Free smoking cessation mobile apps available in Australia: a quality review and content analysis

Mobile Applications for the Treatment of Tobacco Use and Dependence

PURPOSE OF REVIEW

Smoking remains a leading preventable cause of premature death in the world; thus, developing effective and scalable smoking cessation interventions is crucial. This review uses the Obesity-Related Behavioral Intervention Trials (ORBIT) model for early phase development of behavioral interventions to conceptually organize the state of research of mobile applications (apps) for smoking cessation, briefly highlight their technical and theory-based components, and describe available data on efficacy and effectiveness.

RECENT FINDINGS

Our review suggests that there is a need for more programmatic efforts in the development of mobile applications for smoking cessation, though it is promising that more studies are reporting early phase research such as user-centered design. We identified and described the app features used to implement smoking cessation interventions, and found that the majority of the apps studied used a limited number of mechanisms of intervention delivery, though more effort is needed to link specific app features with clinical outcomes. Similar to earlier reviews, we found that few apps have yet been tested in large well-controlled clinical trials, although progress is being made in reporting transparency with protocol papers and clinical trial registration.

SUMMARY

ORBIT is an effective model to summarize and guide research on smartphone apps for smoking cessation. Continued improvements in early phase research and app design should accelerate the progress of research in mobile apps for smoking cessation.

A content analysis of free smoking cessation mobile applications in the USA

Aims

To evaluate the quality and content of free smoking cessation apps and assess their adherence to the US Public Health Service guideline for treating tobacco use and dependence.

Methods

In total 180 apps were downloaded from the App Store and Google Play Store in January 2018; the top-ranking 30 apps were retrieved for the search terms: ‘smoking cessation’, ‘quit smoking’, ‘stop smoking’. Technical quality was rated using the Mobile Application Rating Scale (MARS) and by assessing other characteristics, behavioral change strategies and adherence to the 5As.

Results/findings

A total 67 free-to-download apps were identified for full review (n = 40 from the Apple App Store and n = 27 from the Google Play Store). The average MARS score was 16.2/19.0: Engagement (3.3/5.0), Functionality (4.4/5.0), Aesthetics (4.0/5.0), and Information (2.6/5.0). Overall, 43 apps allowed sharing, 12 allowed for an app community, and five required a password. The following features were observed: assessment (n = 51), feedback (n = 38), information/education (n = 45), monitoring (n = 52), and goal setting (n = 23). Significant differences were found among apps adhering to the 5As: Ask (n = 44), Advise (n = 54), Assess (n = 30), Assist (n = 62), and Arrange (n = 0).

Conclusions

Given the growth in smoking cessation apps, future efforts should focus on improving their technical quality and adherence to the 5As.

The Characteristics and Quality of Mobile Phone Apps Targeted at Men Who Have Sex With Men in China: A Window of Opportunity for Health Information Dissemination?

BACKGROUND

A number of mobile phone apps has been developed specifically for men who have sex with men (MSM). We will call these mobile phone apps MSM apps for simplicity. At present, the characteristics and quality and purpose of these MSM apps are unclear.

OBJECTIVE

The aim of this study was to objectively and comprehensively evaluate the characteristics and quality of the MSM apps to assess whether they disseminated health information among the MSM in China.

METHODS

We searched 2 dominant mobile phone app stores (Apple Store and Android Market) to obtain MSM apps using the keywords MSM, gay, lesbian, gay, bisexual, and transgender (LGBT), ，，，，, and . Apps were excluded if they did not have a Chinese language interface or if their target population was not MSM. Basic information about the eligible apps for this study, such as app name, app store category, and date of last update was gathered from the specified app stores. The quality of apps was rated by 2 independent raters using Mobile App Rating Scale (MARS). The intraclass correlation coefficient (ICC) between raters was computed as a measure for interrater reliability of the MARS. All analyses were conducted using SPSS version 20.0 (SPSS Inc).

RESULTS

A total of 575 apps were reviewed between September 15, 2018 and September 30, 2018, out of which, 532 apps were excluded. Finally, 43 apps were included. Of the 43 apps, 16 were from the Apple Store, 10 were from Android Market, and 17 were available in both app stores. In addition, 39 out of 43 apps were for social and sexual networking, whereas 10 contained sexual health information, for example, HIV/sexually transmitted diseases knowledge, HIV test, and condom use. The average rating was 4 stars. The number of downloads for 21 apps exceeded 10,000. A total of 31 apps had acceptable quality (as defined by a MARS score of >3), with functionality as the highest scoring domain, followed by information quality, esthetics, and engagement. Interrater reliability was excellent for the overall mean app quality scores (ICC=.946; 95% CI 0.904-0.970) and the subjective quality scores (ICC=.910; 95% CI 0.841-0.950).

CONCLUSIONS

By reviewing the available apps, we found that MSM apps are popular. The majority of MSM apps are for dating, whereas few of them contain HIV prevention and health information. The overall quality of the apps is acceptable. The utilization of mobile phone technologies is a promising way for delivering HIV prevention messages to MSM. We recommend that researchers and app developers should work together to disseminate health information for MSM via mobile technologies.

Using science to sell apps: Evaluation of mental health app store quality claims

Despite the emergence of curated app libraries for mental health apps, personal searches by consumers remain a common method for discovering apps. App store descriptions therefore represent a key channel to inform consumer choice. This study examined the claims invoked through these app store descriptions, the extent to which scientific language is used to support such claims, and the corresponding evidence in the literature. Google Play and iTunes were searched for apps related to depression, self-harm, substance use, anxiety, and schizophrenia. The descriptions of the top-ranking, consumer-focused apps were coded to identify claims of acceptability and effectiveness, and forms of supporting statement. For apps which invoked ostensibly scientific principles, a literature search was conducted to assess their credibility. Seventy-three apps were coded, and the majority (64%) claimed effectiveness at diagnosing a mental health condition, or improving symptoms, mood or self-management. Scientific language was most frequently used to support these effectiveness claims (44%), although this included techniques not validated by literature searches (8/24 = 33%). Two apps described low-quality, primary evidence to support the use of the app. Only one app included a citation to published literature. A minority of apps (14%) described design or development involving lived experience, and none referenced certification or accreditation processes such as app libraries. Scientific language was the most frequently invoked form of support for use of mental health apps; however, high-quality evidence is not commonly described. Improved knowledge translation strategies may improve the adoption of other strategies, such as certification or lived experience co-design.

The App Behavior Change Scale: Creation of a Scale to Assess the Potential of Apps to Promote Behavior Change

BACKGROUND

Using mobile phone apps to promote behavior change is becoming increasingly common. However, there is no clear way to rate apps against their behavior change potential.

OBJECTIVE

This study aimed to develop a reliable, theory-based scale that can be used to assess the behavior change potential of smartphone apps.

METHODS

A systematic review of all studies purporting to investigate app's behavior change potential was conducted. All scales and measures from the identified studies were collected to create an item pool. From this item pool, 3 health promotion exerts created the App Behavior Change Scale (ABACUS). To test the scale, 70 physical activity apps were rated to provide information on reliability.

RESULTS

The systematic review returned 593 papers, the abstracts and titles of all were reviewed, with the full text of 77 papers reviewed; 50 papers met the inclusion criteria. From these 50 papers, 1333 questions were identified. Removing duplicates and unnecessary questions left 130 individual questions, which were then refined into the 21-item scale. The ABACUS demonstrates high percentage agreement among reviewers (over 80%), with 3 questions scoring a Krippendorff alpha that would indicate agreement and a further 7 came close with alphas >.5. The scale overall reported high interrater reliability (2-way mixed interclass coefficient=.92, 95% CI 0.81-0.97) and high internal consistency (Cronbach alpha=.93).

CONCLUSIONS

The ABACUS is a reliable tool that can be used to determine the behavior change potential of apps. This instrument fills a gap by allowing the evaluation of a large number of apps to be standardized across a range of health categories.

A Mobile App to Provide Evidence-Based Information About Crystal Methamphetamine (Ice) to the Community (Cracks in the Ice): Co-Design and Beta Testing

BACKGROUND

Despite evidence of increasing harms and community concern related to the drug crystal methamphetamine ("ice"), there is a lack of easily accessible, evidence-based information for community members affected by its use, and to date, no evidence-based mobile apps have specifically focused on crystal methamphetamine.

OBJECTIVE

This study aims to describe the co-design and beta testing of a mobile app to provide evidence-based, up-to-date information about crystal methamphetamine to the general community.

METHODS

A mobile app about crystal methamphetamine was developed in 2017. The development process involved multiple stakeholders (n=12), including technology and drug and alcohol experts, researchers, app developers, a consumer expert with lived experience, and community members. Beta testing was conducted with Australian general community members (n=34), largely recruited by the Web through Facebook advertising. Participants were invited to use a beta version of the app and provide feedback about the content, visual appeal, usability, engagement, features, and functions. In addition, participants were asked about their perceptions of the app's influence on awareness, understanding, and help-seeking behavior related to crystal methamphetamine, and about their knowledge about crystal methamphetamine before and after using the app.

RESULTS

The vast majority of participants reported the app was likely to increase awareness and understanding and encourage help-seeking. The app received positive ratings overall and was well received. Specifically, participants responded positively to the high-quality information provided, usability, and visual appeal. Areas suggested for improvement included reducing the amount of text, increasing engagement, removing a profile picture, and improving navigation through the addition of a "back" button. Suggested improvements were incorporated prior to the app's public release. App use was associated with an increase in perceived knowledge about crystal methamphetamine; however, this result was not statistically significant.

CONCLUSIONS

The Cracks in the Ice mobile app provides evidence-based information about the drug crystal methamphetamine for the general community. The app is regularly updated, available via the Web and offline, and was developed in collaboration with experts and end users. Initial results indicate that it is easy to use and acceptable to the target group.

Smartphone Apps About Crystal Methamphetamine ("Ice"): Systematic Search in App Stores and Assessment of Composition and Quality

Background

Amid considerable community concern about the prevalence and harms associated with the use of crystal methamphetamine (“ice”), the increased use of smartphones to access health information and a growing number of available smartphone apps related to crystal methamphetamine, no previous reviews have examined the content and quality of these apps.

Objective

This study aims to systematically review existing apps in the iTunes and Google Play Stores to determine the existence, composition, and quality of educational smartphone apps about methamphetamines, including ice.

Methods

The iTunes and Google Play Stores were systematically searched in April 2017 for iOS Apple and Android apps, respectively. English-language apps that provided educational content or information about methamphetamine were eligible for inclusion. Eligible apps were downloaded and independently evaluated for quality by 2 reviewers using the Mobile Application Rating Scale (MARS).

Results

A total of 2205 apps were initially identified, of which 18 were eligible and rated using the MARS. The mean MARS quality total score for all rated apps was 3.0 (SD 0.6), indicating poor to acceptable quality. Overall, mean scores were the highest for functionality (mean 4.0, SD 0.5) and lowest for engagement (mean 2.3, SD 0.7).

Conclusions

This study demonstrates a shortage of high-quality educational and engaging smartphone apps specifically related to methamphetamine. The findings from this review highlight a need for further development of engaging and evidence-based apps that provide educational information about crystal methamphetamine.

A systematic evaluation of mobile apps to improve the uptake of and adherence to HIV pre-exposure prophylaxis

Background Pre-exposure prophylaxis, or PrEP, has been shown to be effective at reducing the risk of HIV infection, yet persons at-risk for acquiring HIV exhibit suboptimal uptake of and adherence to this prevention modality. Although PrEP use among all at-risk groups is low, mobile apps have been shown to increase the use of PrEP; however, it is unknown whether currently available apps have been designed with features to facilitate PrEP uptake and adherence.

METHODS

The Google Play store and Apple App store were systematically searched for currently available PrEP-related apps. A qualitative evaluation was conducted on apps that met the inclusion criteria for the presence of features that can contribute to PrEP uptake and adherence, and the quality of apps was assessed using the Mobile Apps Rating Scale (MARS) tool.

RESULTS

From the systematic search, less than 2% (11/621) of the identified apps were relevant to improving PrEP uptake and adherence. Demonstrating a moderate capacity for facilitating PrEP use, the 11 PrEP-related apps, on average, contained features that addressed two of four factors that can contribute to the uptake of PrEP, particularly features that provided comprehensive information on PrEP and resources to locate providers and clinics offering PrEP services. Findings from the app quality assessment suggested that existing PrEP-related apps are of acceptable quality (mean overall MARS score: 3.2 on a five-point scale).

CONCLUSION

Overall, currently available mobile apps for PrEP demonstrate some promise as potential avenues for increasing PrEP uptake and adherence among persons at-risk for HIV infection.

Mobile App Tools for Identifying and Managing Mental Health Disorders in Primary Care

PURPOSE OF REVIEW

Mental health apps are intriguing yet challenging tools for addressing barriers to treatment in primary care. In the current review, we seek to assist primary care professionals with evaluating and integrating mental health apps into practice. We briefly summarize two leading frameworks for evaluating mental health apps and conduct a systematic review of mental health apps across a variety of areas commonly encountered in primary care.

RECENT FINDINGS

Existing frameworks can guide professionals and patients through the process of identifying apps and evaluating dimensions such as privacy and security, credibility, and user experience. For specific apps, several problem areas appear to have relatively more scientific evaluation in the current app landscape, including PTSD, smoking, and alcohol use. Other areas such as eating disorders not only lack evaluation, but contain a significant subset of apps providing potentially harmful advice.

SUMMARY

Overall, individuals seeking mental health apps will likely encounter strengths such as symptom tracking and psychoeducational components, while encountering common weaknesses such as insufficient privacy settings and little integration of empirically-supported techniques. While mental health apps may have more promise than ever, significant barriers to finding functional, usable, effective apps remain for health professionals and patients alike.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of the breadth of research studies published from April 2017 to April 2018 on mobile-based interventions for mental health, with a special emphasis on smartphone-based interventions.

RECENT FINDINGS

Several studies during the review period have described the process of applying user-centred design in the development of mental health apps and novel approaches to enhance user-engagement. Studies on consumer perspectives indicate largely positive findings about open-ness to utilize mental health apps. There is a scarcity of similar studies on health providers. Efficacy studies have provided evidence for apps for a variety of psychiatric disorders. There are fewer studies on preventive and promotive interventions. Although a plethora of mental health apps is available for public, most have not undergone scientific evaluation. Many well researched apps are not accessible to public. The potential of smartphone technology in enhancing healthcare service delivery in low-resource settings has also been examined in a few studies.

SUMMARY

Evidence for acceptability, feasibility and efficacy of mobile-based mental health interventions for facilitating recovery is on the rise. More research is needed on implementation and integration of these interventions in diverse real-world clinical and community contexts.

A Face-Aging Smoking Prevention/Cessation Intervention for Nursery School Students in Germany: An Appearance-Focused Interventional Study

The Education Against Tobacco (EAT) network delivers smoking prevention advice in secondary schools, typically using the mirroring approach (i.e., a “selfie” altered with a face-aging app and shared with a class). In November 2017, however, the German assembly of EAT opted to expand its remit to include nursing students. To assess the transferability of the existing approach, we implemented it with the self-developed face-aging app “Smokerface” (=mixed − methods approach) in six nursing schools. Anonymous questionnaires were used to assess the perceptions of 197 students (age 18–40 years; 83.8% female; 26.4% smokers; 23.3% daily smokers) collecting qualitative and quantitative data for our cross-sectional study. Most students perceived the intervention to be fun (73.3%), but a minority disagreed that their own animated selfie (25.9%) or the reaction of their peers (29.5%) had motivated them to stop smoking. The impact on motivation not to smoke was considerably lower than experienced with seventh graders (63.2% vs. 42.0%; notably, more smokers also disagreed (45.1%) than agreed (23.5%) with this statement. Agreement rates on the motivation not to smoke item were higher in females than in males and in year 2–3 than in year 1 students. Potential improvements included greater focus on pathology (29%) and discussing external factors (26%). Overall, the intervention seemed to be appealing for nursing students.

The Emerging Imperative for a Consensus Approach Toward the Rating and Clinical Recommendation of Mental Health Apps

With over 10,000 mental health- and psychiatry-related smartphone apps available today and expanding, there is a need for reliable and valid evaluation of these digital tools. However, the updating and nonstatic nature of smartphone apps, expanding privacy concerns, varying degrees of usability, and evolving interoperability standards, among other factors, present serious challenges for app evaluation. In this article, we provide a narrative review of various schemes toward app evaluations, including commercial app store metrics, government initiatives, patient-centric approaches, point-based scoring, academic platforms, and expert review systems. We demonstrate that these different approaches toward app evaluation each offer unique benefits but often do not agree to each other and produce varied conclusions as to which apps are useful or not. Although there are no simple solutions, we briefly introduce a new initiative that aims to unify the current controversies in app elevation called CHART (Collaborative Health App Rating Teams), which will be further discussed in a second article in this series.

Facial-Aging Mobile Apps for Smoking Prevention in Secondary Schools in Brazil: Appearance-Focused Interventional Study

Background

Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous. Interventions that harness the broad availability of mobile phones as well as adolescents' interest in their appearance may be a novel way to improve school-based prevention. A recent study conducted in Germany showed promising results. However, the transfer to other cultural contexts, effects on different genders, and implementability remains unknown.

Objective

In this observational study, we aimed to test the perception and implementability of facial-aging apps to prevent smoking in secondary schools in Brazil in accordance with the theory of planned behavior and with respect to different genders.

Methods

We used a free facial-aging mobile phone app (“Smokerface”) in three Brazilian secondary schools via a novel method called mirroring. The students’ altered three-dimensional selfies on mobile phones or tablets and images were “mirrored” via a projector in front of their whole grade. Using an anonymous questionnaire, we then measured on a 5-point Likert scale the perceptions of the intervention among 306 Brazilian secondary school students of both genders in the seventh grade (average age 12.97 years). A second questionnaire captured perceptions of medical students who conducted the intervention and its conduction per protocol.

Results

The majority of students perceived the intervention as fun (304/306, 99.3%), claimed the intervention motivated them not to smoke (289/306, 94.4%), and stated that they learned new benefits of not smoking (300/306, 98.0%). Only a minority of students disagreed or fully disagreed that they learned new benefits of nonsmoking (4/306, 1.3%) or that they themselves were motivated not to smoke (5/306, 1.6%). All of the protocol was delivered by volunteer medical students.

Conclusions

Our data indicate the potential for facial-aging interventions to reduce smoking prevalence in Brazilian secondary schools in accordance with the theory of planned behavior. Volunteer medical students enjoyed the intervention and are capable of complete implementation per protocol.

Specific features of current and emerging mobile health apps: user views among people with and without mental health problems

BACKGROUND

Despite widespread development of mobile health apps, there is a paucity of research investigating user views of apps and their features, particularly among people with mental health problems. This study aimed to gain an understanding of the acceptability of specific features of current and emerging mobile health apps among people with and without mental health problems.

METHODS

Adults living in Australia were recruited to complete a self-report questionnaire regarding demographic characteristics, mental health, technology use, and attitudes regarding specific features of mobile health apps.

RESULTS

A total of 284 participants were recruited, including 53% with a history of mental illness. Few concerns were reported with mobile app features (mean =1.8 features; SD =2.19) and statistical analyses found that age, gender, income, rurality, mental health status and technology use did not affect the expression of these concerns. Key issues identified included privacy and security of personal information, apps acting automatically, sharing personal information and the invasive nature of some features.

CONCLUSIONS

These results suggest that mental illness may not be a barrier to widespread use of mobile technologies for health purposes. It is hoped that this research will assist developers and clinicians to develop and integrate mobile health apps into everyday care more effectively.