JMIR Human Factors

Feasibility and Acceptability of the SISKA System for Continuous Student Emotional and Mental Health Guidance: Mixed Methods Study

2026-11-06T13:45:18-05:00

Background: University students face substantial underserved mental health needs. Digital “front doors” that combine brief screening, decision support, and timely counselor follow-up may help close access and workflow gaps on campus. SISKA (Sistem Informasi Layanan Konseling Akademik “academic counseling information system”) was developed as an Android app with a counselor-facing web dashboard to support routine self-assessment, risk-tiering, just-in-time guidance, referral activation, and continuous follow-up within real university workflows. Objective: The study aims to evaluate the feasibility, acceptability, and usability of SISKA in Indonesian public universities and to identify strengths and friction points to inform implementation at scale. Methods: This exploratory sequential mixed-methods study recruited trained lecturer-counselors (n=20) who provided qualitative input on practicality and integration and 3 student cohorts to assess (1) usability (n=35 students who completed all 10 System Usability Scale [SUS] questions), (2) use analytics (n=1057 active accounts from December 2024 to October 2025), and (3) changes in mental health before and after the intervention (n=119 students with ≥1 counseling session and paired daily mental health assessment scores). This was a single-arm feasibility study without a comparator group. Analyses included descriptive summaries and paired tests; qualitative data were analyzed thematically to explain quantitative patterns. Results: Monthly uptake showed a launch spike, a mid-year trough, and a late-year uptick. Usability metrics showed a short learning curve and manageable cognitive load (SUS mean score 83.3, SD 10.5) with strong item agreement on ease, quick learning, and integration. In the pre- and postintervention cohort, daily mental health assessment scores declined from a mean 33.9 (SD 8.07) to a mean 32.8 (SD 8.94; Δ=−1.14; =.03), indicating a statistically significant but small preliminary reduction in distress following counseling. Qualitatively, students described feelings of psychological safety, that the psychoeducation was helpful, and that the scheduling was oriented to the services; friction points included interface inconsistencies, multistep confirmation, and intermittent connectivity or notification issues. Conclusions: SISKA appears feasible and acceptable for campus deployment, enabling earlier support pathways and showing proximal improvement among counseled students. Priorities for scaling up the app include user interface standardization, streamlined confirmation flows, and reliable, context-sensitive notifications, alongside embedding measurement-based care loops to convert routine self-reports into timely feedback and action. These findings support the readiness of the app for structured implementation in university settings.

Wellness4Teachers Supportive Text Messaging Program Association With Observed Improvement in Psychological Symptoms Among Teachers in Canada: Single-Arm Prospective Longitudinal and Naturalistic Controlled Study

2026-11-05T15:30:21-05:00

Background: Wellness4Teachers is a daily supportive text messaging program implemented to mitigate psychological distress and support teachers’ well-being in Canada. Objective: This study aimed to assess whether Wellness4Teachers can reduce the severity and prevalence of psychological issues and improve resilience among teachers in Alberta, Newfoundland and Labrador, and Nova Scotia. Methods: This study used a single-arm prospective longitudinal design with a secondary exploratory naturalistic contemporaneous comparison. Teachers self-subscribed to the program for 6 months and completed web-based surveys. Longitudinal outcomes were assessed at baseline, 6 weeks, 3 months, and 6 months. The naturalistic comparison included an intervention group (IG), which received messages for 6 months and completed 6-month assessments between March 1 and June 30, 2023, and a control group (CG), which enrolled and completed baseline assessments during the same period before receiving messages. Standardized scales were used for assessing psychological symptoms. Likely generalized anxiety disorder (GAD), likely major depressive disorder (MDD), resilience, burnout, and stress were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, the Patient Health Questionnaire-9 (PHQ-9), the Brief Resilience Scale, the Maslach Burnout Inventory-Educator Survey, and the Perceived Stress Scale-10 (PSS-10), respectively. Data were analyzed using SPSS. Paired- and independent-sample t tests were used to compare longitudinal changes and groups, respectively. McNemar and chi-square tests were used to examine categorical variables. Missing follow-up data were addressed using last observation carried forward, with sensitivity analyses comparing baseline scores with those at 6 weeks, 3 months, and 6 months. The group type (IG vs CG) was entered as a variable together with all demographic and work-related variables into 9 separate logistic regression models. Results: In the longitudinal analysis, PSS-10, Maslach Burnout Inventory-Emotional Exhaustion subscale, PHQ-9, PHQ-9 item 3 (sleep disturbance), PHQ-9 item 9 (suicidal ideation/self-harm), and GAD-7 scores decreased significantly at 6 months, by 5.50% (mean difference [MD]=1.29, 95% CI 0.86-1.72), 4.48% (MD=1.67, 95% CI 0.43-2.92), 18.58% (MD=2.10, 95% CI 1.39-2.80), 17.54% (MD=0.30, 95% CI 0.15-0.44), 37.50% (MD=0.09, 95% CI 0.02-0.17), and 13.52% (MD=1.30, 95% CI 0.62-1.99), respectively. Likely MDD decreased from 55.2% (n=116) to 41.0% (n=86), a 14.2% reduction. In the exploratory contemporaneous comparison, the IG (n=166) had lower PSS-10 (6.04%; MD=–1.41, 95% CI –2.17 to –0.65), PHQ-9 (21.16%; MD=–2.33, 95% CI –3.59 to –1.06), and GAD-7 (22.48%; MD=–2.19, 95% CI –3.39 to –0.98) scores than the CG (n=152). Likely MDD and GAD prevalence were 20.6% and 20.3% lower, respectively. Adjusted analyses showed IG status was associated with lower odds of high stress (odds ratio [OR] 0.42, 95% CI 0.19-0.95), likely MDD (OR 0.47, 95% CI 0.28-0.81), and likely GAD (OR 0.37, 95% CI 0.21-0.64). Conclusions: Wellness4Teachers was associated with improvements in several psychological outcomes over 6 months and may offer a promising approach to support teachers’ psychological well-being.

Workforce Perceptions of a Conceptual Hospital-at-Home Digital Twin: Qualitative Study

2026-11-05T10:00:23-05:00

Background: Hospital-at-home (HaH) services are transformative for delivering acute care in a patient’s home, with support from a multidisciplinary team and remote monitoring technologies, and there is a growing demand for innovation and digital solutions. Digital twin (DT) technology offers the possibility of leveraging real-time data to personalize care, predict risk, and improve patient management. However, perceptions of the workforce regarding the application of HaH DTs remain underexplored, and addressing this is crucial for successful adoption and sustainability. Objective: This qualitative study aimed to explore health and care professionals’ perceptions of the concept of a HaH DT model of care and its perceived impact. Methods: A total of 26 semistructured interviews were conducted between June and December 2025. Participants were based in the United Kingdom and were recruited through purposive sampling via known contacts, professional networking, and social media. A short vignette on DTs was presented to participants at the start of the interview. An interview topic guide centered around acceptability and the domains of the Non-adoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework was used to explore complexity in implementation and potential management. Data analysis involved a hybrid approach drawing on reflexive thematic analysis. Results: Seven overarching themes were identified, highlighting a mixture of perceived benefits, concerns, and recommendations. Participants noted value in personalized, holistic care enabled by real-time data-driven interventions and appropriate patient-clinician contact. However, concerns included trust in DTs, with participants highlighting that implementation requires adapting workforce roles, strong education and training, system-level infrastructure, and a supporting evidence base. Conclusions: This work provides the foundations for stakeholders and developers to better understand the likely adoption of a HaH DT and the likely impact on individuals, organizations, and systems. Findings from this study highlight key recommendations, and further research and implementation efforts should prioritize stakeholder involvement to develop clear actionable plans.

Stakeholder Perspectives on Information About Digital Health Applications in German Outpatient Mental Health Care: Qualitative Interview Study

2026-11-04T10:00:03-05:00

Background: Digital health applications (digitale gesundheitsanwendungen; DiGA) were integrated into the German statutory health care system in 2020 and can be prescribed by physicians and psychotherapists. Nevertheless, their use within routine care, particularly in the treatment of mental disorders, remains limited. Previous research suggests that a lack of information and knowledge among health care providers and patients may contribute to these difficulties. Objective: This study aimed to explore the perspectives of stakeholders on the information-related aspects of DiGA implementation in outpatient mental health care in Germany. This included investigating the perceived information status, information needs, suitable information providers, and potential approaches to improve information provision. Methods: We conducted semistructured interviews with experts representing stakeholder groups relevant to DiGA in outpatient mental health care in Germany. Participants were recruited using purposive stakeholder sampling. Potential participants were identified through existing professional contacts and web-based searches and were subsequently approached by email. The web-based interviews were conducted via Microsoft Teams between September and November 2023. The transcripts were analyzed using qualitative content analysis based on the method described by Kuckartz, combining deductive and inductive category development. Results: A total of 13 interviews with 14 participants were conducted, comprising 5 health care provider representatives, 4 statutory health insurance representatives, 4 DiGA developer representatives, and 1 patient representative. The findings were grouped into 3 main themes: perceived information status, improvement of the information status, and information suppliers. Representatives of health care providers described a general awareness of DiGA but said they lacked more detailed knowledge required to assess and compare individual applications. They also perceived information gaps among patients. Participants distinguished between general information on aspects such as regulatory requirements and organizational processes and more detailed product-specific information. Different potential information suppliers were associated with different opportunities and problems, particularly regarding expertise, objectivity, available resources, and the ability to provide product-specific information. Conclusions: The findings indicate that information-related challenges in the implementation of DiGA extend beyond general awareness. Health care providers may require accessible information with different levels of detail, while the source of information also appears relevant. Addressing these different information needs may support the integration of DiGA into outpatient mental health care.

Engagement-Supportive Mechanisms in Stress-Focused Digital Mental Health Interventions With Adaptive, Conversational, and Context-Aware Systems: Narrative Review

2026-11-02T13:30:23-05:00

Background: Stress is a widespread public health concern associated with cardiovascular disease, depression, anxiety, and reduced quality of life. Digital mental health interventions (DMHIs), delivered through smartphones, web platforms, and wearables, offer scalable support for stress management but often struggle to sustain user engagement. Evidence describing how adaptive, conversational, and context-aware mechanisms function together within stress-focused DMHIs remains fragmented. Objective: This review aims to synthesize evidence on engagement-supportive mechanisms in stress-focused DMHIs, with attention to personalization; biometric feedback; just-in-time adaptive interventions (JITAIs); gamification; AI, including large language models (LLMs); and methodological approaches to studying engagement. It also examines methodological, motivational, and experiential dimensions of engagement. Methods: This narrative review was informed by a structured search of PubMed, IEEE Xplore, and Scopus for peer-reviewed studies published between January 2018 and April 2025, followed by an evidence update through August 2026. Eligible studies described stress-focused DMHIs or related affective support interventions reporting at least 1 engagement-supportive mechanism. Randomized controlled trials, qualitative investigations, simulation or modeling studies, and implementation studies were included. Data were extracted using a structured form capturing study characteristics, engagement mechanisms, outcomes, and alignment with the review domains. Descriptive mapping summarized study types and mechanism frequencies, while a narrative synthesis integrated behavioral, experiential, methodological, and theory-informed findings. Results: Thirty-two studies met the inclusion criteria. Randomized or microrandomized controlled trials were the most common design (n=17), followed by qualitative investigations (n=6), design or implementation studies (n=3), mixed methods studies (n=3), simulation or modeling studies (n=2), and a quasi-experimental study (n=1). Dynamic adaptation was identified in 14 studies, conversational support in 10, static tailoring in 9, social or co-design mechanisms in 9, context-aware prompting in 7, gamified reinforcement in 5, biometric-responsive adaptation in 4, and narrative immersion in 2. These mechanisms frequently overlapped within layered adaptive architectures rather than functioning as isolated engagement features. AI-enabled systems included conversational agents, LLM-supported systems, recommender systems, reinforcement learning, and computational modeling approaches. Outcomes included behavioral indicators such as adherence, retention, and prompt receptivity, alongside experiential indicators such as perceived relevance, trust, emotional support, and immersion. Evidence strength varied substantially; many AI-enabled systems contributed feasibility, acceptability, or optimization-oriented evidence rather than definitive comparative effectiveness evidence. Conclusions: Stress-focused DMHIs are increasingly adopting adaptive, conversational, and context-aware engagement-supportive mechanisms, but the evidence base remains heterogeneous and methodologically uneven. Dynamic adaptation, conversational support, and static tailoring were most frequently represented, whereas biometric-responsive adaptation, narrative immersion, and deeply integrated gamified systems were less common. AI-enabled systems may support contextual responsiveness and personalized interaction but require transparent adaptive logic, privacy safeguards, and human-centered evaluation. Future work should prioritize longitudinal, mixed methods research capable of distinguishing behavioral engagement, experiential engagement, feasibility, acceptability, and sustained stress-related outcomes.

Associations of Health Literacy and eHealth Literacy With Patient Portal Access and Use: Systematic Review

2026-11-02T13:00:18-05:00

Background: Effective patient portal access and use require both digital navigation and understanding of clinical information. Health literacy and eHealth literacy reflect these different demands. Although the 2 constructs overlap, prior research often treats them as interchangeable. It remains unclear whether health literacy and eHealth literacy are associated differently across stages of portal engagement and patterns of portal use. A systematic review is therefore needed to identify consistent patterns across studies. Objective: This study aimed to synthesize associations of health literacy and eHealth literacy with patient portal access, general use, feature-specific use, and frequency of use. Methods: We searched PubMed, Scopus, CINAHL, PsycINFO, Web of Science, and Embase from inception to March 2026 using keywords related to health literacy, eHealth literacy, patient portals, and portal access or use. We included English-language peer-reviewed articles and gray literature involving adults who used real-world patient portals, measured health literacy or eHealth literacy using validated instruments, and reported quantitative associations with portal access or use. Because studies differed substantially in literacy instruments, portal outcomes, and outcome measures, we used direction-based vote counting, complemented by narrative synthesis. Reporting followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement, whereas synthesis methods were guided by the Cochrane Handbook for synthesis without meta-analysis. For full-text, peer-reviewed journal articles, we assessed the risk of bias by using the Joanna Briggs Institute (JBI) critical appraisal tools. Results: Among 1107 screened studies, 30 met the inclusion criteria. Of these, 17 examined health literacy only, 10 examined eHealth literacy only, and 3 examined both constructs in the same sample. Studies focused far more on portal use than on portal access and emphasized general portal use over feature-specific outcomes. Any use was assessed more often than frequency of use. Nine of 10 directionally codable eHealth literacy studies of general portal use showed lower use among individuals with lower eHealth literacy, whereas health literacy findings for general portal use were mixed. Lower health literacy showed a more consistent pattern of lower portal access and several feature-specific outcomes, although comparable eHealth literacy evidence for these outcomes was limited. Most studies met the majority of JBI criteria, although most measured portal use via self-report rather than objective system data. Conclusions: Nearly every directionally codable eHealth literacy study reported lower portal use among patients with lower eHealth literacy. Lower health literacy showed similar patterns for portal access and several feature-specific outcomes. These consistent associations point to literacy-related disparities at multiple stages of portal engagement, although comparable within-sample evidence remains limited. Future studies should measure both constructs in the same sample, use comparable modeling approaches, use objective portal log data when possible, and distinguish access, any use, frequency, and feature-specific behaviors to identify where literacy-related disparities emerge. Trial Registration:

Consensus on Core Competencies of Undergraduate Life Sciences Students for Entry-Level Participation in Clinical Trials: RAND-Modified Delphi Study

2026-11-02T13:00:03-05:00

Background: The competencies required of life sciences graduates to participate in clinical trial research teams are poorly defined. Objective: This study aimed to establish a structured consensus on the core competencies that students must acquire during their degree programs. Methods: A RAND-modified Delphi procedure was conducted using 2 rounds of online questionnaires, a virtual meeting, and a final review. The process began with a questionnaire completed by experts from the University of Córdoba and the Maimonides Institute for Biomedical Research of Córdoba (3 principal investigators, 1 study coordinator, and 1 data manager). The 48 competencies initially proposed were reviewed by a panel of 18 experts representing 6 clinical research groups from universities and biomedical research institutes in Andalusia, Spain. The relevance of each proposed competency was rated on a 9-point Likert scale. Competencies were accepted if they achieved a mean score of 7 points or higher and at least 70% of ratings in the top tertile (scores of 7-9). Results: The 18 experts achieved 100% consensus on a panel of 48 competencies organized into 3 sections: fundamental concepts (n=23, 47.9% of the competencies), clinical trial development (n=23, 47.9% of the competencies), and certifications (n=2, 4.2% of the competencies). Conclusions: This consensus defines the core competencies required of undergraduate life sciences students for entry-level participation in clinical trial research. It also provides a framework for designing training strategies in both undergraduate and graduate programs of study.

Constructing a Theoretical Hybrid Care Pathway From Stakeholder Perspectives: User-Centered Design Study

2026-10-30T13:15:18-04:00

Background: Chronic obstructive pulmonary disease (COPD) is characterized by acute exacerbations that frequently result in hospitalization, highlighting the need for improved follow-up care. Hybrid care incorporates digital health strategies such as remote patient monitoring (RPM). This could offer the opportunity to detect early signs of disease worsening by remotely tracking selected health indicators. However, it is unknown how RPM can effectively be integrated into current practice. Objective: This study aims to cocreate a theoretical hybrid COPD care pathway integrating RPM into the existing care trajectory, considering the expertise of participating care pathway stakeholders. Methods: This 2-phase study was conducted between May and August 2025. At first, semistructured interviews were conducted with stakeholders (ie, patients and health care professionals [HCPs]) involved in COPD care to map the existing care pathway in a single tertiary care hospital in Belgium. Patients were approached during hospitalization based on predefined eligibility criteria, whereas HCPs were recruited through convenience sampling. In phase 2, patient representatives and HCPs were recruited through patient-organization networks and professional referral, respectively, using convenience sampling, and participated in separate interactive workshops. These workshops reviewed existing care pathway phases and HCP roles and explored the integration of RPM, including timing, duration, implementation, data monitoring, and follow-up responsibilities, to codevelop a theoretical hybrid care pathway. Interview and workshop data were independently reviewed by 2 researchers to extract information on care pathway elements, stakeholder roles, limitations, and proposed adaptations. Findings were organized according to the relevant care pathway phase, independently summarized and compared, with discrepancies resolved through discussion and consensus. Interview findings informed the development of an initial infographic representing the existing care pathway, which was subsequently adapted based on workshop findings to represent the proposed cocreated theoretical hybrid care pathway. Results: In total, 10 stakeholders participated in the interviews (5 patients and 5 HCPs), and 6 stakeholders participated in the workshops (3 patient representatives and 3 HCPs). The existing COPD care pathway involves multiple stakeholders whose activities can be organized into 5 functional domains: support, treatment, medical advice, patient education, and monitoring. Stakeholders can be divided into hospital-based, community-based, or cross-setting. The workshop participants identified the need for a stakeholder dedicated to RPM activities in order to integrate RPM strategies into the care pathway. This individual could be responsible for all RPM-related activities (ie, RPM device installation, providing RPM-related education, data review, alert management, and RPM discontinuation) and could serve as the bridge between patients and physicians, ensuring close communication. Conclusions: This study resulted in a cocreated theoretical hybrid COPD care pathway. Stakeholders highlighted the potential value of a dedicated RPM role to coordinate and deliver RPM activities as part of the COPD care pathway. Further research is needed to assess its feasibility and clinical applicability.

Real-World Health Monitoring Using Wrist-Worn Wearables in Community-Dwelling Older Adults in China: Mixed Methods Feasibility Study

2026-10-29T15:00:28-04:00

Background: Real-world behavioral and physiological functioning, including heart rate, daily mobility, and sleep patterns, may provide information about aging and early neurodegenerative changes that is not captured by periodic clinical visits. Wrist-worn wearable devices offer a promising approach for continuous, passive monitoring of these domains. However, evidence regarding feasibility, usability, and acceptability in real-world observational settings among community-dwelling older adults in China remains limited. Objective: This study primarily aimed to evaluate the feasibility, usability, and acceptability of using wrist-worn wearable devices to monitor behavioral and physiological function in community-dwelling older adults under naturalistic conditions. As a secondary objective, the study descriptively characterized wearable-derived behavioral and physiological measures among participants with minimal consecutive valid monitoring. Methods: We enrolled 486 community-dwelling older adults from the Beijing region of the China-Aging cohort, each of whom received a Huawei Band 8 commercial wrist-worn wearable device. A valid monitoring day was defined as 10 or more hours of wear time. Participants were classified into three monitoring-pattern categories based on predefined wear-time criteria: no valid monitoring day, nonconsecutive valid monitoring, and minimal consecutive valid monitoring (≥3 consecutive valid monitoring days). Demographic characteristics, health status, and cognitive and functional measures (Mini-Mental State Examination and Barthel Activities of Daily Living Index) were compared across groups. Usability, acceptability, and perceived barriers were assessed using a structured user experience survey. Results: Of 486 participants, 224 (46.1%) achieved minimal consecutive valid monitoring, 156 (32.1%) had nonconsecutive valid monitoring, and 106 (21.8%) had no valid monitoring day. Self-rated health differed significantly across monitoring patterns (=.005), whereas no significant differences were observed for the other measured baseline characteristics. Among participants with minimal consecutive valid monitoring, mean daily heart rate was 72.1 (SD 8.6) bpm, median daily step count was 6177 (IQR 4249‐8872) steps/day, and sleep data were available for 211 out of 224 (94.2%), with a median sleep duration of 7.23 (IQR 6.48‐8.04) hours. The user experience survey was completed by 106 out of 486 (21.8%) participants, with higher participation among those with more sustained monitoring. Respondents generally reported favorable usability and acceptability; common barriers included device discomfort, data synchronization issues, and battery life. Conclusions: Wrist-worn wearable monitoring was feasible under naturalistic conditions for a substantial proportion of community-dwelling older adults in China, with generally favorable usability and acceptability among survey respondents. However, monitoring patterns varied considerably across individuals, highlighting challenges for long-term use and large-scale implementation. These findings support the potential of wearable technologies for longitudinal monitoring outside clinic-based assessments. Further research is needed to establish the stability and clinical relevance of wearable-derived behavioral measures over longer monitoring periods.

The Use of Digital Technology to Support the Emotional Well-Being of Older People Who Receive Care at Home From the Perspective of Care Recipients: Qualitative Study

2026-10-28T15:00:02-04:00

Background: Older people who receive aged care services at home experience high rates of depression, anxiety, and loneliness, yet have poor access to services to support their well-being. Digital interventions are widely available, but research is required to determine whether they are acceptable to the in-home aged care population. Objective: This study aimed to explore the perspectives of in-home aged care recipients on the use of digital technologies to support their emotional well-being. Methods: Eleven older people (aged 70-87 years) who received in-home aged care from a national provider participated in a semistructured interview. The interview aimed to understand care recipients’ experiences of using technology, as well as their current access to emotional support and attitudes toward using digital technologies to support their well-being. Results: Participants reported high access to technology (mean 5, SD 1.6 devices) but varied usage. Most required support to use technology, typically provided by family members, and reported a range of concerns related to technology use. Participants received a variety of informal supports for their emotional well-being, typically from family members and their communities, but only one accessed professional support. Most were open to using technology to support their emotional well-being, and some were willing to receive such support from their aged care provider. Conclusions: The willingness of older people who receive in-home aged care to use digital technologies to supplement existing informal emotional support is encouraging. Aged care providers are well placed to implement digital well-being programs and can leverage older people’s existing access to digital devices but should consider their requirements for technical support. Technologies and implementation strategies should be purpose-designed for this population and address identified barriers. Trial Registration: