Open access Research Electronic, mobile and telehealth ... · Sydney Local Health District, Sydney,...
23
1 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192 Open access Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis Sharon Parker, 1 Amy Prince, 2 Louise Thomas, 1 Hyun Song, 1 Diana Milosevic, 3 Mark Fort Harris, 1 On behalf of the IMPACT Study Group To cite: Parker S, Prince A, Thomas L, et al. Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis. BMJ Open 2018;8:e019192. doi:10.1136/ bmjopen-2017-019192 Received 23 August 2017 Revised 6 March 2018 Accepted 13 March 2018 1 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia 2 South Western Sydney Primary Health Network, Campbelltown, New South Wales, Australia 3 Planning Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia Correspondence to Ms Sharon Parker; [email protected] Research ABSTRACT Objectives The objective of this review was to assess the benefit of using electronic, mobile and telehealth tools for vulnerable patients with chronic disease and explore the mechanisms by which these impact patient self-efficacy and self-management. Design We searched MEDLINE, all evidence-based medicine, CINAHL, Embase and PsychINFO covering the period 2009 to 2018 for electronic, mobile or telehealth interventions. Quality was assessed according to rigour and relevance. Those studies providing a richer description (‘thick’) were synthesised using a realist matrix. Setting and participants Studies of any design conducted in community-based primary care involving adults with one or more diagnosed chronic health condition and vulnerability due to demographic, geographic, economic and/or cultural characteristics. Results Eighteen trials were identified targeting a range of chronic conditions and vulnerabilities. The data provided limited insight into the mechanisms underpinning these interventions, most of which sought to persuade vulnerable patients into believing they could self-manage their conditions through improved symptom monitoring, education and support and goal setting. Patients were relatively passive in the interaction, and the level of patient response attributed to their intrinsic level of motivation. Health literacy, which may be confounded with motivation, was only measured in one study, and eHealth literacy was not assessed. Conclusions Research incorporating these tools with vulnerable groups is not comprehensive. Apart from intrinsic motivation, health literacy may also influence the reaction of vulnerable groups to technology. Social persuasion was the main way interventions sought to achieve better self-management. Efforts to engage patients by healthcare providers were lower than expected. Use of social networks or other eHealth mechanisms to link patients and provide opportunities for vicarious experience could be further explored in relation to vulnerable groups. Future research could also assess health and eHealth literacy and differentiate the specific needs for vulnerable groups when implementing health technologies. BACKGROUND Chronic conditions result in significant personal and social burden. 1 Electronic and telehealth tools are increasingly common- place, can be provided at relatively low cost 2 and incorporate personally relevant health information. 3 For those vulnerable and underserved community members with chronic or long-term conditions, electronic applications may enhance the reach of health services and the provision of tailored need- based services. 4 5 The growing impetus to use these technologies is largely underpinned by their potential to intervene in the course of healthcare and influence the way people deal with their health issues. 6 There is also an expectation that health technologies will engage consumers in appropriate self-care and self-management, 7 which within the health delivery sphere, shifts the responsi- bility solely from the clinician to one that is jointly shared by the health provider and patient. Electronic health (eHealth) tools incor- porate many opportunities for patients to increase their engagement through focused disease-specific learning, options to receive regular feedback and frequent reinforce- ment (eg, peripheral monitoring devices). 8 Strengths and limitations of this study ► The use of a comprehensive search and systematic process to identify both quantitative and qualitative data. ► The use of Rameses and Preferred Reporting Items for Systematic Reviews and Meta-Analyses report- ing standards. ► Incorporation of theory and mapping against a theo- retical framework and realist matrix. ► Limited data identified due to a lack of detailed con- text provided in the published studies. on October 15, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2017-019192 on 29 August 2018. Downloaded from
Transcript of Open access Research Electronic, mobile and telehealth ... · Sydney Local Health District, Sydney,...
1Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis
Sharon Parker,1 Amy Prince,2 Louise Thomas,1 Hyun Song,1 Diana Milosevic,3 Mark Fort Harris,1 On behalf of the IMPACT Study Group
To cite: Parker S, Prince A, Thomas L, et al. Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Received 23 August 2017Revised 6 March 2018Accepted 13 March 2018
1Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia2South Western Sydney Primary Health Network, Campbelltown, New South Wales, Australia3Planning Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia
Correspondence toMs Sharon Parker; sharon. parker@ unsw. edu. au
Research
AbstrACtObjectives The objective of this review was to assess the benefit of using electronic, mobile and telehealth tools for vulnerable patients with chronic disease and explore the mechanisms by which these impact patient self-efficacy and self-management.Design We searched MEDLINE, all evidence-based medicine, CINAHL, Embase and PsychINFO covering the period 2009 to 2018 for electronic, mobile or telehealth interventions. Quality was assessed according to rigour and relevance. Those studies providing a richer description (‘thick’) were synthesised using a realist matrix.setting and participants Studies of any design conducted in community-based primary care involving adults with one or more diagnosed chronic health condition and vulnerability due to demographic, geographic, economic and/or cultural characteristics.results Eighteen trials were identified targeting a range of chronic conditions and vulnerabilities. The data provided limited insight into the mechanisms underpinning these interventions, most of which sought to persuade vulnerable patients into believing they could self-manage their conditions through improved symptom monitoring, education and support and goal setting. Patients were relatively passive in the interaction, and the level of patient response attributed to their intrinsic level of motivation. Health literacy, which may be confounded with motivation, was only measured in one study, and eHealth literacy was not assessed.Conclusions Research incorporating these tools with vulnerable groups is not comprehensive. Apart from intrinsic motivation, health literacy may also influence the reaction of vulnerable groups to technology. Social persuasion was the main way interventions sought to achieve better self-management. Efforts to engage patients by healthcare providers were lower than expected. Use of social networks or other eHealth mechanisms to link patients and provide opportunities for vicarious experience could be further explored in relation to vulnerable groups. Future research could also assess health and eHealth literacy and differentiate the specific needs for vulnerable groups when implementing health technologies.
bACkgrOunD Chronic conditions result in significant personal and social burden.1 Electronic and telehealth tools are increasingly common-place, can be provided at relatively low cost2 and incorporate personally relevant health information.3 For those vulnerable and underserved community members with chronic or long-term conditions, electronic applications may enhance the reach of health services and the provision of tailored need-based services.4 5 The growing impetus to use these technologies is largely underpinned by their potential to intervene in the course of healthcare and influence the way people deal with their health issues.6 There is also an expectation that health technologies will engage consumers in appropriate self-care and self-management,7 which within the health delivery sphere, shifts the responsi-bility solely from the clinician to one that is jointly shared by the health provider and patient.
Electronic health (eHealth) tools incor-porate many opportunities for patients to increase their engagement through focused disease-specific learning, options to receive regular feedback and frequent reinforce-ment (eg, peripheral monitoring devices).8
strengths and limitations of this study
► The use of a comprehensive search and systematic process to identify both quantitative and qualitative data.
► The use of Rameses and Preferred Reporting Items for Systematic Reviews and Meta-Analyses report-ing standards.
► Incorporation of theory and mapping against a theo-retical framework and realist matrix.
► Limited data identified due to a lack of detailed con-text provided in the published studies.
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
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MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
2 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Additional inbuilt support functions that assess progress, provide goal setting and problem solving, aim to increase the patient’s skill and confidence in managing their health problems.9 Supplementary motivational interviewing and cognitive behavioural components can also be provided via the internet, mobile device or telephone.10
The claims made by health-related apps, websites and other electronic tools remain largely unverified, and more specifically, little is known about their value for vulnerable and marginalised groups. Within the Innovative Models Promoting Access-to-Care Transformation (IMPACT) programme, we aimed to assess, via a systematic review and realist synthesis, the perceived benefit of using elec-tronic tools to enhance the engagement of vulnerable patients with chronic disease. We used realist method-ology as a way of unpacking the complexity surrounding eHealth interventions.11 This methodology explains the interplay between context, mechanisms and outcomes12 where mechanisms are not activities within the inter-vention, but the responses by people that are triggered by changes in context.13 In this review, we specifically sought to explore mechanisms related to patient self-effi-cacy and self-management. The impact of these tools on access to healthcare more broadly is the topic of a future manuscript.
research questionThe objective of this review was to assess the benefit of using electronic, mobile and telehealth tools for vulner-able patients with chronic disease and to explore the mechanisms by which these tools impact patient self-effi-cacy and self-management.
Our population of interest included adults with one or more diagnosed chronic health conditions. We used the definition of chronic disease provided by the National Public Health Partnership14 framework, a seminal Austra-lian resource setting out a strategic framework for the prevention and control of chronic non-communicable diseases in Australia. This framework identified 12 chronic conditions.
The definition of vulnerability was based on the IMPACT study definition: Indigenous/first nation people, cultur-ally and linguistically diverse groups including recently arrived refugee groups, those experiencing socioeco-nomic hardship and disadvantage (unemployed, low income, those in public housing and homeless) and geographic disadvantage (living in a rural and remote area). For these population groups, these demographic, geographic, economic and/or cultural characteristics impede or compromise access to community-based primary healthcare.
There are many and varied definitions of eHealth, mHealth and telehealth used across the health sector.1 For the purpose of this review, we defined these in the following ways:
► eHealth, is the general transfer of health resources and healthcare by electronic means through the internet and telecommunications.15
► Mobile health (mHealth) is the delivery of healthcare services via mobile/wireless communication devices such as smartphones and tablets.
► Telehealth describes the use of telecommunication techniques (voice, data and images) for providing tele-medicine (remote clinical service delivery), medical education and health education over a distance.16 Telehealth encompasses long-distance clinical health-care, patient and professional health-related educa-tion, public health and health administration.
MethODsOur processes were based on standard systematic review methodology.17 Realist synthesis similarly follows the stages of a traditional systematic review except the appraisal of evidence is theoretically driven and intent on explaining why the intervention works or does not work.18 Reporting was guided by the Rameses publication stan-dards for reporting realist synthesis19 and the Preferred Reporting Items for Systematic Reviews and Meta-Anal-yses statement.20
We searched MEDLINE, all evidence-based medicine, CINAHL, Embase and PsychINFO covering the period 1 January 2009–12 February 2018. Our basic search strategy (box 1) was modified for use in each database.
The criteria for study selection are described in detail in table 1. We did not exclude studies based on design as we wanted to collect a richer understanding of the interventions.
Included studies required a description of the e/m/telehealth intervention and/or its components. Inter-ventions that did not offer broader patient involvement through coaching/skill improvement components and ongoing skill development were excluded, including those programmes used solely for simple self-moni-toring of symptoms. Inpatient hospital-based services were excluded, as were those not presenting evaluative data and those involving primarily children or adolescent populations.
We also selected only studies originating in Organ-isation for Economic Cooperation and Development (OECD) countries.
study selection processTitle and abstract screen were undertaken by at least two authors (SP, AP and LT). For citations requiring full-text review, SP, AP and LT reviewed a subset of papers, with final inclusion determined through joint discussion and review.
Data extraction and study variablesData were collected using a five-page data collection form within an Access database incorporating the Reach, Efficacy, Adoption, Implementation, Main-tenance (REAIM) framework,21 the Template for Intervention Description and Replication (TIDieR) framework,22 the Place, Race, Occupation, Gender, Reli-gion, Education, Socioeconomic status, social capital
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3Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
(PROGRESS) framework23 and several predefined variables including study type, country of origin, the procedures, activities and/or processes used in the interventions, supportive activities, recipients and the personnel involved in delivery of the intervention and reported study outcomes. All data extraction was conducted by two authors.
Quality appraisalWithin realist synthesis, there is no accepted process for assessing quality. Pawson et al12 argues that quality should not determine inclusion, but a realist synthesis should provide a ‘quality filter’,24 which assesses the contribution of data to rigour (whether the method used to generate the data is credible and trustworthy) and relevance (whether it contributes to theory building and/or testing).19
We used a method described by O’Campo et al25 due to recognition that the most useful study informa-tion may not be within the reports of studies with the highest quality. Studies were classified against the criteria (table 2) by one author (SP) and confirmed by a second author (AP). Rigour was assessed as ‘high’, ‘moderate’ or ‘weak’ and plotted on a continuum from 0 to 7. One point was allocated for each positive response and studies graded as high (7 points), moderate (4–6 points) and low (0–3 points). Relevance was assessed based on ‘thick’ or ‘thin’ descriptions of the intervention components and their mechanisms. One point was allocated for each ‘yes’ answer and studies considered thick (3–4 points) or thin (0–2 points).
realist synthesisAt the core of realist synthesis is to make explicit the underlying assumptions as to how an intervention is supposed to work and to then map the evidence in a systematic way to test and refine this theory.26 We devel-oped a linear logic model to explain the engagement of primary care providers and patients in the use of mobile, telehealth and eHealth tools (figure 1). We explored known theories associated with patient self-ef-ficacy and self-management and extracted data against a realist matrix using those included studies that had been assessed as providing a ‘thick’ description of the intervention. The matrix comprised documented results from each study plus relevant author discus-sion that attempted to place their results into context. Realist matrices are a complementary approach to
box 1 Continued
55. exp child/or adolescent/56. 54 not 5557. editorial.pt.58. case reports.pt.59. letter.pt.60. 57 or 58 or 5961. 56 not 6062. limit 61 to (English language and yr=‘2009 -Current’)
box 1 search strategy conducted 12 February 2018 and modified for each database
search terms1. telemedicine/2. ehealth. mp.3. E health. mp.4. electronic health. mp.5. internet health. mp.6. mhealth. mp.7. m health. mp.8. mobile health. mp.9. mobile health devices. mp.
10. social media/11. telephone/12. telehealth. mp.13. tele health. mp.14. telehomecare. mp.15. text messaging/16. exp therapy, computer-assisted/17. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or
14 or 15 or 1618. exp medical records systems, computerized/19. 17 not 1820. primary health care/21. exp family practice/22. exp general practice/23. exp physicians, family/24. practice nurse.mp.25. pharmacists/26. nutritionists/or physical therapists/27. aboriginal health worker.mp.28. audiologist.mp.29. diabetes educator.mp.30. exercise physiologist.mp.31. occupational therapist.mp.32. osteopathic physicians/33. podiatrist.mp.34. home care services/35. 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or
31 or 32 or 33 or 3436. chronic disease/37. long term illness.mp.38. long term condition.mp.39. multimorbidity.mp.40. multi morbidity.mp.41. myocardial ischemia/42. stroke/43. lung neoplasms/44. colorectal neoplasms/45. exp depression/46. diabetes mellitus, type 2/47. arthritis/48. pulmonary disease, chronic obstructive/49. osteoporosis/50. asthma/51. renal insufficiency, chronic/52. dental caries/53. 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or
47 or 48 or 49 or 50 or 51 or 5254. 19 and 35 and 53
Continued
on October 15, 2020 by guest. P
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Open access
Tab
le 1
S
tud
y se
lect
ion
crite
ria
Sel
ecti
on
crit
eria
Incl
usio
nE
xclu
sio
n
Pop
ulat
ion
– co
nsum
er1.
Gen
eral
ad
ult
(18+
yea
rs) p
opul
atio
n w
ith o
ne o
r m
ore
dia
gnos
ed c
hron
ic h
ealth
co
nditi
ons
as c
lass
ified
by
the
Nat
iona
l Pub
lic H
ealth
Par
tner
ship
14: i
scha
emic
he
art
dis
ease
(als
o kn
own
as c
oron
ary
hear
t d
isea
se),
stro
ke, l
ung
canc
er,
colo
rect
al c
ance
r, d
epre
ssio
n, t
ype
2 d
iab
etes
, art
hriti
s, o
steo
por
osis
, ast
hma,
ch
roni
c ob
stru
ctiv
e p
ulm
onar
y d
isea
se, c
hron
ic k
idne
y d
isea
se a
nd o
ral d
isea
se.
Pat
ient
s d
escr
ibed
as
havi
ng m
ultim
orb
idity
(ie,
tw
o or
mor
e ch
roni
c co
nditi
ons)
.
Mix
ed p
opul
atio
ns o
f ad
ult
and
chi
ldre
n un
less
the
se g
roup
s ha
ve
bee
n se
par
ated
as
par
t of
the
ana
lysi
s.P
atie
nts
with
men
tal h
ealth
con
diti
ons
that
may
imp
air
cogn
ition
or
und
erst
and
ing,
suc
h as
dem
entia
and
psy
chos
is.
Pop
ulat
ion
– p
ract
ition
er
2. P
artic
ipan
ts c
lass
ified
as
vuln
erab
le b
ased
on
IMPA
CT
defi
nitio
n an
d o
f sp
ecifi
c re
leva
nce
to S
outh
Wes
t S
ydne
y in
clud
ing:
Ind
igen
ous/
first
nat
ion
peo
ple
, cul
tura
lly a
nd li
ngui
stic
ally
div
erse
gro
ups
incl
udin
g re
cent
ly a
rriv
ed
refu
gee
grou
ps,
tho
se e
xper
ienc
ing
soci
oeco
nom
ic h
ard
ship
and
dis
adva
ntag
e (u
nem
plo
yed
, low
inco
me,
tho
se in
pub
lic h
ousi
ng a
nd h
omel
ess)
; and
geo
grap
hic
dis
adva
ntag
e (li
ving
in a
rur
al a
nd r
emot
e ar
ea).
Any
hea
lth p
rofe
ssio
nal p
rovi
din
g p
rimar
y ca
re t
o a
com
mun
ity-b
ased
pop
ulat
ion
incl
udin
g ge
nera
l pra
ctiti
oner
/fam
ily p
hysi
cian
, pra
ctic
e nu
rse
or c
omm
unity
/cl
inic
nur
se, p
harm
acis
t, a
llied
hea
lth p
rofe
ssio
nals
(Ab
orig
inal
hea
lth w
orke
rs
or A
bor
igin
al a
nd T
orre
s S
trai
t Is
land
er h
ealth
pra
ctiti
oner
s, a
udio
logi
sts,
ch
irop
ract
ors,
dia
bet
es e
duc
ator
s, d
ietit
ians
, exe
rcis
e, p
hysi
olog
ists
, men
tal
heal
th w
orke
rs, o
ccup
atio
nal t
hera
pis
ts, o
steo
pat
hs, p
hysi
othe
rap
ists
, pod
iatr
ists
, p
sych
olog
ists
and
sp
eech
pat
holo
gist
s).
e/m
/Tel
ehea
lth
inte
rven
tions
Com
pre
hens
ive
(mul
ticom
pon
ent)
or s
imp
le (o
ne c
omp
onen
t) p
atie
nt d
irect
ed
or p
atie
nt-f
ocus
ed t
ools
ava
ilab
le v
ia a
per
sona
l com
put
er, t
elep
hone
or
mob
ile
dev
ice
(mob
ile p
hone
or
tab
let).
Thi
s in
clud
es t
he p
rovi
sion
of i
nsta
nt fe
edb
ack
or S
MS
rem
ind
ers
that
enc
oura
ge p
atie
nts
to a
chie
ve t
heir
heal
th g
oals
and
in
tera
ctiv
e p
rogr
amm
es t
hat
pro
vid
e on
goin
g m
onito
ring
with
sel
f-as
sess
men
t ac
tiviti
es.
Acc
ess
to t
he t
ools
sho
uld
invo
lve
an in
itial
dire
ct in
tera
ctio
n b
etw
een
a p
rimar
y he
alth
care
pro
vid
er (d
efine
d a
bov
e) a
nd t
he p
atie
nt (d
efine
d a
bov
e) d
urin
g w
hich
in
stru
ctio
n or
tra
inin
g is
pro
vid
ed t
o th
e p
atie
nt t
o ai
d u
nder
stan
din
g, p
rom
ote
know
led
ge o
r in
crea
se s
kills
, inc
lud
ing
coac
hing
and
ed
ucat
ion
tool
s p
rovi
ded
ov
er t
he p
hone
.Th
e in
terv
entio
n/to
ol s
houl
d p
rovi
de
pat
ient
s w
ith a
sho
rt t
o m
ediu
m t
erm
or
ongo
ing
inte
ract
ive
met
hod
of e
duc
atio
n, t
rain
ing
or s
kill
dev
elop
men
t th
at
sup
por
ts s
elf-
man
agem
ent
and
em
pow
erm
ent
rela
ted
to
thei
r m
anag
emen
t of
ch
roni
c d
isea
se a
nd it
s ris
k fa
ctor
s.
e/m
/Tel
ehea
lth in
terv
entio
n/s
imp
lied
but
not
des
crib
ed.
Dev
ices
or
pro
gram
mes
use
d fo
r si
mp
le s
elf-
mon
itorin
g of
sym
pto
ms
rela
ted
to
chro
nic
cond
ition
suc
h as
sug
ar o
r b
lood
pre
ssur
e ex
cep
t w
here
the
se a
re a
com
pon
ent
of a
bro
ader
inte
ract
ive
inte
rven
tion.
Rea
din
gs r
ecor
ded
via
the
inte
rnet
or
thro
ugh
dev
ices
tha
t al
low
th
e d
ownl
oad
of r
ead
ings
. The
se m
ay b
e in
clud
ed if
the
y ar
e on
e co
mp
onen
t of
a m
ore
com
pre
hens
ive
self-
man
agem
ent
pro
gram
me.
Tele
pho
ne t
riage
ser
vice
s w
here
a p
atie
nt is
ad
vise
d a
s to
wha
t le
vel
of c
are
to s
eek
(Gen
eral
Pra
ctiti
oner
(GP
) or
hosp
ital).
Sin
gle
cont
act
for
the
pro
visi
on o
f sim
ple
ed
ucat
iona
l mat
eria
l on
ly w
ithou
t ad
ded
coa
chin
g/sk
ill im
pro
vem
ent
and
ong
oing
ski
ll d
evel
opm
ent.
Tele
med
icin
e fo
r ro
utin
e co
nsul
tatio
ns w
ith n
o he
alth
ed
ucat
ion
com
pon
ent/
inte
ntio
n.E
stab
lishi
ng, u
tilis
ing
or r
evie
win
g el
ectr
onic
hea
lth r
ecor
d s
yste
ms
with
in C
omm
unity
Bas
ed P
rimar
y H
ealth
Car
e (C
BP
HC
).
Com
par
ator
Usu
al c
are,
enh
ance
d u
sual
car
e (e
g, a
dd
ed c
ouns
ellin
g or
ed
ucat
ion)
or
a se
cond
in
terv
entio
n ar
m.
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
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MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
5Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Sel
ecti
on
crit
eria
Incl
usio
nE
xclu
sio
n
Out
com
esP
rimar
y ou
tcom
es:
1. H
ealth
ser
vice
use
:
►In
crea
sed
att
end
ance
at
prim
ary
care
ser
vice
.
►N
umb
er o
f Gen
eral
Pra
ctiti
oner
vis
its p
er y
ear.
►
Use
of t
he e
/m/t
eleh
ealth
inte
rven
tion
by
pat
ient
s an
d p
ract
ition
ers
incl
udin
g p
ract
ition
er a
dop
tion/
incl
usio
n in
day
-to-
day
pra
ctic
e or
neg
ativ
e im
plic
atio
ns
from
use
rep
orte
d b
y p
atie
nts
or p
rovi
der
s.
►S
atis
fact
ion
with
ser
vice
/pra
ctiti
oner
car
e.
►D
ecre
ased
Em
erge
ncy
Dep
artm
ent
(ED
) pre
sent
atio
ns.
►
Red
uctio
n in
cos
t of
pro
vid
ing
prim
ary
care
►
Red
uctio
n in
med
icat
ion
erro
rs.
►
Red
uctio
n in
ad
vers
e ev
ents
incl
udin
g d
rug-
rela
ted
eve
nts.
2. B
ehav
iour
al o
utco
mes
a) P
atie
nt b
ehav
iour
►
Num
ber
of p
atie
nts
with
reg
ular
mon
itorin
g of
the
ir cl
inic
al p
aram
eter
s.
►N
umb
er o
f peo
ple
who
sel
f-re
por
t im
pro
vem
ents
in t
heir
man
agem
ent
of
chro
nic
dis
ease
or
risk
fact
ors.
►
Sel
f-re
por
ted
or
mea
sure
d c
hang
e in
leve
l or
risk/
enga
gem
ent
in r
isk
beh
avio
ur.
►
Leve
ls o
f mot
ivat
ion.
►
Leve
ls o
f kno
wle
dge
and
/or
und
erst
and
ing.
►
Leve
l of h
ealth
lite
racy
—se
lf-re
por
ted
or
valid
ated
inst
rum
ents
.
►Le
vel o
f e-h
ealth
lite
racy
—se
lf re
por
ted
or
valid
ated
inst
rum
ent.
►
Sel
f-ef
ficac
y.
►Le
vel o
f con
fiden
ce w
ith s
elf-
man
agem
ent
of t
heir
cond
ition
and
ass
ocia
ted
ris
k fa
ctor
s.
►S
elf-
rep
orte
d o
r m
easu
red
cha
nges
in c
omm
unic
atio
n/in
tera
ctio
n w
ith t
heir
PC
p
rovi
der
.
►Q
ualit
y of
life
.b
) Pra
ctiti
oner
beh
avio
ur
►E
nhan
ced
use
of t
ools
/sat
isfa
ctio
n w
ith t
ools
.
►S
elf-
rep
orte
d o
r m
easu
red
incr
ease
d p
atie
nt c
omm
unic
atio
n.2.
Sec
ond
ary
outc
omes
Hea
lth-r
elat
ed o
utco
mes
►
Com
plia
nce
with
tre
atm
ent/
med
icat
ion.
►
Dec
reas
ed e
xace
rbat
ion
of s
ymp
tom
s.
►D
ecre
ased
mor
talit
y an
d m
orb
idity
.
►N
egat
ive
outc
omes
from
the
use
of t
he in
terv
entio
n/si
de
effe
cts.
Tab
le 1
C
ontin
ued
Con
tinue
d
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Open access
outcome chains and other programme logic models. A realist matrix focuses on the causal mechanisms at work in a programme or project,27 and it helps to map the factors from a programme that may be contributing to outcomes by reflecting on:
► Agency: whose actions exactly are causing the change to occur?
► Context: what are the external variables or ‘moder-ators’ that affect outcomes? Including the impact of the social and political situation, broad social or geographic features and different population profiles.
► Resources: what resources have been provided or are available?
► Mechanism: how are the resources and the thing/person being changed interact?
► Outcome: what is the anticipated change relating to self-efficacy and self-management under the specified conditions?
Patient and public involvementOur research question was formulated through a collab-orative process with the South-Western Sydney Local Innovative Partnership comprising policy makers, health-care providers and field experts involved in service provi-sion to key vulnerable communities. We did not involve patients directly in this process.
resultsFrom 1540 records initially identified, 1111 duplicates were removed, and a further 869 were excluded after title and S
elec
tio
n cr
iter
iaIn
clus
ion
Exc
lusi
on
Set
ting
A c
omm
unity
-bas
ed p
rimar
y he
alth
care
set
ting
such
as
gene
ral p
ract
ice
prim
ary
heal
thca
re c
linic
s, A
bor
igin
al h
ealth
care
cen
tres
; com
mun
ity h
ealth
care
clin
ics
and
aft
er-h
ours
GP
clin
ics
with
in a
hos
pita
l or
any
com
bin
atio
n of
the
se s
ettin
gs.
This
incl
udes
prim
ary
heal
th c
are
(PH
C) s
ervi
ces
pro
vid
ed in
a p
erso
n’s
hom
e.O
utp
atie
nt c
linic
s su
ch a
s ca
rdia
c re
hab
ilita
tion
and
dia
bet
es c
linic
s (m
ay b
e on
or
adja
cent
to
a ho
spita
l site
) if t
hey
cate
r fo
r p
eop
le r
esid
ing
in t
he c
omm
unity
and
p
rovi
de
valu
able
ser
vice
s fo
r th
e m
anag
emen
t of
chr
onic
con
diti
ons.
Sol
ely
inp
atie
nt h
osp
ital-
bas
ed s
ervi
ces.
Non
-hea
lth-b
ased
set
tings
, tha
t is
, gym
s, p
rivat
e in
sura
nce
com
pan
ies
and
so
on.
GP,
gen
eral
pra
ctiti
oner
; IM
PAC
T, In
nova
tive
Mod
els
Pro
mot
ing
Acc
ess-
to-C
are
Tran
sfor
mat
ion.
Tab
le 1
C
ontin
ued
Table 2 Quality appraisal
Assessment of rigour
1. Is there a clear statement of the aims of the research?
2. Did the study include an appropriate comparison group?
3. Did the study use appropriate eligibility criteria to obtain its target group?
4. Did the study use standardised methods for selecting/putting people into the study and state how they did this?
5. Did the study provide details about sample size?
6. Did the study have a comparatively long study period (≥6 months)?
7. Is the methodology appropriate for what they were trying to achieve?
Assessment of relevance
1. Is the intervention programme description detailed?
2. Did the study describe factors that affected programme implementation?
3. Did the study consider reasons for the results that they achieved?
4. Did the study discuss reasons for programme success or failure?
Based on: O’Campo et al.25
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7Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
abstract screening. Eligibility was frequently difficult to assess from the title and abstract, so 243 citations under-went a brief full-text review, resulting in 192 exclusions. We identified nine additional related publications that were also eligible. Fifty-nine citations underwent data extraction. Thirty were excluded on the basis that they described simple telemonitoring only, did not provide data related to the intervention, were of an incorrect publication type or contained a population not meeting our definition of vulnerable. Twenty-nine citations relating to 18 separate studies were ultimately included (figure 2).20
Randomised controlled trials (RCTs) and cluster RCTs were the predominant study types. Two studies compared alternative interventions.28 29
Appraisal of studies for rigour and relevanceGenerally, studies were of moderate to high rigour (15/18 studies), and 12/18 studies provided additional valuable contextual information (tables 3–6).
Assessment of self-efficacy and self-management from study reported outcomesStudies predominantly assessed a range of clinical and functional outcomes. Several proxy outcomes (that might reasonably be used to make assumptions about the effect on self-efficacy and self-management) were included such as feasibility, satisfaction and acceptability (tables 3–6). Several studies reported positive changes in health behaviour (improved lifestyle indicators), increased compliance and adherence to lifestyle goals and satisfaction with services.
From our logic model, we anticipated that access to reli-able electronic tools, supported through a healthcare envi-ronment, would enhance patients’ ability to obtain, process and understand relevant health information (health literacy), thereby improving efficacy and their capacity to self-manage their chronic condition. The information provided by the studies was inconclusive as to whether this was achieved. Only one study29 actively assessed health
literacy and tailored their intervention accordingly. No studies assessed e-health literacy.
Overall satisfaction with the use of eHealth and tele-health tools by patients was generally positive. Satisfaction was directly related to the participant’s perceived relevance of the tools and the level of positivity in the relationship with the intervention provider. In two studies,30 31patients expressed high levels of satisfaction from their interac-tion with nurses, which promoted better understanding of their condition. Others showed high levels of willingness among patients to use telemonitoring equipment (95%) and recommend it to others (90%) or pay for telehealth services32 and a sense that equipment helped them to monitor and improve their health.33
theoretical basis for the interventionsFor most studies, the choice of intervention had no docu-mented theoretical basis. Interventions developed from either a supporting rationale or belief in the benefit of the intervention. These broad principles or frameworks surrounded equitable access, evidence-based medicine, quality improvement, cost effectiveness, better disease management (chronic care and transitional models) and the improvement of health literacy. Only two associated studies specifically commented on the theoretical basis underpinning their intervention.34 35 This incorporated motivational interviewing ‘grounded in social cogni-tive theory constructs of self-efficacy, social support and outcome expectancies, which emphasized the building of participant skills in behaviour change strategies’.
theory mappingWe used theory to explore how electronic, mobile and telehealth interventions might influence an individu-al’s response (through learning and behaviour change) towards self-efficacy and self-management. Self-efficacy and self-management are interwoven concepts. Self-efficacy is the sense of patient confidence in their ability to exert
Figure 1 Logic model.
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Open access
control over their own motivation, behaviour and social environment, and self-management is active participation by the patient in their own healthcare.
The theory of self-efficacy stems from social cognitive theory and describes the interaction between behavioural, personal and environmental factors in relation to health and chronic disease.36 Confidence in the ability to perform specific health behaviours will subsequently influence which behaviours patients will engage in36–38 and is an important driver of sustained behaviour change.8
The components of self-efficacy theory that influences actions are performance accomplishments, vicarious expe-rience, social persuasion and physiological and emotional states.39 From our matrix (table 7), the study interventions used a range of resources designed to increase patient skill mastery such as assessment and feedback,34 goal setting,28 29 34 35 40 41 workbooks,29 34 35 websites and training to use tools.33 41 42 Additional resource materials that encouraged participation or guided participants through the intervention process were frequently provided and translated.32 43
Mastery with the ‘technology divide’ was inbuilt in some interventions but not all. Self-efficacy can be enhanced by
observing and interacting with those who have had similar experiences (ie, via vicarious experience). When we observe others succeed through sustained effort (eg, lose weight), this raises our beliefs that we too possess the capabilities to master the activities needed for success in that area.
Within the included studies vicarious experience was not overtly targeted with the exception of the study by Cher-rington et al,40 which used peer community health workers (with diabetes or caring for someone with diabetes) to link patients with diabetes to primary care via a web application and telephone coaching.
The largest concentration of effort within the interven-tions related to social persuasion or those activities where people are led, through suggestion, into believing that they can achieve a task. This was provided through motivational interviewing to manage expectations,35 40 behavioural acti-vation approaches28 33 40 41 44 and counselling.29 44 Activities were purposefully designed to provide encouragement (eg, goal setting), were easily attainable and focused on achievements and rewards.35 Physical and/or psychological morbidities were common among the populations, and due to the negative judgements and emotional reactions that go hand in hand with these conditions, significant effort
Figure 2 PRISMA flow chart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
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rotected by copyright.http://bm
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pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
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Open access
Tab
le 3
Te
lehe
alth
stu
die
s
Stu
dy,
co
untr
yVu
lner
abili
ty/
chro
nic
dis
ease
Inte
rven
tio
n an
d
com
par
ato
rC
om
po
nent
s an
d d
eliv
ery
of
the
inte
rven
tio
nO
utco
mes
ass
esse
dR
igo
ur/r
elev
ance
Dw
ight
-Joh
nson
et
al47
, 20
11,
US
A
His
pan
ic p
rimar
y ca
re p
atie
nts
with
d
epre
ssio
n in
rur
al
Was
hing
ton,
US
A.
Tele
pho
ne-b
ased
C
BT
vers
us
enha
nced
usu
al
care
.
Eig
ht s
essi
ons
of C
BT
by
tele
pho
ne. P
atie
nt g
iven
a
wor
kboo
k tr
ansl
ated
to
Sp
anis
h. S
essi
ons
cond
ucte
d
by
five-
par
t tim
e S
pan
ish-
spea
king
the
rap
ists
with
a
mas
ter’s
in s
ocia
l wor
k.
Sat
isfa
ctio
n, s
ymp
tom
se
verit
y, u
se o
f m
edic
atio
n an
d u
pta
ke/
imp
lem
enta
tion.
Mod
erat
e/th
in
Eak
in e
t al
48,
Aus
tral
ia*
Prim
ary
care
p
atie
nts
with
in a
so
cioe
cono
mic
ally
d
isad
vant
aged
re
gion
of
Que
ensl
and
, A
ustr
alia
, with
m
ultip
le c
omor
bid
ch
roni
c co
nditi
ons.
Tele
pho
ne
coun
selli
ng
inte
rven
tion
(wei
ght
and
phy
sica
l ac
tivity
) ver
sus
usua
l car
e.
Mai
led
wor
kboo
k w
ith in
form
atio
n on
hea
lthy
eatin
g an
d P
A a
nd a
ped
omet
er. 1
8 p
hone
cal
ls o
ver
12 m
onth
s fr
om s
tud
y co
unse
llors
. Cal
ls w
ent
from
b
iwee
kly
to m
onth
ly a
nd u
sed
the
4A
s ap
pro
ach
(ass
essm
ent
and
feed
bac
k, a
dvi
ce o
n PA
and
d
iet,
ass
ista
nce
with
goa
l set
ting
and
dev
elop
ing
a p
erso
nalis
ed p
lan
for
mod
ifyin
g PA
and
die
t ac
cord
ing
to g
uid
elin
e re
com
men
dat
ions
and
arr
angi
ng fo
llow
-up
sup
por
t in
the
form
of s
ubse
que
nt c
alls
).
PA le
vels
and
die
t,
no m
eetin
g gu
idel
ine
reco
mm
end
atio
ns, u
pta
ke/
imp
lem
enta
tion.
Hig
h/th
ick
Eak
in e
t al
,A
ustr
alia
49 5
0 * A
dul
t p
atie
nts
with
ty
pe
2 d
iab
etes
from
a
soci
oeco
nom
ical
ly
dis
adva
ntag
ed a
rea
of Q
ueen
slan
d,
Aus
tral
ia.
Tele
pho
ne
del
iver
ed w
eigh
t lo
ss in
terv
entio
n (li
ving
wel
l with
d
iab
etes
) ver
sus
usua
l car
e.
Wor
kboo
k an
d u
p t
o 27
tel
epho
ne c
alls
ove
r 18
mon
ths.
The
tel
epho
ne c
ouns
ello
r w
orks
with
p
artic
ipan
ts t
o en
cour
age
red
uced
ene
rgy
inta
ke
by
2000
kJ
per
day
and
30
min
a d
ay o
f mod
erat
e-in
tens
ity, p
lann
ed a
ctiv
ity. M
ultim
odal
beh
avio
ur
ther
apie
s ar
e us
ed t
o p
rom
ote
self-
mon
itorin
g, g
oal
sett
ing,
pro
ble
m s
olvi
ng, s
ocia
l sup
por
t, s
timul
us
cont
rol,
pos
itive
sel
f-ta
lk a
nd s
elf-
rew
ard
.
No
mee
ting
pro
gram
me
targ
ets
for
die
t, p
hysi
cal
activ
ity, w
eigh
t lo
ss, w
eigh
t ci
rcum
fere
nce,
leve
ls o
f PA
an
d u
pta
ke.
Hig
h/th
ick
Gab
rielia
n et
al30
201
3,U
SA
Pre
viou
sly
hom
eles
s ve
tera
ns w
ith
chro
nic
dis
ease
who
ha
ve b
een
reho
used
th
roug
h U
S D
ept.
of
Hou
sing
and
U
rban
Dev
elop
men
t S
upp
ortiv
e H
ousi
ng
Pro
gram
.
Car
e C
oord
inat
ion
Hom
e Te
lehe
alth
(C
CH
T) p
lus
pee
r su
pp
ort
for
‘tec
hnol
ogy
div
ide’
ve
rsus
usu
al c
are.
CC
HT
– p
roto
col d
riven
inho
me
mes
sagi
ng a
nd
reco
rdin
g of
dai
ly m
onito
ring
tran
smitt
ed v
ia t
he
pho
ne a
nd s
trat
ified
acc
ord
ing
to t
hree
ris
k ca
tego
ries
(col
our
cod
ed) p
rom
ptin
g a
tele
pho
ne c
all b
y R
N
whe
re in
dic
ated
.B
iwee
kly
vete
ran
sup
por
t b
y p
eers
.
Feas
ibili
ty, s
atis
fact
ion.
Wea
k/th
in Con
tinue
d
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rotected by copyright.http://bm
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MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
10 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Stu
dy,
co
untr
yVu
lner
abili
ty/
chro
nic
dis
ease
Inte
rven
tio
n an
d
com
par
ato
rC
om
po
nent
s an
d d
eliv
ery
of
the
inte
rven
tio
nO
utco
mes
ass
esse
dR
igo
ur/r
elev
ance
Gel
lis e
t al
31 2
014,
US
AM
edic
ally
frai
l ol
der
hom
ebou
nd
ind
ivid
uals
with
C
OP
D o
r C
HF
and
com
orb
id
dep
ress
ion.
Pat
ient
s w
ere
recr
uite
d fr
om
a ho
spita
l-af
filia
ted
ho
me
care
age
ncy,
w
hich
ser
vice
s lo
w-
inco
me
peo
ple
.
Inte
grat
ed
Tele
heal
th
Ed
ucat
ion
and
A
ctiv
atio
n M
odel
ve
rsus
usu
al
care
with
inho
me
nurs
ing
plu
s p
sych
oed
ucat
ion.
Tele
mon
itorin
g fo
r ch
roni
c ill
ness
and
dep
ress
ion
care
m
anag
emen
t, a
nd P
rob
lem
-Sol
ving
The
rap
y (P
ST)
fo
r co
mor
bid
dep
ress
ion.
Pat
ient
s w
ere
give
n an
in
hom
e d
evic
e to
log
sym
pto
ms
and
mea
sure
men
ts
dai
ly. N
urse
s co
ntac
ted
for
follo
w-u
p w
here
req
uire
d.
Nur
ses
pro
vid
ed b
rief P
ST
over
the
pho
ne fo
r 8
wee
ks.
Sym
pto
m s
ever
ity,
num
ber
of E
D v
isits
/d
ays
hosp
italis
ed,
pro
ble
m s
olvi
ng s
kills
and
sa
tisfa
ctio
n.
Mod
erat
e/th
in
Kah
n et
al51
200
9, U
SA
Dis
adva
ntag
ed –
M
emb
ers
of G
old
C
hoic
e, a
par
tially
ca
pita
ted
Med
icai
d
man
aged
car
e p
rogr
amm
e fo
r in
div
idua
ls w
ith
dia
bet
es a
nd a
b
ehav
iour
al h
ealth
d
iagn
osis
.
Tele
pho
nic
nurs
e ca
se m
anag
emen
t (T
NC
M).
No
com
par
ison
gr
oup
.
The
TNC
M m
onito
rs m
emb
ers
with
dia
bet
es b
etw
een
offic
e vi
sits
, pro
vid
es d
iab
etes
cou
nsel
ling
and
fa
cilit
ates
sel
f-ca
re b
y re
min
din
g th
e p
atie
nts
abou
t ap
poi
ntm
ents
, lab
wor
k an
d s
pec
ialty
ref
erra
ls.
Issu
es r
elat
ing
to
imp
lem
enta
tion.
Wea
k/th
in
Pic
kett
et
al52
201
4,
US
AR
ecen
tly
hosp
italis
ed o
lder
ad
ults
(>55
yea
rs)
in a
n ur
ban
acu
te
care
hos
pita
l with
d
epre
ssio
n.
Tele
pho
ne
faci
litat
ed
dep
ress
ion
care
ve
rsus
usu
al c
are.
Thos
e in
the
faci
litat
ed g
roup
wer
e re
asse
ssed
b
y te
lep
hone
at
2, 4
, 6, 8
and
12
wee
ks, r
ecei
ving
te
chni
que
s fo
r p
rob
lem
sol
ving
, beh
avio
ural
ac
tivat
ion,
sel
f-m
anag
emen
t, m
onito
ring
resp
onse
to
trea
tmen
t an
d c
ount
erin
g p
rem
atur
e d
isco
ntin
uatio
n of
med
icat
ion.
Initi
atio
n of
med
icat
ion/
pre
scrib
ing.
Mod
erat
e/th
in
She
ldon
et
al44
201
4,U
SA
Low
-inc
ome
cultu
rally
div
erse
p
atie
nts
with
d
epre
ssio
n at
tend
ing
any
of e
ight
prim
ary
care
clin
ics.
Tele
pho
ne
Ass
essm
ent
Sup
por
t an
d
Cou
nsel
ling
Pro
gram
.N
o co
mp
aris
on
grou
p.
Six
tel
epho
ne c
alls
(one
ass
essm
ent
and
up
to
five
ther
apy
calls
) cov
erin
g b
ehav
iour
al a
ctiv
atio
n fo
r d
epre
ssio
n (fo
rm o
f CB
T) a
nd m
otiv
atio
nal
inte
rvie
win
g st
rate
gies
into
med
icat
ion
adhe
renc
e an
d
dep
ress
ion
coun
selli
ng.
Rec
ruitm
ent,
eng
agem
ent/
rete
ntio
n an
d fi
del
ity.
Mod
erat
e/th
ick
Tab
le 3
C
ontin
ued
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
11Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
within the interventions targeted cognitive behavioural pursuits, reframing and increasing positive experiences and pleasurable activities.
Contextual factors identifiedThere was extensive contextual heterogeneity among the interventions (table 8). Patients were enrolled from a range of primary care settings (general practice, commu-nity health, supported veteran programmes, outpatient programmes, community home care and US federally funded health centres/Medicaid). The interventions were overwhelmingly home based and some unsupervised. Interventions targeted populations with a range of chronic conditions and vulnerabilities (older age >55 years, low socioeconomic status, difficulties with accommodation (previously homeless persons in supported accommoda-tion, and rural communities with a mixture of lower socio-economic and underserved populations). Studies largely were artificial environments where intervention providers were put in place specifically for the period of the research. In some studies, it was not possible to know the degree to which routine clinical/service staff were incorporated into the delivery of the intervention. Some services ‘tagged’ interventions onto existing service structure, and in many cases extra services and staff were temporarily employed to conduct interventions. Only one study32 had a system of ‘organisational readiness’ where significant time had been spent developing a mental health service that could provide depression treatment to patients.
Interactions involved a range of primary care providers (nurses, counsellors, diabetes educators, pharmacists and lay/peer workers). Although providers were predominantly nurses operating in a variety of roles, there was no evidence that this was associated with a different outcome to that of other providers. Surprisingly, general practitioners (GPs) (or their equivalents) did not deliver any of the interven-tions so no conclusions could be drawn about their role in delivering or negotiating these interventions with patients. Interventions were additional to the care of the GP or compared with the usual care provided by the GP. In some cases, enhanced usual care was used and in others the GP was peripheral to the main intervention activity in that they prescribed medications or reviewed guidelines with the patient or participated in dialogue with the intervention staff over management.
Nine studies were subcategorised as providing a purely telehealth intervention, seven combined eHealth elements with telehealth, one was a mix of mHealth and eHealth and one was predominantly mHealth (tables 4–7). All but one study provided a telephone-based service. Interventions were all multicomponent and designed to address one or more health disparity for underserved populations. In addi-tion to telephone or video support, interventions provided a varied range of additional components including but not limited to: in home devices with prompts (6 studies), self-management education (15 studies), brief counselling (7 studies), ancillary patient devices (eg, pedometers, BP cuffs and blood glucose monitors) (6 studies), paper or S
tud
y, c
oun
try
Vuln
erab
ility
/ch
roni
c d
isea
seIn
terv
enti
on
and
co
mp
arat
or
Co
mp
one
nts
and
del
iver
y o
f th
e in
terv
enti
on
Out
com
es a
sses
sed
Rig
our
/rel
evan
ce
Wol
f et
al29
201
4,U
SA
Pat
ient
s w
ith t
ype
2 d
iab
etes
att
end
ing
fed
eral
ly q
ualifi
ed
heal
th c
entr
es
des
igne
d t
o ca
ter
for
und
erse
rved
US
co
mm
uniti
es.
Two
inte
rven
tion
arm
s:1.
Car
ve in
(clin
ic
bas
ed).
2. C
arve
out
(o
utso
urce
d
tele
pho
ne-b
ased
su
pp
ort).
Car
ve in
: pat
ient
dia
bet
es g
uid
e, b
rief c
ouns
ellin
g an
d
actio
n p
lan
with
prim
ary
care
pro
vid
er w
ith t
elep
hone
fo
llow
-up
at
2 w
eeks
and
2 m
onth
s an
d v
ia p
hone
or
in p
erso
n at
3, 6
and
9 m
onth
s.C
arve
out
: dia
bet
es g
uid
e d
istr
ibut
ed b
y p
rimar
y ca
re
pro
vid
er a
nd r
efer
ral t
o te
lep
hone
dia
bet
es e
duc
ator
w
ho fa
cilit
ates
act
ion
pla
n an
d fo
llow
-up
. Cou
nsel
ling
pro
vid
ed b
y a
rese
arch
ass
ista
nt. P
atie
nt fo
llow
ed u
p
at s
ame
inte
rval
s as
car
ve in
by
dia
bet
es e
duc
ator
.
Kno
wle
dge
/lite
racy
, Hb
A1c
, sy
stol
ic B
P a
nd L
DL
chol
este
rol,
upta
ke a
nd
satis
fact
ion
with
ser
vice
.
Mod
erat
e/th
ick
*Ass
ocia
ted
cita
tions
. B
P, b
lood
pre
ssur
e; C
BT,
cog
nitiv
e–b
ehav
iour
al t
hera
py;
CO
PD
, chr
onic
ob
stru
ctiv
e p
ulm
onar
y d
isea
se; L
DL,
low
-den
sity
lip
opro
tein
; PA
, phy
sica
l act
ivity
; RN
, Reg
iste
red
Nur
se; C
HF,
co
nges
tive
hear
t fa
ilure
; ED
, em
erge
ncy
dep
artm
ent
Tab
le 3
C
ontin
ued
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
12 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Tab
le 4
eH
ealth
and
tel
ehea
lth s
tud
ies
Stu
dy,
co
untr
yVu
lner
abili
ty/c
hro
nic
dis
ease
Inte
rven
tio
n d
escr
ipti
on
Co
mp
one
nts
and
del
iver
y o
f th
e in
terv
enti
on
Out
com
es a
sses
sed
Rig
our
/rel
evan
ce
Car
doz
a an
d
Ste
inb
erg53
201
0,U
SA
Eld
erly
pat
ient
s fo
llow
ing
dis
char
ge
from
an
inp
atie
nt
sett
ing
with
a d
iagn
osis
of
HF,
CO
PD
, DM
or
HTN
.
Cas
e m
anag
ed
tele
med
icin
e.N
o co
mp
aris
on
grou
p.
Con
diti
on-b
ased
inst
rum
ents
incl
udin
g a
scal
e, d
igita
l BP,
he
art
rate
mon
itor,
pul
se o
xim
eter
, glu
com
eter
and
‘hea
lthy
bud
dy’
—a
tele
pho
ne m
odem
for
info
rmat
ion
tran
smis
sion
m
onito
red
dai
ly b
y a
nurs
e. F
ailu
re t
o tr
ansm
it d
ata
inst
igat
ed
an F
U P
C o
r ho
me
visi
t. H
ome
visi
ts a
vera
ging
1–3
a w
eek
for
60 d
ays
incl
udin
g re
view
of c
ond
ition
, com
plia
nce,
pat
ient
ed
ucat
ion.
Dis
ease
man
agem
ent
soft
war
e p
rogr
amm
e tr
acke
d p
atie
nts
over
tim
e, a
nd s
ymp
tom
ass
essm
ent
was
per
form
ed t
hrou
gh
pat
ient
car
e m
anag
emen
t sy
stem
tha
t re
cord
ed n
ine
qua
lity
of c
are
ind
icat
ors
(pai
n, d
ysp
noea
, urin
ary
inco
ntin
ence
, d
ress
ing,
bat
hing
, toi
letin
g, t
rans
ferr
ing,
am
bul
atio
n an
d
med
icat
ion
man
agem
ent).
Reh
osp
italis
atio
n an
d
emer
genc
y d
epar
tmen
t vis
its,
com
plia
nce,
qua
lity
of h
ealth
p
erce
ptio
n, q
ualit
y of
car
e,
mor
talit
y an
d s
atis
fact
ion.
Mod
erat
e/th
in
Che
rrin
gton
et
al40
20
15, U
SA
†54 5
5 Lo
w-i
ncom
e A
fric
an-
Am
eric
an p
atie
nts
from
saf
ety
net
neig
hbou
rhoo
ds
with
p
oorly
con
trol
led
typ
e 2
dia
bet
es p
lus
pee
r su
pp
ort
Com
mun
ity
Hea
lth W
orke
rs (C
HW
) w
ho e
ither
als
o ha
d
typ
e 2
dia
bet
es o
r ca
red
for
som
eone
with
d
iab
etes
.
Dia
bet
es
Con
nect
web
ap
plic
atio
n an
d t
elep
hone
co
achi
ng a
nd
goal
set
ting
pro
vid
ed b
y p
eer
sup
por
t C
HW
.
Dia
bet
es C
onne
ct w
eb a
pp
licat
ion
that
allo
wed
for
com
mun
icat
ion
bet
wee
n th
e C
HW
, the
pat
ient
and
the
d
iab
etes
tea
m.
The
web
ap
plic
atio
n co
nsis
ted
of t
hree
cor
e fe
atur
es:
1. C
onta
ct t
rack
ing
and
cal
l rem
ind
er s
yste
m.
2. S
ecur
e co
mm
unic
atio
n sy
stem
.3.
Pro
gres
s re
por
ts.
CH
Ws
wer
e al
loca
ted
to
pat
ient
s an
d p
rovi
ded
tel
epho
ne
coac
hing
and
goa
l set
ting
to p
atie
nts
via
tele
pho
ne (w
eekl
y fo
r 3
mon
ths
and
mon
thly
for
anot
her
3 m
onth
s). T
hey
also
he
ld a
mon
thly
sup
por
t/ed
ucat
ion
grou
p a
nd t
rack
ed p
atie
nt
pro
gres
s ov
er t
ime
and
link
ed t
hem
with
the
Dia
bet
es H
ealth
Te
am a
nd a
cted
as
a m
edia
tor
bet
wee
n th
e p
atie
nt a
nd
prim
ary
care
.S
elf-
man
agem
ent
educ
atio
n w
as p
rovi
ded
by
the
CH
W
thro
ugh
grou
p/t
elep
hone
and
face
-to-
face
inte
ract
ions
. CH
Ws
wer
e tr
aine
d in
com
mun
icat
ion,
pro
ble
m s
olvi
ng, g
oal s
ettin
g,
mot
ivat
iona
l int
ervi
ewin
g (2
4 ho
urs)
and
via
onl
ine
mod
ules
on
grou
p fa
cilit
atio
n, b
asic
res
earc
h an
d c
onfid
entia
lity.
Pro
cess
out
com
es fr
om
web
-bas
ed a
pp
licat
ion
(num
ber
of c
onta
cts
and
nu
mb
er o
f goa
ls s
et).
Qua
litat
ive
feed
bac
k re
gard
ing
CH
W r
oles
, goa
ls
and
cha
lleng
es a
nd fe
edb
ack
abou
t m
essa
ging
sys
tem
and
tr
acki
ng o
f pat
ient
s. B
arrie
rs
to p
atie
nt s
elf-
man
agem
ent.
Mod
erat
e/th
ick
Cho
ng a
nd M
oren
o32
2012
,U
SA
His
pan
ic lo
w-
inco
me
pat
ient
s of
a
com
mun
ity h
ealth
ce
ntre
with
maj
or
dep
ress
ion.
Tele
psy
chia
try
serv
ices
thr
ough
th
e in
tern
et u
sing
a
web
cam
ver
sus
usua
l car
e.
Mon
thly
tel
epsy
chia
try
sess
ions
at
the
com
mun
ity h
ealth
ce
ntre
for
6 m
onth
s p
rovi
ded
by
one
of t
wo
His
pan
ic
psy
chia
tris
ts u
sing
an
onlin
e vi
rtua
l mee
ting
pro
gram
me.
Sym
pto
m s
ever
ity/in
cid
ence
,ac
cep
tab
ility
of
tele
psy
chia
try,
feas
ibili
ty
of im
ple
men
ting
a te
lep
sych
iatr
y p
rogr
amm
e an
d s
atis
fact
ion
with
car
e.
Mod
erat
e/th
ick
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
13Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Stu
dy,
co
untr
yVu
lner
abili
ty/c
hro
nic
dis
ease
Inte
rven
tio
n d
escr
ipti
on
Co
mp
one
nts
and
del
iver
y o
f th
e in
terv
enti
on
Out
com
es a
sses
sed
Rig
our
/rel
evan
ce
Dav
is e
t al
56 2
011,
US
A†57
58
Vete
rans
from
m
inor
ity g
roup
s w
ith
dep
ress
ion.
Tele
med
icin
e E
nhan
ced
A
ntid
epre
ssan
t M
anag
emen
t st
udy
vers
us
usua
l car
e.
Ste
pp
ed c
are
mod
el o
f dep
ress
ion
trea
tmen
t fo
r up
to
12 m
onth
s. T
he o
ff-si
te in
terv
entio
n te
am fo
cuse
d o
n op
timis
ing
pha
rmac
othe
rap
y. T
he R
N u
sed
a s
crip
ted
uni
form
p
roto
col d
urin
g te
lep
hone
cal
ls t
o p
atie
nts
to a
dd
ress
tr
eatm
ent
bar
riers
and
rea
sons
for
non-
adhe
renc
e an
d
stra
tegi
es fo
r m
anag
ing
sid
e ef
fect
s. A
pha
rmac
ist
calle
d
pat
ient
s w
ho h
ad n
ot r
esp
ond
ed t
o tr
eatm
ent
to p
rovi
de
man
agem
ent.
Psy
chia
tris
ts s
uper
vise
d t
he o
ff-si
te t
eam
and
p
rovi
ded
con
sulta
tions
via
inte
ract
ive
vid
eo/S
kyp
e.
Dep
ress
ion-
rela
ted
PC
en
coun
ters
and
uni
nten
ded
in
crea
se in
non
-dep
ress
ion-
rela
ted
sp
ecia
lty P
H
enco
unte
rs.
Res
pon
se r
ate,
cos
t.
Mod
erat
e/th
ick
Fort
ney
et a
l28 2
013,
US
AM
edic
ally
und
erse
rved
p
atie
nts
with
d
epre
ssio
n at
tend
ing
five
fed
eral
ly q
ualifi
ed
rura
l hea
lth c
entr
es.
Two
inte
rven
tion
arm
s:1.
Pra
ctic
e-b
ased
co
llab
orat
ive
care
.2.
Tel
emed
icin
e-b
ased
co
llab
orat
ive
care
.
1. P
ract
ice-
bas
ed c
olla
bor
ativ
e ca
re: u
psk
illed
sta
ff at
clin
ic
educ
atio
n/ac
tivat
ion,
sel
f-m
anag
emen
t go
al s
ettin
g.2.
Tel
emed
icin
e-b
ased
col
lab
orat
ive
care
: Ful
l-tim
e d
epre
ssio
n ca
re m
anag
er –
ste
pp
ed d
epre
ssio
n ca
re b
ased
on
pro
toco
ls w
ith m
edic
atio
n m
anag
emen
t b
y p
harm
acis
t.
Psy
chia
tric
con
sulta
tion
via
vid
eo c
onfe
renc
ing.
CB
T w
as
pro
vid
ed b
y vi
deo
conf
eren
cing
.
No
of p
rimar
y ca
re a
nd
men
tal h
ealth
vis
its, l
evel
s of
pre
scrib
ing,
res
pon
se,
rem
issi
on, s
atis
fact
ion
and
fid
elity
/up
take
.
Mod
erat
e/th
ick
She
a et
al43
U
SA
†59 6
0 O
lder
, eth
nica
lly
div
erse
, Med
icar
e b
enefi
ciar
ies
with
d
iab
etes
livi
ng in
fe
der
ally
des
igna
ted
un
der
serv
ed a
reas
of
New
Yor
k st
ate.
Tele
med
icin
e (ID
EAT
el) v
ersu
s us
ual c
are.
Hom
e te
lem
edic
ine
unit
to v
ideo
conf
eren
ce w
ith a
dia
bet
es
educ
ator
eve
ry 4
–6 w
eeks
for
self-
man
agem
ent
educ
atio
n,
revi
ew o
f tra
nsm
itted
hom
e b
lood
glu
cose
and
blo
od p
ress
ure
mea
sure
men
ts a
nd in
div
idua
lised
goa
l set
ting.
Acc
ess
to
spec
ial e
duc
atio
nal w
eb p
age
crea
ted
for
the
pro
ject
in b
oth
Eng
lish
and
Sp
anis
h.
Phy
sica
l im
pai
rmen
t, a
nd
phy
sica
l act
ivity
and
sel
f-re
por
ted
ped
omet
er u
se.
BP,
Hb
A1c
and
cho
lest
erol
.
Mod
erat
e/th
ick
She
eran
et
al42
201
1,U
SA
Pat
ient
s ov
er 6
5 ye
ars
with
dep
ress
ion
(Eng
lish
and
Sp
anis
h sp
eaki
ng) w
ho w
ere
enro
lled
in h
omec
are
with
one
of t
hree
ho
mec
are
agen
cies
(V
erm
ont,
New
Yor
k an
d F
lorid
a).
Tele
mon
itor-
bas
ed
Dep
ress
ion
Car
e M
anag
emen
t (D
CM
) –
Dep
ress
ion
Tele
-ca
re P
roto
col.
No
com
par
ison
gr
oup
.
The
DC
M (n
urse
or
soci
al w
orke
r) c
oord
inat
es c
are
bet
wee
n th
e p
atie
nt, p
hysi
cian
and
men
tal h
ealth
sp
ecia
list.
Tele
mon
itors
mea
sure
dai
ly w
eigh
t, b
lood
sug
ar a
nd h
eart
ra
te t
hrou
gh c
him
e (s
ynth
etic
voi
ce t
hrou
gh s
pea
kers
) or
touc
h sc
reen
, whi
ch p
rom
pts
pat
ient
s to
ent
er m
easu
rem
ents
. Th
ey a
lso
ask
sim
ple
que
stio
ns a
bou
t he
alth
and
pro
vid
e b
asic
ed
ucat
ion.
Pro
toco
l ele
men
ts a
vaila
ble
in b
oth
Sp
anis
h an
d E
nglis
h.N
urse
s fo
llow
ed u
p p
atie
nts
by
tele
pho
ne a
s ne
eded
on
care
, ed
ucat
ion
and
to
reas
sure
pat
ient
s an
d e
ncou
rage
p
leas
urab
le a
ctiv
ities
and
ass
ess
dep
ress
ion
stat
us.
Sym
pto
m s
ever
ity,
feas
ibili
ty, a
ccep
tab
ility
and
sa
tisfa
ctio
n.
Mod
erat
e/th
ick
BP,
blo
od p
ress
ure;
CB
T, c
ogni
tive–
beh
avio
ural
the
rap
y; C
OP
D, c
hron
ic o
bst
ruct
ive
pul
mon
ary
dis
ease
; DM
, dia
bet
es m
ellit
us; F
U, f
ollo
w-u
p; H
F, h
eart
failu
re; H
TN, h
yper
tens
ion;
P
C, P
rimar
y C
are;
RN
, Reg
iste
red
Nur
se; H
bA
1C, g
lyca
ted
hae
mog
lob
in.
†Ind
icat
es t
here
are
ass
ocia
ted
pub
licat
ions
.
Tab
le 4
C
ontin
ued
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
14 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
electronic patient information resources (9 studies), medi-cation management (7 studies), stepped care (2 studies) and bilingual providers (4 studies).
MechanismsWithin realist synthesis, a mechanism is a response that is triggered by changes in context.13 Given the contextual heterogeneity, it was not possible to clearly identify these reactions.
The level of an individual’s ‘motivation’ or ‘activa-tion’ was one possible mechanism prompting patients to respond either positively or negatively to the situations
in which the intervention was employed.35 44 Feelings of ‘being supported’,32 40 44 having ‘a sense of purpose’,44 experiencing ‘a sense of achievement’44 and the sharing of experiences33 are interwoven reactions that may serve to motivate people. It was difficult to know how the level of rapport/interaction between patient and provider contributed in these instances, although it was highlighted as an important contributor in some studies28 33 42 44 and is a well-recognised enabling factor in self-efficacy and self-management programmes generally.
One study suggested that patients with limited motivation should be excluded from these types of
Table 5 mHealth studies
Study, countryVulnerability/chronic disease
Intervention description
Components and delivery of the intervention
Outcomes assessed
Rigour/relevance
Wayne, 2015,41
Canada61Low SES community (multiracial) with type 2 diabetes.
Cloud-based platform for mobile phone/software-based health management plus smartphone-based health coaching technology.
Participants received a Samsung Galaxy Ace II mobile phone running on Google Android Ice Cream Sandwich (Android 4.0.2) with a data-only carrier plan.Patients received a user account with the Connected Wellness Platform (CWP) provided by NexJ Systems, which supported participants in health-related goal setting and progress monitoring. This allowed individual tracking of key metrics, (blood glucose levels, exercise frequency/duration/intensity, food intake (via photo journaling) and mood). HC primarily focused on planning to reach health targets, exercise (frequency, duration and intensity) and modifying diet to to reduce carbohydrate intake.Communication with the HC 24/7 via secure messaging, scheduled phone contact, and/or during inperson meetings. Health data from the CWP were immediately visible to HCs through a secure, web-accessible portal.Participant data and software-enabled communication required two-way certificate-based authentication and passwords that were stored in encrypted columns. Based on patient’s goals, HCs used the 24 hours/day logging function to guide healthy lifestyle choices, while providing support when clients diverged from intended health goals and routines.Concurrent exercise education programme with trainers and blood glucose testing before and after exercise sessions.
HbA1c levels, weight, BMI, waist circumference, psychometric assessment (satisfaction, QoL and mood).
High/thick
BMI, body mass index; QoL, quality of life; SES, socioeconomic status; HF, heart failure, HbA1c, glycated haemoglobin.
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
15Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Tab
le 6
m
Hea
lth a
nd e
Hea
lth s
tud
ies
Stu
dy,
co
untr
yVu
lner
abili
ty/
chro
nic
dis
ease
Inte
rven
tio
n d
escr
ipti
on
Co
mp
one
nts
and
del
iver
y o
f th
e in
terv
enti
on
Out
com
es
asse
ssed
Rig
our
/re
leva
nce
Dav
is e
t al
, 20
15U
SA
Und
erse
rved
, low
S
ES
, Eng
lish
and
S
pan
ish
spea
king
p
atie
nts
with
a
prim
ary
dia
gnos
is o
f C
OP
D o
r H
F.
Rem
ote
mon
itorin
g d
evic
e (R
MD
), w
hich
co
uld
use
eith
er
land
line
or w
irele
ss
tech
nolo
gy. T
he R
MD
al
low
ed p
atie
nts
to
ente
r sy
mp
tom
-rel
ated
d
ata
such
as
pul
se
oxim
etry
, hea
rt r
ate
and
w
eigh
t. T
he R
MD
was
al
so p
rep
rogr
amm
ed
with
a s
et o
f que
stio
ns
that
ver
bal
ly t
rans
mitt
ed
in E
nglis
h an
d
Sp
anis
h ta
rget
ed t
o sy
mp
tom
atol
ogy.
Inte
grat
ed m
obile
hea
lth t
echn
olog
y an
d h
ome
visi
ts.
The
RM
D o
per
ated
on
land
line
or w
irele
ss s
yste
ms.
The
RM
D w
as
cust
omis
ed b
ased
on
dis
ease
sev
erity
and
allo
wed
pat
ient
s to
en
ter
sym
pto
m-r
elat
ed d
ata
such
as
pul
se o
xim
etry
, hea
rt r
ate
and
w
eigh
t. It
con
sist
ed o
f a p
rep
rogr
amm
ed s
et o
f que
stio
ns t
hat
wer
e ve
rbal
ly t
rans
mitt
ed in
Eng
lish
or S
pan
ish
and
tar
gete
d t
o C
OP
D o
r H
F sy
mp
tom
atol
ogy,
whi
ch w
ere
answ
ered
yes
or
no b
y p
ushi
ng s
pec
ific
but
tons
on
the
dev
ice.
The
RM
D a
lso
incl
uded
an
inte
ract
ive
educ
atio
nal c
omp
onen
t in
whi
ch in
form
atio
n w
as v
erb
ally
tra
nsm
itted
to
the
pat
ient
with
tip
s on
sym
pto
m
man
agem
ent.
Acu
te c
hang
es in
sym
pto
mat
olog
y tr
igge
red
an
acut
e al
ert
that
was
dire
ctly
com
mun
icat
ed t
o th
e R
MD
mon
itorin
g st
aff f
or im
med
iate
res
pon
se.
The
inte
rven
tion
incl
uded
a p
hone
cal
l mad
e to
the
pat
ient
s b
y R
MD
sta
ff or
prim
ary
care
bas
ed o
n p
atie
nt a
nsw
ers.
Dur
ing
this
ca
ll, s
ymp
tom
s w
ere
dis
cuss
ed, m
anag
emen
t w
as r
evie
wed
, ed
ucat
ion
was
pro
vid
ed a
nd t
he p
hysi
cian
was
con
tact
ed if
re
qui
red
. Pho
ne c
alls
wer
e p
rom
pte
d if
the
pat
ient
had
mad
e no
co
ntac
t in
3 d
ays.
Hom
e vi
sits
wer
e m
ade
to s
et u
p t
he d
evic
e w
ithin
1 w
eek
of
dis
char
ge. P
atie
nts
wer
e al
so t
rain
ed t
o us
e th
e d
evic
e. M
edic
atio
n an
d fu
nctio
nal s
tatu
s w
as a
sses
sed
, and
a p
erso
nal h
ealth
pla
n w
as d
evel
oped
, inc
lud
ing
follo
w-u
p b
y th
e p
hysi
cian
. Ad
diti
onal
ho
me
visi
ts w
ere
trig
gere
d t
o p
erfo
rm s
ymp
tom
rev
iew
and
as
req
uire
d u
p u
ntil
90 d
ays
from
enr
olm
ent.
Em
erge
ncy
dep
artm
ent
use
with
in 3
0 d
ays
of
dis
char
ge.
Rea
dm
issi
on r
ates
.Fu
nctio
nal s
tatu
s.S
atis
fact
ion.
Mod
erat
e/th
ick
CO
PD
, chr
onic
ob
stru
ctiv
e p
ulm
onar
y d
isea
se; S
ES
, soc
ioec
onom
ic s
tatu
s.; H
F, h
eart
failu
re
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
16 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Tab
le 7
R
ealis
t m
atrix
Stu
dy
Ag
ency
Co
ntex
tR
eso
urce
sM
echa
nism
s
Out
com
e (a
ntic
ipat
ed
chan
ge
rela
ted
to
sel
f-m
anag
emen
t an
d s
elf-
effi
cacy
)
Tele
heal
th s
tud
ies
Eak
in e
t al
, 200
934U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
stud
y co
unse
llor
del
iver
ing
the
inte
rven
tion
and
th
e p
atie
nt.
Eth
nica
lly d
iver
se p
atie
nts
with
typ
e 2
dia
bet
es fr
om a
reg
ion
on t
he o
utsk
irts
of
a st
ate
cap
ital c
ity in
Aus
tral
ia.
Com
par
ativ
ely
elev
ated
ind
icat
ors
of
soci
al d
isad
vant
age
incl
udin
g a
grea
ter
per
cent
age
of s
ingl
e-p
aren
t fa
mili
es,
unem
plo
ymen
t an
d fo
reig
n-b
orn
resi
den
ts.
Par
ticip
ants
usu
ally
sup
por
ted
thr
ough
a
fee
for
serv
ice
prim
ary
heal
thca
re
pra
ctic
e al
thou
gh in
terv
entio
n is
ho
me
bas
ed a
nd u
nsup
ervi
sed
.C
ouns
ello
rs (m
aste
r’s-l
evel
gra
dua
tes
with
a b
ackg
roun
d in
nut
ritio
n) t
rain
ed
in p
hysi
cal a
ctiv
ity p
rom
otio
n an
d
mot
ivat
iona
l int
ervi
ewin
g te
chni
que
s.
Det
aile
d w
orkb
ook
to p
rom
ote
educ
atio
n on
phy
sica
l act
ivity
and
hea
lthy
eatin
g;
ped
omet
er.
Tele
pho
ne s
upp
ort
pro
vid
ing
asse
ssm
ent
(and
feed
bac
k); a
dvi
ce o
n p
hysi
cal a
ctiv
ity
and
die
t; a
nd a
ssis
tanc
e w
ith g
oal s
ettin
g an
d
a p
erso
nalis
ed p
lan
for
mod
ifyin
g p
hysi
cal
activ
ity a
nd d
iet.
Follo
w-u
p s
upp
ort
in t
he fo
rm o
f sub
seq
uent
te
lep
hone
con
tact
s.
Unk
now
nB
ehav
iour
cha
nge
– in
crea
sed
p
hysi
cal a
ctiv
ity a
nd im
pro
ved
d
iet
(dec
reas
ed c
alor
ies
from
fa
t an
d in
crea
sed
inta
ke o
f fr
uit,
veg
etab
les
and
fib
re).
Eak
in e
t al
, 201
435U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
coun
sello
r d
eliv
erin
g th
e in
terv
entio
n an
d
the
pat
ient
.
Eth
nica
lly d
iver
se p
atie
nts
with
typ
e 2
dia
bet
es fr
om a
reg
ion
on t
he o
utsk
irts
of
a st
ate
cap
ital c
ity in
Aus
tral
ia.
Com
par
ativ
ely
elev
ated
ind
icat
ors
of
soci
al d
isad
vant
age
incl
udin
g a
grea
ter
per
cent
age
of s
ingl
e-p
aren
t fa
mili
es,
unem
plo
ymen
t an
d fo
reig
n-b
orn
resi
den
ts.
Par
ticip
ants
usu
ally
sup
por
ted
thr
ough
a
fee
for
serv
ice
prim
ary
heal
thca
re
pra
ctic
e al
thou
gh in
terv
entio
n is
hom
e b
ased
and
uns
uper
vise
d.
Det
aile
d p
atie
nt w
orkb
ook.
Acc
eler
omet
er w
as w
orn
by
pat
ient
s to
col
lect
p
hysi
cal a
ctiv
ity (P
A) d
ata
and
rec
ord
use
of
dev
ice.
Mot
ivat
iona
l int
ervi
ewin
g p
rovi
din
g su
pp
ort
and
man
agin
g ex
pec
tatio
ns; i
den
tifyi
ng h
ealth
b
enefi
ts o
f wei
ght
loss
; set
ting
goal
s fo
r d
iet
and
PA
; sel
f-m
onito
ring
pro
gres
s; fo
cusi
ng o
n ac
hiev
emen
ts a
nd r
ewar
ds.
Unk
now
n.A
utho
rs p
rop
ose
that
eng
agem
ent
and
mot
ivat
ion
of p
artic
ipan
ts w
as
low
and
onl
y m
otiv
ated
pat
ient
s sh
ould
be
incl
uded
in s
uch
pro
gram
mes
.
Beh
avio
ur c
hang
e –
loss
of
wei
ght,
incr
ease
in m
oder
ate/
vigo
rous
phy
sica
l act
ivity
, and
d
iet
qua
lity.
Imp
rove
d c
linic
al b
iom
arke
rs:
Hb
A1c
, lip
ids
and
BP.
She
ldon
et
al, 2
01444
Unc
lear
– b
ased
on
the
inte
ract
ion
bet
wee
n th
e th
erap
ist
del
iver
ing
the
inte
rven
tion
and
th
e p
atie
nt.
Low
-inc
ome,
cul
tura
lly d
iver
se, m
edic
ally
un
der
serv
ed p
atie
nts
with
dep
ress
ion
in
US
(Med
icai
d).
Sel
f-no
min
atio
n of
fere
d t
o p
atie
nts
thro
ugh
clin
ics
and
dire
ct r
efer
ral o
ptio
ns
by
PC
P.M
ultid
isci
plin
ary
cont
act
and
the
rap
ists
tr
aine
d.
Beh
avio
ural
act
ivat
ion
del
iver
ed a
s b
rief
inte
rven
tion
to r
educ
e se
lf-p
unis
hmen
t an
d
incr
ease
pos
itive
rei
nfor
cem
ent
by
teac
hing
m
ood
mon
itorin
g an
d s
ocia
l eng
agem
ent
(form
of
CB
T).
Pro
toco
l-d
riven
inco
rpor
atin
g la
ngua
ge s
kills
to
fost
er c
olla
bor
atio
n an
d m
otiv
atio
n.M
otiv
atio
nal i
nter
view
ing
to e
nhan
ce
med
icat
ion
adhe
renc
e.Fl
exib
le t
imef
ram
es fo
r p
atie
nts
who
wer
e m
ore
diffi
cult
to r
e-d
irect
– u
p t
o 75
min
s.P
leas
ant
activ
ities
list
.
Mot
ivat
ion:
I w
ant
to t
alk
abou
t m
y p
rob
lem
s an
d s
eek
advi
ce.
Doi
ng t
hing
s w
hen
I don
’t re
ally
feel
lik
e it
will
stil
l hel
p m
e ac
hiev
e m
y go
als.
Rap
por
t w
ith a
‘war
m a
nd o
bje
ctiv
e’
ther
apis
t (th
is p
erso
n un
der
stan
ds
my
issu
es a
nd is
the
re t
o he
lp m
e).
‘The
sel
f-he
lp r
esou
rces
giv
e m
e a
sens
e of
pur
pos
e’.
Thes
e sk
ills
will
be
usef
ul in
the
fu
ture
(ski
ll m
aste
ry).
Imp
rove
d e
ngag
emen
t w
ith
dep
ress
ion
man
agem
ent
and
in
crea
sed
sel
f- m
anag
emen
t es
pec
ially
in r
elat
ion
to
med
icat
ion
man
agem
ent
lead
ing
to im
pro
ved
ad
here
nce.
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
17Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Stu
dy
Ag
ency
Co
ntex
tR
eso
urce
sM
echa
nism
s
Out
com
e (a
ntic
ipat
ed
chan
ge
rela
ted
to
sel
f-m
anag
emen
t an
d s
elf-
effi
cacy
)
Wol
f et
al, 2
01429
*U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
prim
ary
care
clin
ic s
taff
and
th
e p
atie
nt.
Pat
ient
s w
ith t
ype
2 d
iab
etes
att
end
ing
fed
eral
ly q
ualifi
ed h
ealth
cen
tres
(urb
an,
sub
urb
an a
nd r
ural
) des
igne
d t
o ca
ter
for
und
erse
rved
US
com
mun
ities
.D
iab
etes
cha
mp
ion
to d
econ
stru
ct t
asks
an
d a
ssig
n re
spon
sib
ilitie
s to
clin
ic s
taff.
Clin
ic s
taff
trai
ned
in c
ouns
ellin
g—te
ach
bac
k—p
ositi
ve e
ncou
rage
men
t, p
rob
lem
so
lvin
g an
d c
oach
ing
of p
atie
nts
to
dev
elop
act
ion
pla
ns.
Sem
istr
uctu
red
scr
ipt
to e
ncou
rage
st
and
ard
ised
inte
ract
ions
with
pat
ient
s.N
o fin
anci
al s
upp
ort
rece
ived
to
sust
ain
staf
f rol
es.
Car
ve in
: dia
bet
es g
uid
e re
view
ed b
etw
een
pat
ient
s an
d P
C s
taff.
Col
ourf
ul 4
8-p
age
dia
bet
es g
uid
e ta
ilore
d t
o lo
w li
tera
cy le
vels
(fi
fth-
grad
e le
vel)
with
des
crip
tive
pho
togr
aphs
to
dep
ict
self-
care
con
cep
ts.
Pat
ient
eng
agem
ent
activ
ities
del
iver
ed b
y a
nurs
e: b
rief c
ouns
ellin
g in
terv
entio
n an
d a
ctio
n p
lans
and
iter
ativ
e co
unse
lling
pro
cess
to
iden
tify
ind
ivid
ual b
ehav
iour
al g
oals
tha
t ar
e ea
sily
att
aina
ble
and
incr
ease
the
ir co
nfid
ence
.Tr
acki
ng s
yste
m t
o fo
llow
-up
pat
ient
s.
Pat
ient
des
ires
to h
ave
care
p
rovi
ded
with
in t
he P
C p
ract
ice
as o
pp
osed
to
care
from
an
outs
ourc
ed s
ervi
ce (e
ven
if m
ore
spec
ialis
ed).
Imp
rove
d k
now
led
ge s
elf-
man
agem
ent
for
peo
ple
with
lo
w h
ealth
lite
racy
.Im
pro
ved
acc
ess/
upta
ke o
f se
rvic
e.Im
pro
ved
clin
ical
bio
mar
kers
: H
bA
1C, P
B a
nd c
hole
ster
ol.
Pat
ient
sat
isfa
ctio
n.
U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
Pra
ctic
e re
des
ign
to in
corp
orat
e b
rief
dia
bet
es e
duc
atio
n an
d c
ouns
ellin
g.R
efer
ral t
o d
iab
etes
ed
ucat
or.
Trai
ned
res
earc
h st
aff d
eliv
ered
co
unse
lling
.A
t th
e tim
e of
the
inte
rven
tion,
the
re h
ad
bee
n an
inje
ctio
n of
sta
te fu
ndin
g th
at
had
res
ulte
d in
mor
e re
sour
ces
than
had
b
een
pre
viou
sly
avai
lab
le.
Car
ve o
ut: d
iab
etes
gui
de
revi
ewed
bet
wee
n p
atie
nts
and
dia
bet
es e
duc
ator
.C
olou
rful
48-
pag
e d
iab
etes
gui
de
tailo
red
to
low
lite
racy
leve
ls (fi
fth-
grad
e le
vel)
with
d
escr
iptiv
e p
hoto
grap
hs t
o d
epic
t se
lf-ca
re
conc
epts
.P
atie
nt e
ngag
emen
t ac
tiviti
es d
eliv
ered
b
y d
iab
etes
ed
ucat
or: b
rief c
ouns
ellin
g in
terv
entio
n an
d a
ctio
n p
lans
, ite
rativ
e co
unse
lling
pro
cess
to
iden
tify
ind
ivid
ual
beh
avio
ural
goa
ls t
hat
are
easi
ly a
ttai
nab
le a
nd
incr
ease
the
ir co
nfid
ence
.
Aut
hors
pro
pos
e th
at t
he
outs
ourc
ed in
terv
entio
n w
orke
d
bet
ter
for
pat
ient
s w
ho h
ad n
ot
reac
hed
gly
caem
ic c
ontr
ol t
o re
ach
it an
d t
hose
who
wer
e st
able
re
mai
ned
wel
l man
aged
(goa
l at
tain
men
t).
eHea
lth
plu
s te
lehe
alth
Che
rrin
gton
et
al,
2015
40U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
pat
ient
an
d t
he p
eer
CH
W;
the
CH
W a
nd t
he
dia
bet
es t
eam
as
an a
dvo
cate
for
the
pat
ient
; the
CH
W is
in
fluen
ced
by
thei
r in
tera
ctio
n w
ith t
he
prim
ary
care
tea
m.
Afr
ican
-Am
eric
an p
atie
nts
from
un
der
serv
ed/s
afet
y ne
t or
gani
satio
ns in
so
uthe
rn U
SA
.P
atie
nts
wer
e p
art
of a
saf
ety
net
neig
hbou
rhoo
d/C
HW
s w
ere
also
pee
rs
from
the
sam
e lo
catio
n an
d e
ither
had
d
iab
etes
or
care
d fo
r so
meo
ne w
ith
dia
bet
es.
Inte
rven
tion
free
of c
ost
but
man
aged
by
pee
r su
pp
ort/
CH
Ws.
Mal
e an
d fe
mal
e. 6
7.1%
of p
artic
ipan
ts
and
CH
Ws
wer
e fe
mal
e.H
igh
leve
ls o
f mob
ile p
hone
ow
ners
hip
b
ut lo
w u
se o
f tex
t m
essa
ging
or
inte
rnet
us
e.
Sel
f-m
anag
emen
t gr
oup
ed
ucat
ion
and
su
pp
ort
with
goa
l set
ting,
mot
ivat
iona
l in
terv
iew
ing
and
coa
chin
g.P
eers
who
als
o ha
d li
fe e
xper
ienc
e w
ith
dia
bet
es a
nd it
s m
anag
emen
t.C
omm
unity
-bas
ed d
iab
etes
sel
f-m
anag
emen
t ed
ucat
ion
sess
ion.
Sha
red
exp
erie
nce,
em
otio
nal
sup
por
tiven
ess
and
ava
ilab
ility
; fa
mily
-foc
used
dyn
amic
.
Incr
ease
d a
cces
s to
the
p
rimar
y ca
re t
eam
via
the
C
HW
, bet
ter
follo
w-u
p.
Imp
rove
d k
now
led
ge/
und
erst
and
ing
and
ad
here
nce
by
pat
ient
s ar
ound
die
t,
phy
sica
l act
ivity
, sel
f-m
onito
ring
of b
lood
glu
cose
, m
edic
atio
n/in
sulin
ad
just
men
t.
Tab
le 7
C
ontin
ued
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
18 Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Stu
dy
Ag
ency
Co
ntex
tR
eso
urce
sM
echa
nism
s
Out
com
e (a
ntic
ipat
ed
chan
ge
rela
ted
to
sel
f-m
anag
emen
t an
d s
elf-
effi
cacy
)
Cho
ng a
nd M
oren
o,
2012
32U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
psy
chia
tris
t an
d
pat
ient
.
His
pan
ic, l
ow-i
ncom
e, u
nins
ured
pat
ient
s w
ith d
epre
ssio
n in
a r
ural
set
ting.
88%
wer
e w
omen
, mar
ried
or
with
a
par
tner
. Low
rat
es o
f ed
ucat
ion
and
em
plo
ymen
t. P
oore
r re
pre
sent
atio
n of
m
en d
ue t
o re
stric
tion
from
low
leve
l em
plo
ymen
t.P
atie
nts
orie
nted
mor
e to
Mex
ican
tha
n to
Ang
lo c
ultu
re.
No
pre
viou
s tr
eatm
ent
for
men
tal h
ealth
.Te
lem
edic
ine
had
bee
n op
erat
ing
with
in
the
clin
ic fo
r so
me
time
(org
anis
atio
nal
read
ines
s), a
nd fo
r 5
year
s, t
he c
linic
ha
d b
een
tryi
ng t
o in
crea
se a
cces
s to
d
epre
ssio
n tr
eatm
ent
for
pat
ient
s.N
o co
sts
incu
rred
by
pat
ient
s. C
are
pro
vid
ed in
a c
linic
– p
atie
nts
take
n to
te
lem
edic
ine
room
from
the
rec
ruite
r’s
offic
e an
d n
ot d
irect
ly fr
om t
he w
aitin
g ro
om t
o re
duc
e st
igm
a.
Cul
tura
lly c
omp
atib
le c
omp
onen
ts –
His
pan
ic-
spea
king
psy
chia
tris
ts (o
ne m
ale,
one
fem
ale)
.Th
e cl
inic
was
hou
sed
in a
n ag
ency
loca
ted
w
ithin
the
com
mun
ity w
ith e
ase
of t
rans
por
t so
it
was
– e
asy
to g
et t
here
.V
irtua
l mee
ting
spac
e.
Pat
ient
s sa
id t
he p
rogr
amm
e m
ade
them
feel
bet
ter
and
it h
elp
ed m
e fe
el s
upp
orte
d.
Incr
ease
d a
cces
s to
d
epre
ssio
n m
anag
emen
t vi
a cu
ltura
lly r
elev
ant
serv
ice.
Dec
reas
e in
dep
ress
ion
sym
pto
ms
and
imp
rove
d
med
icat
ion
adhe
renc
e.P
atie
nt s
atis
fact
ion.
Dav
is e
t al
56, 2
011
Unc
lear
– b
ased
on
the
inte
ract
ion
bet
wee
n th
e cl
inic
nu
rse/
clin
ical
p
harm
acis
t an
d
pat
ient
.
Vete
rans
from
min
ority
gro
ups
in a
rur
al
sett
ing
with
dep
ress
ion.
Ste
pp
ed c
are
dep
ress
ion
mod
ule
with
car
e es
cala
ted
for
thos
e no
t re
spon
din
g to
low
er
leve
ls o
f car
e b
y in
volv
ing
mor
e p
rofe
ssio
nals
w
ith a
dd
ition
al e
xper
tise.
Unk
now
n –
auth
ors
pro
pos
e th
ese
may
rel
ate
to e
duc
atio
n an
d
activ
atio
n.
Incr
ease
d a
dhe
renc
e to
m
edic
atio
n an
d b
ette
r re
spon
se t
o tr
eatm
ent.
Fort
ney
et a
l, 20
1328
*U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
PC
P
and
on-
site
nur
se
dep
ress
ion
care
m
anag
er a
nd t
he
pat
ient
.
Med
ical
ly u
nder
serv
ed p
opul
atio
n in
a
rem
ote
sett
ing
(Ark
ansa
s’ M
issi
ssip
pi
Del
ta, O
zark
Hig
hlan
ds)
with
dep
ress
ion
and
num
erou
s co
mor
bid
ities
.H
igh
unem
plo
ymen
t/la
ck o
f ins
uran
ce.
Hal
f tim
e-fu
nded
dep
ress
ion
care
m
anag
er (n
urse
) – n
o p
rior
MH
tra
inin
g b
ut r
ecei
ved
stu
dy
trai
ning
.D
ecis
ion
sup
por
t us
ed t
o gu
ide
trea
tmen
t –
no c
linic
al s
uper
visi
on.
Pat
ient
s co
uld
cho
ose
‘wat
chfu
l wai
ting’
or
ant
idep
ress
ant
trea
tmen
t.P
atie
nts
pre
fere
nce
for
face
-to-
face
or
tele
pho
ne e
ncou
nter
s.
Pra
ctic
e-b
ased
col
lab
orat
ive
care
.U
p-s
kille
d s
taff
at c
linic
ed
ucat
ion/
activ
atio
n,
self-
man
agem
ent
goal
set
ting.
Unk
now
n –
auth
ors
pro
pos
e th
at p
atie
nts
wer
e m
ore
likel
y to
eng
age
in s
elf-
man
agem
ent
activ
ities
bec
ause
the
dep
ress
ion
care
man
ager
(des
pite
bei
ng o
ff-si
te) p
ract
iced
a m
ore
inte
nsiv
e p
rogr
amm
e an
d p
rovi
ded
mor
e en
cour
agem
ent
to u
nder
take
p
hysi
cal,
rew
ard
ing
and
soc
ial
activ
ities
.
Cha
nges
in d
epre
ssio
n se
verit
y, t
reat
men
t re
spon
se
and
rem
issi
on.
Sel
f-m
anag
emen
t.P
atie
nt s
atis
fact
ion.
Unc
lear
– b
ased
on
the
inte
ract
ion
bet
wee
n m
ultip
le
PC
pro
vid
ers,
off-
site
dep
ress
ion
care
m
anag
er a
nd p
atie
nt.
Med
ical
ly u
nder
serv
ed p
opul
atio
n in
a
rem
ote
sett
ing
(Ark
ansa
s’ M
issi
ssip
pi
Del
ta, O
zark
Hig
hlan
ds)
with
dep
ress
ion
and
num
erou
s co
mor
bid
ities
.H
igh
unem
plo
ymen
t/la
ck o
f ins
uran
ce.
Off-
site
tea
m fu
nded
by
stud
y.
Tele
med
icin
e-b
ased
col
lab
orat
ive
care
.Fu
ll-tim
e d
epre
ssio
n ca
re m
anag
er.
CB
T d
eliv
ered
by
vid
eoco
nfer
enci
ng.
Tab
le 7
C
ontin
ued
Con
tinue
d
on October 15, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2017-019192 on 29 A
ugust 2018. Dow
nloaded from
19Parker S, et al. BMJ Open 2018;8:e019192. doi:10.1136/bmjopen-2017-019192
Open access
Stu
dy
Ag
ency
Co
ntex
tR
eso
urce
sM
echa
nism
s
Out
com
e (a
ntic
ipat
ed
chan
ge
rela
ted
to
sel
f-m
anag
emen
t an
d s
elf-
effi
cacy
)
She
a et
al,
2009
42U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
the
off-
site
nu
rse
man
ager
and
th
e p
atie
nt.
Old
er e
thni
cally
div
erse
med
ical
ly
und
erse
rved
pat
ient
s w
ith t
ype
2 d
iab
etes
rec
eivi
ng M
edic
are.
¾ s
pok
e p
rimar
ily S
pan
ish.
Nur
ses
trai
ned
in c
omp
uter
-bas
ed c
ase
man
agem
ent
tool
s an
d t
o fa
cilit
ate
inte
ract
ions
thr
ough
vid
eoco
nfer
enci
ng.
PC
Ps
kep
t fu
ll re
spon
sib
ility
of
inte
rven
tion
pat
ient
s –
trie
d t
o av
oid
d
isru
ptio
n of
rel
atio
nshi
ps.
Web
-ena
ble
d c
omp
uter
and
mod
em
conn
ectio
n to
exi
stin
g te
lep
hone
line
– w
eb
cam
and
vid
eoco
nfer
enci
ng c
apac
ity.
Hom
e gl
ucom
eter
, BP
cuf
f con
nect
ed t
o th
e te
lem
edic
ine
unit.
Dire
ct u
plo
ad o
f dat
a to
cl
inic
al d
atab
ase.
Ed
ucat
iona
l web
pag
e in
Eng
lish
and
Sp
anis
h an
d in
reg
ular
or
low
lite
racy
ver
sion
s in
eac
h la
ngua
ge.
Unk
now
nIm
pro
ved
clin
ical
bio
mar
kers
: H
BA
1c, B
P a
nd L
DL
chol
este
rol.
She
eran
et
al, 2
01142
Unc
lear
– b
ased
on
the
inte
ract
ion
bet
wee
n th
e te
lehe
alth
nur
se a
nd
pat
ient
.
Eth
nica
lly d
iver
se s
amp
le o
f old
er
pat
ient
s w
ith d
epre
ssio
n –
hom
ebou
nd.
Thre
e M
edic
are-
cert
ified
hom
e ca
re
agen
cies
(urb
an, s
ubur
ban
and
rur
al).
Nur
ses
trai
ned
on
tele
heal
th p
roto
col.
Sp
anis
h an
d E
nglis
h ve
rsio
ns o
f tel
emon
itorin
g to
ols
and
mat
eria
ls.
Touc
h sc
reen
and
/or
synt
hetic
voi
ce t
o p
rom
pt
pat
ient
s –
onlin
e in
tera
ctiv
e sc
reen
can
‘ask
’ p
atie
nts
que
stio
ns.
Bas
ic e
duc
atio
n an
d b
ehav
iour
al a
ctiv
atio
n/go
al s
ettin
g.
I fel
t m
ore
conn
ecte
d t
o th
e ag
ency
.Th
e fr
eque
nt c
heck
s fr
om t
he
tele
mon
itor
wer
e co
mfo
rtin
g,
reas
surin
g.I b
ette
r un
der
stoo
d m
y d
epre
ssio
n.I w
as a
ble
to
be
mor
e ho
nest
ab
out
my
feel
ings
with
a m
achi
ne.
I don
’t lik
e us
ing
a m
achi
ne t
o d
iscu
ss m
y fe
elin
gs.
Tele
mon
itorin
g re
duc
es t
he s
ense
of
stig
ma.
Cha
nge
in b
ehav
iour
.S
atis
fact
ion.
Red
uctio
n in
dep
ress
ion
seve
rity.
mH
ealt
h
Way
ne e
t al
, 201
541U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
pat
ient
s,
HC
s, e
xerc
ise
grou
ps
and
web
-bas
ed
pro
gram
me.
Pat
ient
s w
ith t
ype
2 d
iab
etes
. The
p
opul
atio
n w
as fr
om a
low
er S
ES
ne
ighb
ourh
ood
(90%
of p
artic
ipan
ts)
and
a m
idle
vel S
ES
com
mun
ity (1
0% o
f p
artic
ipan
ts).
All
pat
ient
s un
der
the
age
of
70
year
s.P
atie
nts
incl
uded
firs
t na
tion,
Afr
ican
, C
arib
bea
n, C
auca
sian
, His
pan
ic, S
outh
A
sian
, Sou
th E
ast
Asi
an, W
est
Ind
ian.
36
% u
nem
plo
yed
Clie
nts
det
erm
ined
the
ir ow
n he
alth
re
late
d g
oals
. 24/
7 m
onito
ring
allo
wed
in
terv
entio
n b
ased
on
des
irab
le p
rogr
ess,
re
lap
se a
nd r
esis
tanc
e. In
tera
ctiv
e sy
stem
Hea
lth c
oach
ing
pro
toco
l hig
hlig
htin
g b
ehav
iour
cha
nge
for
ind
ivid
uals
with
typ
e 2
dia
bet
es m
ellit
us.
Con
curr
ent
exer
cise
ed
ucat
ion
pro
gram
me
with
tra
iner
s an
d b
lood
glu
cose
tes
ting
bef
ore
and
aft
er e
xerc
ise
sess
ions
.
Mea
l pho
togr
aphi
ng t
o en
forc
e fo
od
por
tions
and
car
boh
ydra
te in
take
.R
emin
der
mes
sage
s.S
elf-
awar
enes
s of
hab
itual
b
ehav
iour
s.‘F
eed
bac
k w
as m
otiv
atin
g’,
red
uced
feel
ings
of i
sola
tion
and
b
eing
mis
und
erst
ood
.E
mot
iona
l hap
pin
ess.
Ther
apeu
tic a
llian
ce.
Act
ivat
ion
thro
ugh
com
onito
ring.
Imp
rove
d H
bA
1c,
red
uced
wei
ght
and
wai
st
circ
umfe
renc
e.S
atis
fact
ion,
imp
rove
d m
enta
l he
alth
out
com
es a
nd Q
oL.
Incr
ease
d k
now
led
ge a
nd
self-
man
agem
ent,
con
trol
and
co
nfid
ence
.
mH
ealt
h an
d e
Hea
lth
Tab
le 7
C
ontin
ued
Con
tinue
d
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interventions,35 instead of providing efforts to ‘kick start’ motivation. Intuitively being motivated to seek assistance is a major driver in this process, but it is also a complex reaction in this type of population. Low levels of health literacy can affect the degree to which a person is moti-vated to act and equally low motivation can be construed as low health literacy. Only one study measured and/or categorised participants by their health literacy level.29 It is therefore not possible to comment how the levels of health literacy (or eHealth literacy) influenced partici-pant response.
Other contributing factorsDespite a strong underlying certitude around the value of the interventions to produce improvements in patient self-efficacy and self-management, we identified from the studies a tendency for the intervention provider to be the dominant player within the interaction, and the patient a more passive participant.
Studies reported several barriers to the use and uptake of tools by patients. These included a general unease or mistrust with the use of technology42 43 and a pref-erence for face-to-face contact on the part of patients32 and pressures of added workloads,44 reduced time and inadequate skills on the part of clinicians to take on addi-tional roles.34 We found less age-related barriers in this review with elderly populations equally satisfied if inter-ventions were well designed, user friendly and supported. We anticipated that the most significant enabling factor would be patient training. However, overall, we found the information relating to patient education and training to be sparse.
DisCussiOnWe identified 18 studies testing a variety of electronic, mobile and eHealth interventions with vulnerable popu-lations. The included studies provided limited insight into the relationships between context, mechanisms and self-management outcomes related to these interventions. We identified a wide range of contextual factors and vari-ation in the outcomes reported. Predominantly, the inter-ventions sought to persuade patients into believing they could self-manage their conditions by encouraging goal setting, providing rewards for achievement, enhancing the patient’s responsibility for symptom monitoring and providing education and additional support. Within this review, patients were viewed by providers as relatively passive, and the level of patient response directly aligned to their intrinsic level of motivation. Health literacy, which can often be confounded with motivation, was only measured in one study, and eHealth literacy was not assessed.
The provision of these tools to patients with chronic disease assumes that they directly impact on a patient’s level of health literacy and subsequently their capacity to self-manage their health conditions. The studies in this review however reported poorly on self-management and literacy outcomes, and we therefore do not know if the intensive S
tud
yA
gen
cyC
ont
ext
Res
our
ces
Mec
hani
sms
Out
com
e (a
ntic
ipat
ed
chan
ge
rela
ted
to
sel
f-m
anag
emen
t an
d s
elf-
effi
cacy
)
Dav
is e
t al
, 201
533U
ncle
ar –
bas
ed
on t
he in
tera
ctio
n b
etw
een
pat
ient
s,
web
-bas
ed
pro
gram
mes
, m
onito
rs a
nd
phy
sici
ans.
Und
erse
rved
, low
SE
S, E
nglis
h an
d S
pan
ish
spea
king
pat
ient
s.
Pre
dom
inan
tly o
lder
, ret
ired
, une
mp
loye
d
and
with
dis
abili
ty.
Par
ticip
ants
wer
e al
l rec
ruite
d in
hos
pita
l as
the
y w
ere
bei
ng d
isch
arge
d a
fter
ex
per
ienc
ing
acut
e ex
acer
bat
ions
of
illne
ss.
Pat
ient
s w
ere
all u
nins
ured
in t
he U
S
syst
em o
f hea
lthca
re a
nd h
ence
par
t of
m
edic
al in
sura
nce
pro
gram
mes
.
Inte
ract
ive
educ
atio
nal c
omp
onen
t in
whi
ch
info
rmat
ion
was
ver
bal
ly t
rans
mitt
ed t
o th
e p
atie
nt w
ith t
ips
on s
ymp
tom
man
agem
ent
via
the
RM
D.
Pro
gram
me
and
info
rmat
ion
fold
er, c
onta
ct
info
rmat
ion
and
pre
prin
ted
ed
ucat
ion
mat
eria
ls
abou
t sy
mp
tom
man
agem
ent
pro
vid
ed fr
ee o
f ch
arge
.S
upp
ort
and
info
rmat
ion
from
mon
itorin
g st
aff.
Up
fron
t lo
adin
g of
info
rmat
ion
and
at
tent
ion
by
the
PC
at
the
hom
e vi
sits
.P
erso
nalis
ed c
onsi
sten
t fe
edb
ack
rein
forc
ed t
hrou
gh h
abitu
al p
roce
ss
of s
ymp
tom
rep
ortin
g.
Red
uced
hos
pita
l ad
mis
sion
an
d e
mer
genc
y d
epar
tmen
t us
e.S
ymp
tom
man
agem
ent/
self-
man
agem
ent
and
con
fiden
ce
to m
anag
e th
eir
sym
pto
ms.
Sat
isfa
ctio
n an
d im
pro
ved
Q
oL.
*Ass
esse
s tw
o in
terv
entio
n ar
ms.
CB
T, c
ogni
tive–
beh
avio
ural
the
rap
y; C
HW
s, c
omm
unity
hea
lth w
orke
rs; L
DL,
low
-den
sity
lip
opro
tein
; QoL
, qua
lity
of li
fe; S
ES
, soc
ioec
onom
ic s
tatu
s; P
CP,
prim
ary
care
pro
vid
er; H
C's
, hea
lth c
oach
es;
Hb
A1c
, gly
cate
d h
aem
oglo
bin
; FB
Tab
le 7
C
ontin
ued
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educational or behavioural activation components of the interventions identified were ultimately effective. Using tools to assess baseline health literacy and eHealth literacy levels may therefore be beneficial particularly if the inter-vention is tailored to individual needs and abilities. It would be highly valuable if future research could unpack this further since the mechanisms around this were largely unclear from this review, and the inter-relationship between these factors is highly complex. This is particularly true for those patients with competing physical and/or psycholog-ical morbidities.
These findings have implications for future implementa-tion. Some studies have reported variable uptake and poor maintenance, leading some to suggest that these interven-tions be only offered to those with high levels of intrinsic motivation.35 An alternative would be to concentrate efforts on identifyingthe specific needs of vulnerable groups, and highly tailoring interventions to these needs to be more effective. This would seem to be indicated since we found reasonable levels of satisfaction and acceptance when patients perceived the intervention to be relevant to their needs, and adequately supported. We found no evidence of negative patient consequences from any of the interven-tions. Acceptance of health technology may also be related to a participants’ understanding of their condition and their overall interest in their own health or health literacy. There was also some evidence to suggest that the level of acceptance was not consistent for all participants who fall into the ‘vulnerable’ category. It is possible that this relates to the many and varied contextual factors providing influ-ence at a given time, such as competing health, social and
cultural issues, although this could not be elaborated from this review.
Although these tools have been widely studied in the general population, we generally found a lack of studies involving vulnerable participants, particularly in groups speaking English as a second language. Most studies were conducted in the USA where social disadvantage was the major focus.
The strength of this review is a comprehensive search, the use of systematic processes to identify both quantitative and qualitative data and the use of Rameses publication standards as a basis for our reporting.19 We also incorpo-rated a realist matrix and mapped our results according to self-efficacy theory to both determine and understand the mechanisms by which eHealth and telehealth influences self-efficacy and self-management for vulnerable patients with chronic disease. This withstanding, we found the realist component of this review challenging. The major draw-back for this approach in our experience was the limited descriptions of context and mechanisms provided gener-ally within published studies. The limited quantity of usable data inhibited our ability to effectively identify why these types of interventions worked (or did not work) differently across the varying primary healthcare contexts. Others have commented that the iterative and flexible methods required for realist reviews are at odds with the inflexible, structured processes inherent when conducting system-atic reviews generally.13 Berg and Nanavati45 in a review of published realist reviews found that limitations frequently cited include the scarcity of detail around the mechanisms by which an intervention was expected to work and the
Table 8 Characteristics of included studies
Study characteristic Number Study characteristic Number
Design Setting
RCT 9 General practice 6
Cluster RCT 2 Community health 2
Quality improvement 1 Supported veteran programme 1
Observational 2 Outpatient programme 1
Descriptive evaluation 1 Community home care 6
Qualitative 1 Federally funded health centres/Medicaid 2
Cohort 2
Intervention Geographical area
Telehealth 9 USA 15
eHealth and telehealth 7 Australia 2
mHealth 1 Canada 1
mHealth and eHealth 1
Chronic condition Vulnerability
Depression 7 Older age (>55 years) 3
Diabetes 6 Low SES 12
Multimorbidity 5 Homeless/supported accommodation 1
Rural/low SES/underserved communities 2
RCT, randomised controlled trial; SES, socioeconomic status.
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diversity of contexts within studies that hamper generalis-ability. Developing the necessary skill set within the team, and sourcing appropriate guidance to perform a realist synthesis were also challenging. We chose to use a realist matrix and narrative summary because it provided a more structured process that we could follow. Others have also highlighted difficulties with incorporating realist methods, arguing that few studies incorporate it successfully while maintaining transparent and systematic methods because ‘best practice’ is under developed46 and there is currently little uniformity in practice.45
COnClusiOnsAlthough electronic, mobile and telehealth interventions have been widely assessed in several disease-specific groups covering the general population, specific research with vulnerable groups is much less comprehensive. Within the studies, the level of reported success was variable, but the reasons for this variation were not clear. Apart from intrinsic motivation, health literacy may be a factor influencing the reaction of vulnerable groups to technology. Symptom monitoring and management, goal setting, behavioural activation and motivational counselling were able to be successfully delivered by telephone or other modalities, but efforts to engage patients by healthcare providers were lower than expected.
Social persuasion and goal setting were the dominant components by which studies sought to achieve better self-management. Other theoretical aspects that underpin self-efficacy such as vicarious learning and interaction with similar people were less used but may warrant further research.
We would also encourage in future research some assess-ment of both health and eHealth literacy if including vulnerable populations, and further work to differentiate specific requirements for these groups that might differ to the general population when implementing health technologies.
Acknowledgements This review was conducted as part of the Innovative Models Promoting Access-to-Care Transformation (IMPACT) programme. The IMPACT investigators are: Prof Grant Russell, MonashUniversity and Southern Academic Primary Care Research Unit, Australia; A/Prof Jeannie Haggerty, McGillUniversity and St Mary’s Research Centre, Canada; A/Prof Simone Dahrouge, Bruyère Research Institute and the University ofOttawa, Canada; Prof Mark Harris, Centre forPrimary Health Care and Equity, University of New South Wales, Australia; Dr Jean-Frederic Levesque, Bureau of Health Information and theUniversity of New South Wales, Australia; A/Prof Virginia Lewis, AustralianInstitute for Primary Care and Ageing, La Trobe University, Melbourne,Australia; A/Prof Catherine Scott, PolicyWisefor Children and Families and the University of Calgary, Canada; Professor Nigel Stocks, the Universityof Adelaide, Australia. We also acknowledge the commitment provided by theresearch teams and primary care communities from IMPACT sites in both Australiaand Canada. We would also like to thank Nila Sharma forassisting with the update of the search and retrieval of studies.
Collaborators The IMPACT Study Group: Professor Grant Russell; A/Professor Jeannie Haggerty; Dr Jean-Fred Levesque; Professor Mark Harris; A/Professor Simone Dahrouge; A/Professor Virginia Lewis; A/Professor Cathie Scott; and Professor Nigel Stocks.
Contributors SP contributed to the project methodology and design of the review, coordinated the review, designed and conducted the search, adjudicated
and appraised studies, extracted and analysed data and drafted the manuscript. AP coordinated the deliberate forums and question development, designed and conducted the search, adjudicated and appraised studies, extracted and analysed data and reviewed the manuscript. LT and HS contributed to the search and the design of the analysis, extracted and analysed data and reviewed the draft manuscript. DM contributed to the question development through the LIP and reviewed the manuscript. MH contributed to the design of the IMPACT program of work, analysed and interpreted data and reviewed the manuscript. All authors have signed off on the final content of this manuscript.
Funding IMPACT is jointly funded by the Canadian Institutes of Health Research (TTF-130729) Signature Initiative in Community-Based Primary Health Care, the Fonds de recherche du Québec - Santé, and the Australian Primary Health Care Research Institute (Centre of Research Excellence), which is supported by a grant from the Australian Government Department of Health, under the Primary Health Care Research, Evaluation and Development Strategy. The information and opinions contained in this paper do not necessarily reflect the views or policy of these funding agencies. The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available. Data extracted from included studies relevant to the discussion in this manuscript have been provided in tables 4–7.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
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