara
and Chen, Z. Amy
and Gupta, Nakull
and Turyahabwe, Stavia
and Katamba, Achilles
and Cattamanchi, Adithya
and Sammann, Amanda",
title="Iterative Adaptation of a Tuberculosis Digital Medication Adherence Technology to Meet User Needs: Qualitative Study of Patients and Health Care Providers Using Human-Centered Design Methods",
journal="JMIR Form Res",
year="2020",
month="Dec",
day="8",
volume="4",
number="12",
pages="e19270",
keywords="human-centered design",
keywords="tuberculosis",
keywords="digital adherence technology",
keywords="digital health",
keywords="adherence",
keywords="medication",
keywords="treatment",
keywords="outcome",
keywords="lung",
keywords="respiratory",
keywords="infectious disease",
abstract="Background: Digital adherence technologies have been widely promoted as a means to improve tuberculosis medication adherence. However, uptake of these technologies has been suboptimal by both patients and health workers. Not surprisingly, studies have not demonstrated significant improvement in treatment outcomes. Objective: This study aimed to optimize a well-known digital adherence technology, 99DOTS, for end user needs in Uganda. We describe the findings of the ideation phase of the human-centered design methodology to adapt 99DOTS according to a set of design principles identified in the previous inspiration phase. Methods: 99DOTS is a low-cost digital adherence technology wherein tuberculosis medication blister packs are encased within an envelope that reveals toll-free numbers that patients can call to report dosing. We identified 2 key areas for design and testing: (1) the envelope, including the form factor, content, and depiction of the order of pill taking; and (2) the patient call-in experience. We conducted 5 brainstorming sessions with all relevant stakeholders to generate a suite of potential prototype concepts. Senior investigators identified concepts to further develop based on feasibility and consistency with the predetermined design principles. Prototypes were revised with feedback from the entire team. The envelope and call-in experience prototypes were tested and iteratively revised through focus groups with health workers (n=52) and interviews with patients (n=7). We collected and analyzed qualitative feedback to inform each subsequent iteration. Results: The 5 brainstorming sessions produced 127 unique ideas that we clustered into 6 themes: rewards, customization, education, logistics, wording and imagery, and treatment countdown. We developed 16 envelope prototypes, 12 icons, and 28 audio messages for prototype testing. In the final design, we altered the pill packaging envelope by adding a front flap to conceal the pills and reduce potential stigma associated with tuberculosis. The flap was adorned with either a blank calendar or map of Uganda. The inside cover contained a personalized message from a local health worker including contact information, pictorial pill-taking instructions, and a choice of stickers to tailor education to the patient and phase of treatment. Pill-taking order was indicated with colors, chevron arrows, and small mobile phone icons. Last, the call-in experience when patients report dosing was changed to a rotating series of audio messages centered on the themes of prevention, encouragement, and reassurance that tuberculosis is curable. Conclusions: We demonstrated the use of human-centered design as a promising tool to drive the adaptation of digital adherence technologies to better address the needs and motivations of end users. The next phase of research, known as the implementation phase in the human-centered design methodology, will investigate whether the adapted 99DOTS platform results in higher levels of engagement from patients and health workers, and ultimately improves tuberculosis treatment outcomes. ",
doi="10.2196/19270",
url="https://formative.jmir.org/2020/12/e19270",
url="http://www.ncbi.nlm.nih.gov/pubmed/33289494"
}


@Article{info:doi/10.2196/20871,
author="Selby, Kevin
and Durand, Marie-Anne
and Gouveia, Alexandre
and Bosisio, Francesca
and Barazzetti, Gaia
and Hostettler, Maxime
and D'Acremont, Val{\'e}rie
and Kaufmann, Alain
and von Plessen, Christian",
title="Citizen Responses to Government Restrictions in Switzerland During the COVID-19 Pandemic: Cross-Sectional Survey",
journal="JMIR Form Res",
year="2020",
month="Dec",
day="3",
volume="4",
number="12",
pages="e20871",
keywords="COVID-19",
keywords="coronavirus",
keywords="Switzerland",
keywords="mitigation strategies",
keywords="citizen knowledge",
abstract="Background: The success of government-recommended mitigation measures during the COVID-19 pandemic depends largely on information uptake and implementation by individual citizens. Objective: Our aim was to assess citizens' knowledge and perceptions about COVID-19 recommendations in the Canton of Vaud, Switzerland. Methods: A cross-sectional electronic survey with open and closed questions was disseminated by community-based partners prior to the relaxation of government restrictions. Outcomes included citizen knowledge (9-question measure) and worry about the virus, perception of government measures, and recommendations for improvements. Comparisons used linear regression, controlling for age, sex, education, and health literacy. Free-text answers were analyzed thematically. Results: Of 807 people who accessed the survey, 684 (85\%) completed all questions and 479 (60\%) gave free-text recommendations. Overall, 75\% were female, the mean age was 48 years, and 93\% had high health literacy. Knowledge scores were high, with a median score of 8 out of 9. Mean levels of worry about the COVID-19 pandemic were higher in women than men (55/100 versus 44/100, P<.001), and in respondents with lower health literacy (57/100 versus 52/100, P=.03). Self-reported adherence to recommendations was high (85\%) and increased with age and worry (both P<.001). Respondents rated their own adherence higher than others (85\% versus 61\%, P<.001). Moreover, 34\% of respondents reported having self-quarantined; this rose to 52\% for those aged ?75 years. Those who had self-quarantined reported higher levels of fear. Nearly half (49\%) of respondents felt the government response had been adequate, though younger age and higher levels of worry were associated with considering the response to be insufficient (both P<.001). Analysis of open-text answers revealed 4 major themes: access to and use of masks, gloves, and hand sanitizer; government messaging; lockdown and lockdown exit plan communication; and testing for COVID-19. Conclusions: Knowledge, adherence, and satisfaction regarding government recommendations and response were high in this sample, but many desired greater access to personal protective equipment. Those with lower health literacy and those who have been in self-isolation reported greater concerns about the pandemic. ",
doi="10.2196/20871",
url="https://formative.jmir.org/2020/12/e20871",
url="http://www.ncbi.nlm.nih.gov/pubmed/33156809"
}


@Article{info:doi/10.2196/22043,
author="Jewell, S. Jennifer
and Farewell, V. Charlotte
and Welton-Mitchell, Courtney
and Lee-Winn, Angela
and Walls, Jessica
and Leiferman, A. Jenn",
title="Mental Health During the COVID-19 Pandemic in the United States: Online Survey",
journal="JMIR Form Res",
year="2020",
month="Oct",
day="23",
volume="4",
number="10",
pages="e22043",
keywords="COVID-19",
keywords="mental health",
keywords="pandemic",
keywords="depression",
keywords="anxiety",
keywords="well-being",
keywords="stress",
abstract="Background: The COVID-19 pandemic has had numerous worldwide effects. In the United States, there have been 8.3 million cases and nearly 222,000 deaths as of October 21, 2020. Based on previous studies of mental health during outbreaks, the mental health of the population will be negatively affected in the aftermath of this pandemic. The long-term nature of this pandemic may lead to unforeseen mental health outcomes and/or unexpected relationships between demographic factors and mental health outcomes. Objective: This research focused on assessing the mental health status of adults in the United States during the early weeks of an unfolding pandemic. Methods: Data was collected from English-speaking adults from early April to early June 2020 using an online survey. The final convenience sample included 1083 US residents. The 71-item survey consisted of demographic questions, mental health and well-being measures, a coping mechanisms checklist, and questions about COVID-19--specific concerns. Hierarchical multivariable logistic regression was used to explore associations among demographic variables and mental health outcomes. Hierarchical linear regression was conducted to examine associations among demographic variables, COVID-19--specific concerns, and mental health and well-being outcomes. Results: Approximately 50\% (536/1076) of the US sample was aged ?45 years. Most of the sample was White (1013/1054, 96\%), non-Hispanic (985/1058, 93\%), and female (884/1073, 82\%). Participants reported high rates of depression (295/1034, 29\%), anxiety (342/1007, 34\%), and stress (773/1058, 73\%). Older individuals were less likely to report depressive symptomology (OR 0.78, P<.001) and anxiety symptomology (OR 0.72, P<.001); in addition, they had lower stress scores (--0.15 points, SE 0.01, P<.001) and increased well-being scores (1.86 points, SE 0.22, P<.001). Individuals who were no longer working due to COVID-19 were 2.25 times more likely to report symptoms of depression (P=.02), had a 0.51-point increase in stress (SE 0.17, P=.02), and a 3.9-point decrease in well-being scores (SE 1.49, P=.009) compared to individuals who were working remotely before and after COVID-19. Individuals who had partial or no insurance coverage were 2-3 times more likely to report depressive symptomology compared to individuals with full coverage (P=.02 and P=.01, respectively). Individuals who were on Medicare/Medicaid and individuals with no coverage were 1.97 and 4.48 times more likely to report moderate or severe anxiety, respectively (P=.03 and P=.01, respectively). Financial and food access concerns were significantly and positively related to depression, anxiety, and stress (all P<.05), and significantly negatively related to well-being (both P<.001). Economy, illness, and death concerns were significantly positively related to overall stress scores (all P<.05). Conclusions: Our findings suggest that many US residents are experiencing high stress, depressive, and anxiety symptomatology, especially those who are underinsured, uninsured, or unemployed. Longitudinal investigation of these variables is recommended. Health practitioners may provide opportunities to allay concerns or offer coping techniques to individuals in need of mental health care. These messages should be shared in person and through practice websites and social media. ",
doi="10.2196/22043",
url="http://formative.jmir.org/2020/10/e22043/",
url="http://www.ncbi.nlm.nih.gov/pubmed/33006939"
}


@Article{info:doi/10.2196/17835,
author="Leary, Miriam
and Thomas, James
and Hayes, Ryan
and Sherlock, Lori",
title="Evaluation of an Occupational Exercise Training Program for Firefighters: Mixed Methods Pilot Study",
journal="JMIR Form Res",
year="2020",
month="Sep",
day="21",
volume="4",
number="9",
pages="e17835",
keywords="firefighters",
keywords="exercise",
keywords="mixed methods",
keywords="qualitative",
keywords="clinical",
keywords="performance",
abstract="Background: Occupational exercise training programs can improve overall health and fitness in firefighters, but evidence beyond clinical and performance outcomes is needed before fire departments invest in and successfully adopt health promotion programs. Objective: This mixed methods pilot study sought to pair clinical and performance outcomes with participants' qualitative feedback (eg, participants' enjoyment, lifestyle behavior changes, and team structure) with the goal of informing recommendations for future programs. Methods: Professional firefighters participated in a 14-week occupational exercise training program with assessments conducted pre- and posttraining. Clinical outcomes included weight, BMI, body fat percentage, resting heart rate, systolic blood pressure, and diastolic blood pressure. Performance outcomes included the sharpened Romberg balance test, 1-repetition maximum leg press and bench press, graded exercise test (estimated VO2max), knee range of motion, shoulder flexibility, and hamstring flexibility. Self-administered surveys (Short Form-36, International Physical Activity Questionnaire, Barriers Self-Efficacy Scale, and Barriers to Being Active Quiz) were completed. In 3 private focus groups of 3 to 4 participants, firefighters' experiences in the training program and their health behaviors were explored. Results: Male firefighters (n=14; age: mean 36.4, SD 2.6 years) completed 20 training sessions. There were no significant changes to weight (P=.20), BMI (P=.15), body fat percentage (P=.16), systolic blood pressure (P=.12), estimated VO2max (P=.34), balance (P=.24), knee range of motion (left: P=.35; right: P=.31), or hamstring flexibility (P=.14). There was a significant decrease in diastolic blood pressure (P=.04) and significant increases in shoulder flexibility (P<.001) and leg press 1-repetition maximum volume (P=.04). Participants reported improvements in overall health, endurance, flexibility, and mood as well as improvements to team environment and health behaviors around the station; however, there was a decline in overcoming barriers to physical activity. Conclusions: A 14-week program of exercise training in firefighters elicited improvements in clinical, performance, and self-reported physical activity outcomes. This occupational exercise training program for firefighters increased time spent exercising, improved team building, and led to physical and mental health benefits. Results from this pilot study set a broad, informed, and meaningful foundation for future efforts to increase firefighter participation in occupational fitness programs. ",
doi="10.2196/17835",
url="http://formative.jmir.org/2020/9/e17835/",
url="http://www.ncbi.nlm.nih.gov/pubmed/32955453"
}


@Article{info:doi/10.2196/20606,
author="Huang, Huaping
and Zhao, Wen-Jun
and Li, Gui-Rong",
title="Knowledge and Psychological Stress Related to COVID-19 Among Nursing Staff in a Hospital in China: Cross-Sectional Survey Study",
journal="JMIR Form Res",
year="2020",
month="Sep",
day="18",
volume="4",
number="9",
pages="e20606",
keywords="COVID-19",
keywords="nursing staff",
keywords="knowledge",
keywords="psychological stress",
abstract="Background: Since December 2019, coronavirus disease (COVID-19) has been rapidly spreading worldwide. Nurses play a key role in fighting this disease and are at risk of COVID-19 infection. Therefore, there is an urgent need to assess the mental health condition of nurses and establish appropriate interventions to reduce the negative psychiatric outcomes of the pandemic. Objective: The objectives of this study were to evaluate the knowledge and psychological stress related to COVID-19 among nursing staff and to provide evidence of the need for targeted training and psychological intervention. Methods: This cross-sectional web-based survey study was performed in a class 3 grade A general hospital in a southwest province of China from March 1 to March 15, 2020. A self-designed questionnaire with questions about COVID-19--related prevention and control knowledge and the Triage Assessment Form (TAF) were used to assess nursing staff's knowledge of COVID-19 and their degree of psychological stress, respectively. SPSS 23.0 was applied for statistical analysis of the collected data. Results: A total of 979 nurses completed the questionnaire. The results showed that the nursing staff provided the fewest correct answers to questions about continuous viral nucleic acid testing specifications (379/979 correct answers, 38.7\%), isolation/discharge criteria (539/979 correct answers, 55.1\%), and management measures for patients with suspected symptoms (713/979 correct answers, 72.8\%). The median total score of the TAF was 7.0 (IQR 5.0-12.0), and there were statistically significant differences in scores between different nursing roles, years of work experience, and hospital departments (P<.05). Conclusions: This study indicated that nursing staff have insufficient knowledge about COVID-19. Meanwhile, although the psychological damage to nurses during the pandemic was found to be low, nurse managers must continue to monitor the mental health of nursing staff and perform timely interventions. ",
doi="10.2196/20606",
url="https://formative.jmir.org/2020/9/e20606",
url="http://www.ncbi.nlm.nih.gov/pubmed/32640419"
}


@Article{info:doi/10.2196/18223,
author="Zisman-Ilani, Yaara
and Obeidat, Rana
and Fang, Lauren
and Hsieh, Sarah
and Berger, Zackary",
title="Shared Decision Making and Patient-Centered Care in Israel, Jordan, and the United States: Exploratory and Comparative Survey Study of Physician Perceptions",
journal="JMIR Form Res",
year="2020",
month="Aug",
day="3",
volume="4",
number="8",
pages="e18223",
keywords="shared decision making",
keywords="patient-centered care",
keywords="Middle East",
keywords="physicians",
keywords="perceptions",
abstract="Background: Shared decision making (SDM) is a health communication model that evolved in Europe and North America and largely reflects the values and medical practices dominant in these areas. Objective: This study aims to understand the beliefs, perceptions, and practices related to SDM and patient-centered care (PCC) of physicians in Israel, Jordan, and the United States. Methods: A hypothesis-generating comparative survey study was administered to physicians from Israel, Jordan, and the United States. Results: A total of 36 surveys were collected via snowball sampling (Jordan: n=15; United States: n=12; Israel: n=9). SDM was perceived as a way to inform patients and allow them to participate in their care. Barriers to implementing SDM varied based on place of origin; physicians in the United States mentioned limited time, physicians in Jordan reported that a lack of patient education limits SDM practices, and physicians in Israel reported lack of communication training. Most US physicians defined PCC as a practice for prioritizing patient preferences, whereas both Jordanian and Israeli physicians defined PCC as a holistic approach to care and to prioritizing patient needs. Barriers to implementing PCC, as seen by US physicians, were mostly centered on limited appointment time and insurance coverage. In Jordan and Israel, staff shortage and a lack of resources in the system were seen as major barriers to PCC implementation. Conclusions: The study adds to the limited, yet important, literature on SDM and PCC in areas of the world outside the United States, Canada, Australia, and Western Europe. The study suggests that perceptions of PCC might widely differ among these regions, whereas concepts of SDM might be shared. Future work should clarify these differences. ",
doi="10.2196/18223",
url="https://formative.jmir.org/2020/8/e18223",
url="http://www.ncbi.nlm.nih.gov/pubmed/32744509"
}


@Article{info:doi/10.2196/18703,
author="Greenberg, Jonathan
and Popok, J. Paula
and Lin, Ann
and Kulich, J. Ronald
and James, Peter
and Macklin, A. Eric
and Millstein, A. Rachel
and Edwards, R. Robert
and Vranceanu, Ana-Maria",
title="A Mind-Body Physical Activity Program for Chronic Pain With or Without a Digital Monitoring Device: Proof-of-Concept Feasibility Randomized Controlled Trial",
journal="JMIR Form Res",
year="2020",
month="Jun",
day="8",
volume="4",
number="6",
pages="e18703",
keywords="chronic pain",
keywords="meditation",
keywords="walking",
keywords="feasibility studies",
keywords="actigraphy",
abstract="Background: Chronic pain is associated with poor physical and emotional functioning. Nonpharmacological interventions can help, but improvements are small and not sustained. Previous clinical trials do not follow recommendations to comprehensively target objectively measured and performance-based physical function in addition to self-reported physical function. Objective: This study aimed to establish feasibility benchmarks and explore improvements in physical (self-reported, performance based, and objectively measured) and emotional function, pain outcomes, and coping through a pilot randomized controlled trial of a mind-body physical activity program (GetActive) with and without a digital monitoring device (GetActive-Fitbit), which were iteratively refined through mixed methods. Methods: Patients with chronic pain were randomized to the GetActive (n=41) or GetActive-Fitbit (n=41) programs, which combine relaxation, cognitive behavioral, and physical restoration skills and were delivered in person. They completed in-person assessments before and after the intervention. Performance-based function was assessed with the 6-min walk test, and step count was measured with an ActiGraph. Results: Feasibility benchmarks (eg, recruitment, acceptability, credibility, therapist adherence, adherence to practice at home, ActiGraph wear, and client satisfaction) were good to excellent and similar in both programs. Within each program, we observed improvement in the 6-min walk test (mean increase=+41 m, SD 41.15; P<.001; effect size of 0.99 SD units for the GetActive group and mean increase=+50 m, SD 58.63; P<.001; effect size of 0.85 SD units for the GetActive-Fitbit group) and self-reported physical function (P=.001; effect size of 0.62 SD units for the GetActive group and P=.02; effect size of 0.38 SD units for the GetActive-Fitbit group). The mean step count increased only among sedentary patients (mean increase=+874 steps for the GetActive group and +867 steps for the GetActive-Fitbit group). Emotional function, pain intensity, pain coping, and mindfulness also improved in both groups. Participants rated themselves as much improved at the end of the program, and those in the GetActive-Fitbit group noted that Fitbit greatly helped with increasing their activity. Conclusions: These preliminary findings support a fully powered efficacy trial of the two programs against an education control group. We present a model for successfully using the Initiative on the Methods, Measurement, and Pain Assessment in Clinical Trials criteria for a comprehensive assessment of physical function and following evidence-based models to maximize feasibility before formal efficacy testing. Trial Registration: ClinicalTrial.gov NCT03412916; https://clinicaltrials.gov/ct2/show/NCT03412916 ",
doi="10.2196/18703",
url="https://formative.jmir.org/2020/6/e18703",
url="http://www.ncbi.nlm.nih.gov/pubmed/32348281"
}


@Article{info:doi/10.2196/14747,
author="Zeisler, Marie-Luise
and Bilgic, Leman
and Schumann, Maria
and Wengler, Annelene
and Lemcke, Johannes
and G{\"o}{\ss}wald, Antje
and Lampert, Thomas
and Santos-H{\"o}vener, Claudia
and Schmich, Patrick",
title="Interventions to Increase the Reachability of Migrants in Germany With Health Interview Surveys: Mixed-Mode Feasibility Study",
journal="JMIR Form Res",
year="2020",
month="Apr",
day="15",
volume="4",
number="4",
pages="e14747",
keywords="transients and migrants",
keywords="surveys and questionnaires",
keywords="cross-sectional studies",
keywords="feasibility studies",
keywords="multilingualism and health monitoring",
abstract="Background: Germany is a popular destination for immigrants, and migration has increased in recent years. It is therefore important to collect reliable data on migrants' health. The Robert Koch Institute, Berlin, Germany, has launched the Improving Health Monitoring in Migrant Populations (IMIRA) project to sustainably integrate migrant populations into health monitoring in Germany. Objective: One of IMIRA's objectives is to implement a feasibility study (the IMIRA survey) that focuses on testing various interventions to increase the reachability of migrants with health interview surveys. Possible causes of nonresponse should be identified so as to increase participation in future surveys. Methods: The survey target populations were Turkish, Polish, Romanian, Syrian, and Croatian migrants, who represent the biggest migrant groups living in Germany. We used probability sampling, using data from the registration offices in 2 states (Berlin and Brandenburg); we randomly selected 9068 persons by nationality in 7 sample points. We applied age (3 categories: 18-44, 45-64, and ?65 years) and sex strata. Modes and methods used to test their usability were culturally sensitive materials, online questionnaires, telephone interviews, personal contact, and personal interviews, using multilingual materials and interviewers. To evaluate the effectiveness of the interventions, we used an intervention group (group A) and a control group (group B). There were also focus groups with the interviewers to get more information about the participants' motivation. We used the European Health Interview Survey, with additional instruments on religious affiliation, experience of discrimination, and subjective social status. We evaluated results according to their final contact result (disposition code). Results: We collected data from January to May 2018 in Berlin and Brandenburg, Germany. The survey had an overall response rate of 15.88\% (1190/7494). However, final disposition codes varied greatly with regard to citizenship. In addition to the quantitative results, interviewers reported in the focus groups a ``feeling of connectedness'' to the participants due to the multilingual interventions. The interviewers were particularly positive about the home visits, because ``if you are standing at the front door, you will be let in for sure.'' Conclusions: The IMIRA survey appraised the usability of mixed-mode or mixed-method approaches among migrant groups with a probability sample in 2 German states. When conducting the survey, we were confronted with issues regarding the translation of the questionnaire, as well as the validity of some instruments in the survey languages. A major result was that personal face-to-face contact was the most effective intervention to recruit our participants. We will implement the findings in the upcoming health monitoring study at the Robert Koch Institute. ",
doi="10.2196/14747",
url="https://formative.jmir.org/2020/4/e14747",
url="http://www.ncbi.nlm.nih.gov/pubmed/32305950"
}