Conducting internet-based visits for onboarding populations with limited digital literacy onto an mHealth intervention: Development of a Patient-Centered Approach.

Background COVID-19 pandemic has propelled patient-facing research to shift to digital and telehealth strategies. If strategies are not adapted for minority patients of lower SES, health inequality will further increase. Patient-centered models of care can successfully improve access and experience for minority patients. Objective To present the development process and preliminary acceptability of altering in-person to internet-based remote onboarding procedures for a mobile health intervention, among a population with limited digital literacy. Methods We actively recruited safety-net patients (English and Spanish speaking adults with diabetes and depression receiving care at a public healthcare delivery system in San Francisco) into a randomized trial of text messaging support for physical activity. Because of the COVID pandemic, we converted in-person recruitment/onboarding procedures into internet-based remote processes with human support during the COVID pandemic, and conducted a preliminary examination of how the composition of recruited patients might have changed from pre-COVID to COVID enrollment periods. First, we analyzed the digital profiles of patients (n=32) who had participated in previous in-person onboarding sessions prior to the COVID-19 pandemic. Next, we documented all changes made to our onboarding processes to account for remote recruitment, especially the changes needed for patients who were not as familiar with downloading apps onto their phone on their own. Finally, we utilized the new study procedures to recruit patients (n=11) during COVID-19's social distancing period. Patients recruited during the COVID-19 were also asked about their experience enrolling into a fully digitized mobile health intervention. Results Patient recruitment across both pre-COVID and COVID time periods (N=43) demonstrated relatively high rates of smartphone ownership but lower self-reported digital literacy. 32.6% (14 out of 43 participants) overall reported needing help with their smartphone and apps. Significant changes made to onboarding procedures included: a) the facilitation of app download via Zoom and/or a standard phone calls and b) implementation of brief, one-on-one staff-patient interactions to provide technical assistance personalized to each patient's digital literacy skills. Comparing recruitment pre-COVID (i.e. in-person) to COVID (i.e., remote), the proportion of patients with digital literacy barriers went from 34.4% (11 out of 32 participants pre-COVID) to 27.3% (3 out of 11 participants COVID). Differences in digital literacy scores for pre-COVID and COVID cohorts were not significant (P=.485). Conclusions Patients of lower SES have high interest in using digital platforms to manage their health, but may require additional upfront human support to gain access. Overall, one-on-one staff-patient partnerships allowed us to provide unique technical assistance personalized to each patient's digital literacy, with simple strategies to troubleshoot patient barriers upfront. These additional remote onboarding strategies can mitigate but not eliminate digital barriers for patients without extensive technology experience. Clinicaltrial Clinicaltrials.gov NCT0349025, https://clinicaltrials.gov/ct2/show/NCT03490253.