Home-Based Physiological Monitoring of Patients with COVID-19

Akshay Warrier

Akshay Sood, MD, MPH

Division of Pulmonary, Critical Care and Sleep Medicine

Department of Internal Medicine

University of New Mexico School of Medicine

Albuquerque, NM USA

Abstract

The COVID-19 pandemic has necessitated the rise of telehealth modalities to relieve the incredible stress the pandemic has placed on the healthcare system. This rise has seen the emergence of new software, applications, and hardware for home-based physiological monitoring, leading to the promise of innovative predictive and therapeutic practices. This article is a literature-based review of the most promising technologies and advances regarding home-based physiological monitoring of patients with COVID-19. We conclude that the applications currently on the market, while helping stem the flow of patients to the hospital during the pandemic, require additional evidence related to improvement in patient outcomes. However, new devices and technology are a promising and successful venture into home-based monitoring with clinical implications reaching far into the future.

Abbreviations

• ARDS: Acute Respiratory Distress Syndrome
• CGM: Continuous Glucose Monitoring
• COVID-19: Coronavirus disease 2019
• EKG: Electrocardiogram
• FDA: Food and Drug Administration
• HIPAA: Health Insurance Portability and Accountability Act
• HR: Heart Rate
• HRV: Heart Rate Variability
• PP: Prone Positioning
• PPE: Personal Protective Equipment
• RHR: Resting Heart Rate
• RIP: Respiratory Inductive Plethysmograph
• SpO2: Peripheral Capillary Oxygen Saturation

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which causes the novel coronavirus disease 2019 (COVID-19) infection, has been ravaging the globe. The number of infected cases worldwide has risen to 213 million and deaths beyond 4.4 million by August 2021 (1). Furthermore, healthcare workers are at nearly 12 times higher risk of becoming infected than the general community (2), exposing the dire need for a stronger "telemedicine" infrastructure for home-based patient care (1,3,4,5). Such a system not only needs to provide preventative information to users but also allow them to self-diagnose (using home-based testing kits) and self-triage (using real-time algorithms), thus telling patients when to seek emergency care (2). For the less severe cases, the "hospital-at-home" structure can provide acute care at low cost with coordinated telemedicine visits and necessary at-home treatment. For the hospitalized patients, this system allows an earlier discharge to receive post-illness care at home (2). This, in turn, decreases the burden on the hospitals during the pandemic.

Telemedicine, and the technology to support it, has been available for decades but had not become mainstream in the pre-pandemic era due to funding and licensing complications. The technology generally consists of three main functional units: general provision of information, provider-patient synchronous and asynchronous interactions, and remote monitoring (2). Virtual video-chat technologies and basic remote live monitoring algorithms and software were all ready to be used but had not been previously integrated into a fully functioning home-based health care system (5). However, as the pandemic began to spread, the focus on these specific technologies increased and recently have been implemented into several developing home-based systems. Most current remote monitoring programs have a few key features: scaled asynchronous entry, education and information videos/reports, standardized patient reports, real-time monitoring and modifications by a central platform, and enabled patient requests for feedback and assistance (2). "Digital personal protective equipment" or "digital PPE" such as wearable vital monitors, smart applications, and various other forms of medical monitoring have emerged so that COVID-19 monitoring can happen in real-time and assistance or advice can be algorithmically provided to patients.

Evolution of Smart Applications (Apps) for Home-based Monitoring

The foundation for remote monitoring during the pandemic has been provided by novel applications on smartphones (i.e., smart apps) and websites, and other innovative technologies and software hitting the App and Google Play stores, creating a unique opportunity in telemedicine for COVID-19 (7).

1. Application (App) Characteristics

Ideally, a developed application should be able to provide the following services: 1) symptom screening, 2) live updates and information about COVID-19, such as local test availability, 3) contact tracing and mapping of COVID-19 cases, 4) remote monitoring and patient surveillance, and 5) online chat/video consultation with a provider in a secure bidirectional network (6). In addition, the app characteristics should help ensure a streamlined and efficient system using a HIPAA verified data collection service for patients to use and allow big data capabilities for infection epidemiology (7).

2. Current App Developments

One of the earliest apps developed in Wuhan, China, using the popular WeChat platform, established bidirectional communication between a multidisciplinary medical team and quarantined patients through an eCounseling system. Using this app to triage patients, preliminary results show that continuous monitoring of changing symptoms helps in two ways: 1) reduces overcrowding in emergency rooms (ER); and 2) notifies those too afraid to present to the ER if their condition is critical enough to do so (8). 

Subsequently, the Cleveland Clinic at Cleveland, USA, put forth an app-based system for real-time monitoring of symptoms, facilitating physician advice and joint decision making, home-based physiological monitoring, and planning for advance directives and related discussions (9). The program used their MyChart Care Companion app, which focused on patient engagement to self-input symptoms and physiological signs (9). Although this app is an excellent first step towards remote patient monitoring, it does not provide patients with technology or equipment for home-based monitoring. Instead, it is an intermediary platform between the provider and the patient.

The GetWellLoop program at the University of Minnesota at Minneapolis, USA, implemented many of the same protocols, such as virtual triaging based on a combination of reported symptoms, conditions, and vital signs, and provision of immediate provider assistance, as needed. In addition, through the use of a smartphone app and basic bidirectional chat software, the program has quickly put in place an adequate but still limited roadmap for patient monitoring (10).

A review of these apps in the context of other more universal apps (Table 1) reveals that despite many desired features in disparate apps, comprehensive software has yet to be developed so far for the general public.

However, the quick implementation of these apps during the pandemic was crucial for stemming the flow of patients into hospitals and in bidirectional home-based disease management in real-time and learning about the emerging disease from the front lines (9). These smart apps will continue to play a significant role in the medical system, greatly assisting, though perhaps not yet replacing, traditional home assessments and telemedicine visits. They offer a window into a secure, well-organized database and communication system as a focal point of remote care to streamline traditional modalities by avoiding significant parts of preliminary assessments and paperwork.  

Developments in Home-based Physiological Monitoring

As efforts for vaccination and curative measures continue, research on remote physiologic monitoring has increased (Table 2).

Powerful bioanalytical software coupled with innovative technologies and smart applications offers a pragmatic solution. Realizing the potential of these technologies, the U.S. Food and Drug Administration (FDA) has established a streamlined process for the research and use of home-monitoring devices through various medical platforms (11).

A. Cardiac Monitoring

SARS-COV-2 virus can cause myocarditis, acute coronary syndromes, and arrhythmias, while medications can prolong the corrected QT interval (QTc). Therefore, electrocardiographic (EKG) monitoring, which can help detect tachycardias, conduction defects, and other arrhythmias, and changes of myocardial injury (12), is critical to COVID-19 management (13). Remote single-lead EKG monitoring is considered less accurate than 12-lead telemetry, which is the gold standard. However, several companies now offer mobile solutions for real-time EKG monitoring. After a trial with COVID-19 patients, the FDA cleared one such device, a four-lead MCOT PATCH mobile cardiac telemetry path system for outpatient EKG monitoring (14). Another such device called KardiaMobile 6L by AliveCor offers a real-time QTc measurement service from remote EKG tracings (14). Apple Watches 4 and 5 also have certain EKG monitoring capabilities, modified for diagnostic purposes (15). Beyond EKG monitoring, heart rate (HR), resting heart rate (RHR), and heart rate variability (HRV) biometrics have the greatest predictive capacity (15). These devices illustrate the future of remote monitoring by tracking early heart damage or providing useful warning signs of cardiac status or recovery trajectories (16).

B. Respiratory Rate Monitoring

COVID-19 commonly presents as a lower-respiratory tract infection, necessitating respiratory rate monitoring (17, 18). Due to the relative consistency of an individual's resting respiratory rate, changes can be detected remotely (specifically greater than 27 breaths per minute) (17).  Home-based methods for monitoring respiratory rate utilize one of two techniques: 1) respiratory inductive plethysmograph (RIP), which uses belts to measure relative changes in circumference around the abdomen and ribcage, and 2) optoelectronic plethysmography, which uses cameras to map the topography of the torso using local markers. However, new technology has emerged, such as a wearable sensor around the size of a Band-Aid, which remotely monitors local chest wall strain and transmits information to a device through Bluetooth to health care providers (19).

C. Pulse Oximetry

Pulse oximeters, though traditionally used to measure the oxygen saturation of the peripheral blood (SpO2), can also measure heart rate.  Monitoring SpO2 is critical to managing the subset of asymptomatic or paucisymptomatic COVID-19 patients with severe hypoxemia (often referred to as "silent hypoxia"). There are generally two categories of pulse oximeters. The traditional method uses light transmission through cutaneous tissue (finger or earlobe). Varying in size, traditional pocket oximeters approved for clinical use can range in cost from 20-50 US dollars. The other major categories of oximeters use reflected light measured by apps that utilize smartphone hardware and software, like the Nellcor SpO2 forehead monitor (20).

An initiative at Cleveland University Hospitals promotes using a disposable wireless finger sensor for home-based SpO2 monitoring (21). Emerging as a costly but highly competitive alternative to others in its field is the Nonin Connect 3230 Bluetooth Smart Pulse Oximeter, which offers smartphone compatibility and alert generation linked with clinician databases, for unexpected SpO2 measurements below 94% (22). Differing branded alternatives have also quickly emerged on the market, providing a cheap and quick reading, albeit with significant and varying inaccuracies, which can be useful in especially urgent contexts.

D. Temperature Tracking

COVID-19 often presents with mild to moderate fever, making body temperature an important metric to track (23). Temperature monitoring has become standard at entry points to buildings to identify and triage those infected (24). In a home-based monitoring setting, fever can be a key warning sign of both the onset of COVID-19 as well as disease trajectory (25). Elevated body temperature is correlated with mortality - the mortality rate being more than 40% higher among those with a maximum body temperature over 40.0^° C than those with a lower temperature and increasing for every 0.5^° C elevation (26).

There are several modalities for temperature monitoring, the most common of which are electronic thermometers (placed into the mouth, rectum, or armpit); plastic strip surface thermometers which change color to indicate the temperature (limited by their low accuracy); electronic ear thermometers (commonly used but maybe less accurate due to external ear canal blockage); and non-contact forehead infrared thermometers (27). Wearable technology may be effective for frequently measuring and transmitting temperature information. HEATthermo is one such technology that can reliably measure body surface temperature and heart rate every 10 seconds with good reliability (28). The Taiwanese company iWEECARE has come out with the product Temp Pal. The device is the world's smallest thermometer that offers a 36-hour battery life. It sends secure body temperature data to an app and cloud dashboard through Bluetooth for centralized big data tracking (29). These apps and monitoring platforms make it easy for medical professionals to monitor patients and for the latter to seek advice on treatment from the former, using algorithm-based alert messages (30).

E. Glucose Monitoring

Patients with pre-existing diabetes are uniquely vulnerable to SARS-CoV-2 infection and its associated morbidity and mortality. The virus' inflammatory surge (dubbed "cytokine storm") can result in insulin resistance and new-onset diabetes mellitus and its complications. The systemic hyperglycemia can lead to greater viral replication in vivo coupled with a suppressed immune response (31). Continuous glucose monitoring may therefore be helpful in those infected. Recent developments in the field of Continuous Glucose Monitoring (CGM) devices offer a pragmatic solution. Low cost and small wearable devices, like Freestyle Libre, Dexcom, Medtronic, and Eversense, offer a variety of functions, like audio and visual alerts, automatic insulin injections, data confidentiality and integration, strong smartphone and app compatibility, blind data collection for big data studies, and bidirectional clinician interaction (32).

F. Adapting Existing Wearable Biometric Technology

The most logical response to the need for home-based monitoring involves repurposing existing wearable technology to generate useful multimodal biometric data. One-fifth of Americans currently wear some smartwatch or activity tracker, and most of them can give baseline resting heart rate, sleep data, and activity data (33). Duke University investigated the role of an app that tracks smartwatches and fitness trackers in mapping and diagnosing the disease (34,35) through their DETECT program. Recently, new research with larger population input has come to light due to collaborative studies from Stanford, Fitbit, and Scripps, among others, corroborating the use of smartwatches as a predictive tool for disease (15). A recent study of 30,529 people using Fitbit, Apple Health Kit, and Google Fit data showed that individuals' changes in physiological metrics (like HRV, respiratory rate, temperature, oxygen saturation, blood pressure, cardiac output, etc.) tracked by these devices could significantly improve the detection of COVID-19 days before symptoms (33). In a retrospective study sponsored by Stanford University, researchers determined that 63% of COVID-19 cases could have been detected before symptom onset in real-time (36), using smartwatches to generate resting heart rate (RHR) difference data based on standardized values and using anomalies in "heart rate over steps" data (36). Other studies have also bolstered the use of RHR data to detect COVID-19 with smartwatches (37).

G. Emerging Multimodal Biometric Technologies

As the necessity for home-based monitoring grows, wearable multimodal monitoring technologies are being developed. One of the most promising wearable devices is the Oura ring, an aesthetic piece of jewelry that tracks multimodal data. Its use with Smart apps is being investigated (38,39). Northwestern University has invented a wireless sensor, the size of a postage stamp, that rests on the suprasternal notch to monitor cough intensity and patterns, chest wall movements, and vital signs (40,41). Mayo Clinic has started its own project, offering an albeit bulkier device yielding multimodal data, including patient self-reporting of symptoms, lung function (spirometry), and vital signs including oxygen saturation (42,5). Two powerful technology companies, Lenovo and Motorola, have joined efforts to begin certification of their Vital Moto Mod product for multimodal monitoring of vital signs, though not in a continuous or wearable fashion (43). A Chinese company KoKo LLC has agreed to distribute the Belun Technology's system (including the popular Belun ring) for monitoring vital signs. The device, called BLR-1000, uses a SIM (subscriber identification module) card and a HIPAA (Health Insurance Portability and Accountability Act) secured cloud-based system with secure protocols for data transmission to clinicians through a centralized platform (44).

More innovative research is coming in continuous respiratory rate monitoring through the modulation of radio waves and Wi-Fi signals caused by respiration-related thoracic movements, as well as smart garments and mattress pressure sensors (10), combined with cloud-based analytics. Moreover, technologies are being disseminated even as they are developed: Oakland University, California, USA, started handing out skin temperature tracking devices (BioButtons) to its students; employees in Plano, Texas, and football players at the University of Tennessee are already using proximity detectors; Kinexon from Munich is distributing SafeZone proximity trackers to many companies; and GlaxoSmithKline began manufacturing a virus tracking system with Microshare (45).

Although the devices listed above may greatly facilitate home-based physiological monitoring, physical interaction with the provider is still necessary and reassuring for patients. A recent 2020 survey of SWJPCC readership showed that despite the reduced need for documentation, greater overall efficiency, and decreased virus exposure with remote monitoring, patients valued interpersonal interactions associated with physical visits (63). Of course, considerations must be taken into account of those without easy access to technology and the Internet and those requiring additional services such as translation, interpretation, and further testing. Thus, although televisits may have increased out of necessity during the pandemic, they will likely decrease post-pandemic. However, the developed platforms may positively affect harder-to-reach communities if supplemented with the necessary resources, long after the pandemic abates (64).

Promising Home-based Lung Monitoring, Diagnosis, and Treatment Modailities

Lung ultrasound, useful in the point-of-care diagnosis and management of patients with acute respiratory failure, may be helpful in the diagnosis and management of COVID-19 pneumonia (46-49, 62). However, the lack of robust evidence and the need for technology and training renders this option currently not feasible for use in the home setting (62).

Patients at risk for atelectasis use an incentive spirometer to encourage deep, slow breaths (50,51). Although useful for atelectasis, there is little role for incentive spirometry in the treatment of COVID-19. Used in the investigation of asthma, peak expiratory flow rate measures the speed of exhalation (52,53), but its role in the home-based monitoring of COVID-19 is not known. Patients with COVID-19 pneumonia with hypoxia managed at home can be encouraged to use electronically timed treatments of prone-positioning (PP) sessions (54,55).

There still exist other developing investigations into the field of lung testing and early diagnosis. For example, one innovative study delves into machine learning with existing smartphone software and hardware to review breathing sounds. Although not specific to COVID-19 pneumonia, the acoustic technology may help classify subjects with and without pneumonia (56). Another area of investigation is the outpatient use of lung compliance measurements for COVID-19 pneumonia tracking and diagnosis (57, 58). However, the use of lung compliance for this purpose is limited by the normal lung compliance noted in some patients despite severe hypoxemia (58-60).  

Conclusion

COVID-19 has radically shifted the healthcare infrastructure; however, depending on how we utilize this system, it may open more doors than close them. The age of telehealth and telemonitoring, and the necessary implications of interactions with the Internet of things, are sure to raise privacy and security questions. Many of the companies and institutions developing smart apps and technologies above prioritize the safety of medical information. From HIPAA-secured clouds to centralized operating databases and governmentally approved/sponsored applications, patients and their security are paramount. A deep and critical analysis of the role that these apps will hold over our healthcare system is not only important but necessary.

The use of remote home-based monitoring to decrease hospital stay is the new future of the medical system. While these technologies are increasing in number and versatility, they are not empirically improving patient outcomes significantly at this time, mainly due to their novelty. The technology’s usefulness and predicted applicability, however, is undeniable in several areas as they become both more intuitive and multifaceted. Using such technological modalities to target rural, underprivileged, and underserved communities could be the stepping-stone to a universal healthcare system. Furthermore, such devices and continuous data streaming to clinician platforms also offer critical benefits to patients with varying conditions outside COVID-19. This system of remote monitoring has changed the healthcare system permanently and will change patient-physician interaction during the pandemic and post-pandemic.

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Disclosures

No disclosures of any personal or financial support or author involvement with organization(s) with financial interest in the subject matter, or any actual or potential conflict of interest.

Cite as: Warrier A, Sood A. Home-Based Physiological Monitoring of Patients with COVID-19. Southwest J Pulm Crit Care. 2021;23(3):76-88. doi: https://doi.org/10.13175/swjpcc005-21 PDF 

Social Media: A Novel Engagement Tool for Miners in Rural New Mexico

Shreya Wigh¹

William Cotton Jarrell, CMSP³

Elizabeth Kocher, MPH¹

Roger Karr²

Xin Wang, MS¹

Akshay Sood, MD, MPH^1,2

¹University of New Mexico Health Sciences Center School of Medicine

Albuquerque, NM, USA

²Miners Colfax Medical Center

Raton, NM, USA

³Peabody New Mexico Services

Grants, NM, USA

Abstract

Background: New Mexico miners usually live in rural areas. As compared to urban areas, rural areas in the United States demonstrate a lower use of the Internet and lower adoption of new technologies such as the smartphone and social media. Our study objective was to examine the use of these technologies among miners in rural New Mexico. Our long-term goal is to utilize these technologies to increase our program’s engagement with miners to provide medical screening and education services. Methods: We anonymously surveyed 212 miners at two town hall meetings in rural New Mexico communities, predominantly Hispanic and American Indian, in 2017. We then compiled that data in a Research Electronic Data Capture (REDCap) database and performed a statistical analysis using Statistical Analysis Software (SAS). IRB approval was obtained. Results: 60.8% of the 212 surveyed miners reported using social media. Among social media users, 88.4% reported using Facebook.  Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses). Additionally, 79.7% of miners who owned a smartphone utilized it for texting. Conclusions: A majority of miners in rural New Mexico report use of social media and express willingness to use social media to network with other miners and with our program. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. It is possible to utilize this newer technology to increase program engagement with miners.

Introduction

New Mexico miners usually live in rural and medically underserved areas and suffer from multiple chronic diseases, particularly dust related lung diseases or pneumoconiosis. Rural counties in northern New Mexico have among the highest mortality rates for silicosis and pneumoconiosis, including coal workers’ pneumoconiosis, in the United States (1). To address this challenge, Miners’ Colfax Medical Center and the University of New Mexico have partnered in a federally funded medical screening program for rural miners.  As compared to urban areas, those who live in rural areas reportedly have a lower use of the Internet and are less willing to adopt new communication technologies such as the smartphone and social media (2). We have previously published that the primary source of information about miners’ health related activities for attendees at our miners’ health screening programs are traditional routes of communication such as a relative, friend, and community newspaper or flyer (3). Traditional media is, however, a one-way communication system that doesn’t create program engagement or work towards promoting word-of-mouth - the hallmark of social media (4). Our programs could utilize social media to promote awareness, encourage miner engagement, and increase the spread of accurate health messaging among New Mexico miners. Serving older, less educated, poorer, racial/ethnic minority, miners living in geographically remote and medically underserved rural areas of New Mexico may however affect the use and effectiveness of this communication tool.

The objective of our study was to examine the use of Internet-based smartphone and social media technology among miners in rural New Mexico. We hypothesized a low usage rate of these novel communication technologies among rural miners in New Mexico. Our long-term goal is to use these technologies to increase bidirectional engagement with miners with our federally funded Black Lung and Radiation Exposure Screening and Education Programs that currently provide medical screening, health care, and education services to coal and uranium miners in New Mexico.

Methods

Study design: This is a cross sectional survey of 212 miners, mostly coal miners, at two town hall meetings held in rural and medically underserved communities of Grants and Socorro, New Mexico, in 2017. These communities are predominantly American Indian and Hispanic respectively. The town hall meetings were held in conjunction with mobile health screening clinics for miners.

Survey creation: We created a survey on the use of the smartphone and social media, which asked construct-specific questions with either Yes/No responses or multiple choices. Examples of questions included whether miners would be willing to use social media to stay in touch with the mining community and if they had access to a computer with internet. The questions were formatted for an eighth-grade vocabulary, since our previous studies have shown that 57.2% of New Mexico miners do not complete high school education (3).

Survey administration: The paper copy of the survey was given to miners to fill out during the town hall meeting by the mine safety officer, on a voluntary and anonymous basis.

Analytic and database strategy: We compiled the survey data into a Research Electronic Data Capture (REDCap) database. We compared characteristics between social media users with social media non-users. Statistical analysis included an analysis of frequency distributions and Chi-square test, using Statistical Analysis Software (SAS 13.0, Cary, NC). A p-value less than 0.05 was considered statistically significant. We obtained human Institutional Review Board (IRB) approval for research exempt status (HRPO 14-058). The study was sponsored by Health Resource Services and Administration (HRSA) and Patient Centered Outcomes Research Institute (PCORI).

Results

60.8% of the 212 miners surveyed reported using social media. Among the social media users, 88.4% reported using Facebook, 27.9% reported using Instagram, and 26.4% reported using Snapchat.  Social media users reported utilizing the technology for an average of 47.9 ± 134.3 (SD) minutes daily, for approximately 6.0 ± 4.4 (SD) years. Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses, Table 1).

Table 1. Difference in characteristics between self-reported social media users and nonusers, among rural miners in New Mexico.

86.3% of the miners surveyed also reported possessing a smart phone (93.8% versus 74.7% of the social media users and non-users respectively; p<0.001). 79.7% of miners owning a smartphone utilized it for texting (91.5% versus 61.5% of social media users versus nonusers respectively; p<0.001).

94.3% of rural miners reported having access to the Internet. Social media users were more likely to report having Internet access via computer or via phone than non-users (p = 0.08 and <0.001 respectively, Table 1). 24.0% of all miners however reported poor Internet connection as a challenge, and as compared to nonusers, social media users were more likely to report this challenge (p=0.01). 13.2% of all miners complained of the high expense of the Internet and the social media user status did not predict this characteristic (p=0.67). There was also no difference between the two groups with respect to the reported difficulty in navigating social media sites (p=0.32).

Discussion

Based on our results, we conclude that the majority of miners in rural New Mexico use Internet-based smartphone and social media technologies and are willing to use social media to network with other miners or programs that deliver health services to miners. We found that Facebook was the most popular social media site. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. This suggests that it is possible to use smartphone texting and social media technology to increase bidirectional program engagement with miners in rural New Mexico.

In 2017, the proportion of US population with a social media profile was variably estimated at 69-81% (5-7). Rural Americans in the US were approximately 8% less likely to use social media than urban Americans (2). The market leader in social media was Facebook, used by 68% and 79% of all and online American adults respectively (7). In our study, 60.8% of the rural miners reported using social media and 53.8% reported using Facebook, which is comparable to that reported in other US rural communities. In 2017, the proportion of American adults who owned a smartphone was 83%, 78%, and 65% for urban, suburban, and rural locations respectively (8). In comparison, 86.3% of rural miners in our study reported possessing a smartphone, indicating a higher level of smartphone possession than that reported by rural Americans overall. In 2017-2018, 89% of all American adults used the Internet (9). In an earlier survey from November 2016, 81% of rural Americans used the Internet, as compared to 89% of urban Americans (10). 63% of rural Americans had a broadband Internet connection at home, 10 percentage points less likely than Americans overall (10). In comparison, 94.3% of rural New Mexico miners in our study reported having access to the Internet, indicating a higher level of Internet access than that reported by rural Americans overall. Contrary to our initial hypothesis, we found that rural New Mexico miners in our study reported adoption of newer communication technologies at a level that was comparable or superior to that reported by rural Americans overall.

Racial/ethnic and health status-related disparities exist with respect to Internet access in the U.S. (9). However, among those with Internet access, these characteristics do not affect their social media use (11). New Internet-based technologies including smartphone and social media, may be changing the communication pattern throughout the U.S. and the world but this change has not been well studied, particularly in rural areas (11).  Potential overarching benefits of social media for health communication are (1) increased interactions with others, (2) more available, shared, and tailored information, (3) increased accessibility and widening access to health information, (4) peer/social/emotional support, (5) public health surveillance, and (6) potential to influence health policy (12). Our findings indicate that social media can similarly be used for health communication purposes among rural miners in New Mexico. Our HRSA-funded miners’ health and benefits programs in New Mexico have established a social media platform to provide rural miners with information on our clinical programs, research, education and other interventions as well as to provide opportunities for bidirectional engagement between the program and miners as well as among miners themselves. Our program has also launched a social media literacy campaign for miners, with the help of a rural mine safety officer.

Currently there is a limited amount of literature evaluating the use of social media for sustained engagement of diverse communities in health promotion (13,14). For instance, the Youth Voices Research Group has reported creating novel opportunities to engage young people to explore health topics ranging from tobacco use, food security, mental health, and navigation of health services, by combining social organizing with arts-informed methods for creative expression, using information technology (14). Creating opportunities for engagement alone is however insufficient. The information exchanged needs to be monitored for quality and reliability, users’ confidentiality and privacy need to be maintained (12), and its impact evaluated. Use of social media in health promotion in underserved populations, such as indigenous populations in Australia, is associated with limited evidence of benefit (15). Online social network health behavior interventions are reported to have small effect sizes, often statistically nonsignificant, with high participant attrition and low fidelity (16). It is therefore necessary for our program to critically evaluate the role and effectiveness of these new technologies in health promotion and health care for our population of rural miners.

The strength of our study includes inclusion of miners from rural and predominantly Hispanic and American Indian communities. Limitations of our study include small sample size and lack of information on individual demographic characteristics. Although our study was limited to New Mexico, our findings may be generalizable to other rural and medically underserved areas of the United States outside of New Mexico.

Conclusions

Most miners in rural New Mexico have Internet access, use smartphones and social media, and are willing to use social media to network with other miners or programs that deliver health services to miners. Rural New Mexico miners in our study report adoption of newer communication technologies at a level that is comparable or superior to that reported by rural Americans overall. This study provides preliminary information on a potential and novel way in which rural mining communities and miners’ health and benefits programs can engage with each other to promote miners’ health by assisting in clinical programs, research, education and other interventions. Miners’ program may consider interactive blogging, photograph elicitation, and video documentaries, alongside real-world social media projects, to promote this engagement. Potential barriers in rural miners include low social media literacy and poor Internet connection. Low social media literacy can however be addressed by targeted education of miners. Emerging areas of research include evaluating the effectiveness of the use of smartphones and social networking platforms such as Facebook, in building effective interventions for health promotion and providing healthcare for miners in rural communities.

Acknowledgments

SW, WCJ, EK, RK, KW, AS made substantial contributions to the conception or design of the work; SW, WCJ, EK, RK, KW, AS made substantial contributions to the acquisition, analysis, or interpretation of data for the work. SW, WCJ, EK, RK, KW, AS made substantial contribution towards drafting the work or revising it critically for important intellectual content. SW, WCJ, EK, RK, KW, AS provided the final approval of the version to be published. SW, WCJ, EK, RK, KW, AS agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Cite as: Wigh S, Jarrell WC, Kocher E, Karr R, Wang X, Sood A. Social media: A novel engagement tool for miners in rural New Mexico. Southwest J Pulm Crit Care. 2018;16(4):206-11. doi: https://doi.org/10.13175/swjpcc017-18 PDF