151
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Matheson FI, Hamilton-Wright S, Kryszajtys DT, Wiese JL, Cadel L, Ziegler C, Hwang SW, Guilcher SJT. The use of self-management strategies for problem gambling: a scoping review. BMC Public Health 2019; 19:445. [PMID: 31035978 PMCID: PMC6489359 DOI: 10.1186/s12889-019-6755-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 04/08/2019] [Indexed: 12/18/2022] Open
Abstract
Background Problem gambling (PG) is a serious public health concern that disproportionately affects people experiencing poverty, homelessness, and multimorbidity including mental health and substance use concerns. Little research has focused on self-help and self-management in gambling recovery, despite evidence that a substantial number of people do not seek formal treatment. This study explored the literature on PG self-management strategies. Self-management was defined as the capacity to manage symptoms, the intervention, health consequences and altered lifestyle that accompanies a chronic health concern. Methods We searched 10 databases to identity interdisciplinary articles from the social sciences, allied health professions, nursing and psychology, between 2000 and June 28, 2017. We reviewed records for eligibility and extracted data from relevant articles. Studies were included in the review if they examined PG self-management strategies used by adults (18+) in at least a subset of the sample, and in which PG was confirmed using a validated diagnostic or screening tool. Results We conducted a scoping review of studies from 2000 to 2017, identifying 31 articles that met the criteria for full text review from a search strategy that yielded 2662 potential articles. The majority of studies examined self-exclusion (39%), followed by use of workbooks (35%), and money or time limiting strategies (17%). The remaining 8% focused on cognitive, behavioural and coping strategies, stress management, and mindfulness. Conclusions Given that a minority of people with gambling concerns seek treatment, that stigma is an enormous barrier to care, and that PG services are scarce and most do not address multimorbidity, it is important to examine the personal self-management of gambling as an alternative to formalized treatment. Electronic supplementary material The online version of this article (10.1186/s12889-019-6755-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flora I Matheson
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Sarah Hamilton-Wright
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - David T Kryszajtys
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Jessica L Wiese
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Carolyn Ziegler
- Health Information Sciences Library, University of Toronto, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Sara J T Guilcher
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
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152
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Curtis BL, Ashford RD, Magnuson KI, Ryan-Pettes SR. Comparison of Smartphone Ownership, Social Media Use, and Willingness to Use Digital Interventions Between Generation Z and Millennials in the Treatment of Substance Use: Cross-Sectional Questionnaire Study. J Med Internet Res 2019; 21:e13050. [PMID: 30994464 PMCID: PMC6492066 DOI: 10.2196/13050] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/11/2019] [Accepted: 02/17/2019] [Indexed: 01/05/2023] Open
Abstract
Background Problematic substance use in adolescence and emerging adulthood is a significant public health concern in the United States due to high recurrence of use rates and unmet treatment needs coupled with increased use. Consequently, there is a need for both improved service utilization and availability of recovery supports. Given the ubiquitous use of the internet and social media via smartphones, a viable option is to design digital treatments and recovery support services to include internet and social media platforms. Objective Although digital treatments delivered through social media and the internet are a possibility, it is unclear how interventions using these tools should be tailored for groups with problematic substance use. There is limited research comparing consumer trends of use of social media platforms, use of platform features, and vulnerability of exposure to drug cues online. The goal of this study was to compare digital platforms used among adolescents (Generation Zs, age 13-17) and emerging adults (Millennials, age 18-35) attending outpatient substance use treatment and to examine receptiveness toward these platforms in order to support substance use treatment and recovery. Methods Generation Zs and Millennials enrolled in outpatient substance use treatment (n=164) completed a survey examining social media use, digital intervention acceptability, frequency of substance exposure, and substance use experiences. Generation Zs (n=53) completed the survey in July 2018. Millennials (n=111) completed the survey in May 2016. Results Generation Zs had an average age of 15.66 (SD 1.18) years and primarily identified as male (50.9%). Millennials had an average age of 27.66 (SD 5.12) years and also primarily identified as male (75.7%). Most participants owned a social media account (Millennials: 82.0%, Generation Zs: 94.3%) and used it daily (Millennials: 67.6%, Generation Zs: 79.2%); however, Generation Zs were more likely to use Instagram and Snapchat, whereas Millennials were more likely to use Facebook. Further, Generation Zs were more likely to use the features within social media platforms (eg, instant messaging: Millennials: 55.0%, Generation Zs: 79.2%; watching videos: Millennials: 56.8%, Generation Zs: 81.1%). Many participants observed drug cues on social media (Millennials: 67.5%, Generation Zs: 71.7%). However, fewer observed recovery information on social media (Millennials: 30.6%, Generation Zs: 34.0%). Participants felt that social media (Millennials: 55.0%, Generation Zs: 49.1%), a mobile phone app (Millennials: 36.9%, Generation Zs: 45.3%), texting (Millennials: 28.8%, Generation Zs: 45.3%), or a website (Millennials: 39.6%, Generation Zs: 32.1%) would be useful in delivering recovery support. Conclusions Given the high rates of exposure to drug cues on social media, disseminating recovery support within a social media platform may be the ideal just-in-time intervention needed to decrease the rates of recurrent drug use. However, our results suggest that cross-platform solutions capable of transcending generational preferences are necessary and one-size-fits-all digital interventions should be avoided.
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Affiliation(s)
- Brenda L Curtis
- Psychology-Addictions Treatment Research Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D Ashford
- Psychology-Addictions Treatment Research Center, University of Pennsylvania, Philadelphia, PA, United States.,Substance Use Disorders Institute, University of the Sciences, Pennsylvania, PA, United States
| | - Katherine I Magnuson
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
| | - Stacy R Ryan-Pettes
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States
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153
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Koivisto J, Hamari J. The rise of motivational information systems: A review of gamification research. INTERNATIONAL JOURNAL OF INFORMATION MANAGEMENT 2019. [DOI: 10.1016/j.ijinfomgt.2018.10.013] [Citation(s) in RCA: 221] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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154
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Carmody JK, Denson LA, Hommel KA. Content and Usability Evaluation of Medication Adherence Mobile Applications for Use in Pediatrics. J Pediatr Psychol 2019; 44:333-342. [PMID: 30358863 PMCID: PMC6415658 DOI: 10.1093/jpepsy/jsy086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/16/2018] [Accepted: 10/01/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The objective of this study was to systematically evaluate commercially available medication adherence apps for the inclusion of behavior change techniques (BCTs) and to conduct a usability analysis on a subset of apps with adolescents and young adults living with a chronic illness. METHODS Medication adherence apps were identified via a search of iTunes app store in August 2016. Seventy-five apps meeting initial inclusion criteria were independently coded by two researchers for the presence/absence of 26 BCTs. Twenty adolescents and young adults (ages: 13-20 years) with inflammatory bowel disease conducted usability testing on a subset of apps (n = 4). RESULTS Across 75 apps coded for presence/absence of 26 BCTs, only 7 unique BCTs were identified. The number of BCTs per app ranged from 2 to 6, with an average of 3.3 BCTs. In usability testing, quality ratings varied across apps. Medisafe received the highest average scores on engagement, functionality, aesthetics, and information subscales. Medisafe and MyTherapy ranked first and second, respectively, on overall quality and perceived impact ratings. CONCLUSION Content evaluation revealed only a limited number of BCTs that have been translated to medication adherence apps. Among apps with comparable content, clear user preferences emerged based on perceived quality and usability. Greater collaboration is needed between psychologists and health technologists to incorporate more evidence-based BCTs in apps. Findings also indicate a need for app developers to consider and incorporate the preferences of younger end users to improve app quality and engagement for pediatric populations.
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Affiliation(s)
- Julia K Carmody
- Center for Adherence and Self-Management
- Center for Health Technology Research
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center
| | - Lee A Denson
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kevin A Hommel
- Center for Adherence and Self-Management
- Center for Health Technology Research
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
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155
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Nguyen AD, Frensham LJ, Baysari MT, Carland JE, Day RO. Patients' use of mobile health applications: what general practitioners think. Fam Pract 2019; 36:214-218. [PMID: 29873708 DOI: 10.1093/fampra/cmy052] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic disease patients are adopting self-management techniques, such as using mobile health applications (apps). As GPs are the main caregivers of chronic disease patients, obtaining GP perspectives regarding patient use of mobile health apps is vital in understanding longer term value and feasibility of these apps. OBJECTIVE The aim was to determine GP perceptions of their current and potential roles in the use of health apps by their patients and how patient-focused apps affect patient management. METHODS Ten GPs participated in semi-structured, face-to-face interviews, which focused on their perceptions of, and involvement in, the use of patient-focused health apps. Interviews were transcribed verbatim and thematically analysed by two independent reviewers. RESULTS GPs found that apps complemented their role in patient management as additional sources of medical information of their patients. They perceived that patient-focused apps would be part of their future practices; however they noted that further work was required to incorporate them into their current practices. Currently, the main role of GPs was in promoting apps to patients. Suggestions for further engagement in mobile health included regularly reviewing patient data entered into health apps during consultations. CONCLUSION GPs view patient-focused health apps positively, particularly to support them in providing patient care. Discussing information recorded in apps during consultations and frequent promotion of apps are feasible ways to integrate apps into their current work practices. Further studies involving evaluations of apps in improving health care delivery and patient communication in general practice are required.
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Affiliation(s)
- Amy D Nguyen
- St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia.,Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Lauren J Frensham
- St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia
| | - Melissa T Baysari
- St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jane E Carland
- St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia
| | - Richard O Day
- St Vincent's Clinical School, UNSW Sydney, Sydney, Australia.,Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, Australia.,School of Medical Sciences, UNSW Sydney, Sydney, Australia
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156
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Abstract
Background: Diabetes is a growing worldwide disease with serious consequences to health and with a high financial burden. Ghana is one of the developing African countries where the prevalence of diabetes is increasing. Moreover, many cases remain undiagnosed, when along with pre-diabetic cases they can be easily detected. The main objective of this study is to propose a novel method to increase diabetes and pre-diabetes early detection in rural areas. A secondary aim is to look for new related behavioral determinants specific to rural Ghana, by comparing subjects at risk with those already diagnosed as diabetic. Methods: The detection approach was based on tests performed pro-actively by community nurses using glucometers and mobile phone apps. As a pilot for future policies, glycemic tests were carried out on 101 subjects from rural communities in Ghana deemed at risk and unaware of their diabetic/pre-diabetic status. A comparison of dietary and lifestyle habits of the screened people was conducted in regards to a cohort of 103 diabetic patients from the same rural communities. Participants for both groups were found through snow-ball sampling. Results: The pilot screening detected 2 diabetic subjects (2% of the cohort) showing WHO diabetic glycemic values, and 20 pre-diabetic subjects (19.8% of the cohort) which showed the effectiveness of the user-friendly approach. Conclusions: Policies based on prevention screening as reported in the manuscript have the potential to reduce diabetes incidence, if actions are taken while patients are pre-diabetic, reduce complication related to late diagnosis and indirectly related health-care costs in the country. The need for further campaigns on alcohol consumption and physical activity has emerged, even in rural areas.
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Affiliation(s)
| | | | - Alessandro Crimi
- African Institute for Mathematical Science, Cape Coast, Ghana, Ghana
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157
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Effah Nyarko B, Amoah RS, Crimi A. Boosting diabetes and pre-diabetes screening in rural Ghana. F1000Res 2019; 8:289. [PMID: 31508210 PMCID: PMC6720030 DOI: 10.12688/f1000research.18497.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2019] [Indexed: 07/20/2024] Open
Abstract
Background: Diabetes is a growing worldwide disease with serious consequences to health and with a high financial burden. Ghana is one of the developing African countries where the prevalence of diabetes is increasing. Moreover, many cases remain undiagnosed, when along with pre-diabetic cases they can be easily detected. Pre-diabetes condition occurs when blood sugar levels are higher than normal but are not high enough to be classified as diabetes, and it is still reversible. The main objective of this study is to propose a novel method to increase diabetes and pre-diabetes early detection in rural areas. A secondary aim is to look for new related behavioral determinants specific to rural Ghana, by comparing subjects at risk with those already diagnosed as diabetic. Methods: The screening approach was based on tests performed pro-actively by community nurses using glucometers and mobile phone apps. As a pilot for future policies, glycemic tests were carried out on 101 subjects from rural communities in Ghana deemed at risk and unaware of their diabetic/pre-diabetic status. A comparison of dietary and lifestyle habits of the screened people was conducted in regards to a cohort of 103 diabetic patients from the same rural communities. Results: The pilot screening detected 2 diabetic subjects (2% of the cohort) showing WHO diabetic glycemic values, and 20 pre-diabetic subjects (19.8% of the cohort) which showed the effectiveness of the user-friendly approach. The need for further campaigns on alcohol consumption and physical activity has emerged, even in rural areas. Conclusions: Policies based on prevention screening as reported in the manuscript have the potential to reduce diabetes incidence, if actions are taken while patients are pre-diabetic, reduce complication related to late diagnosis and indirectly related health-care costs in the country.
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Affiliation(s)
| | | | - Alessandro Crimi
- African Institute for Mathematical Science, Cape Coast, Ghana, Ghana
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158
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Abstract
Gamification, the use of game design elements in applications that are not games, has been developed to provide attractive environments and maintain user interest in several domains. In domains such as education, marketing and health, where gamification techniques are applied, user engagement in applications has increased. In these applications the protection of users’ privacy is an important aspect to consider, due to the applications obtaining a record of the personal information of their users. Thus, the purpose of this paper is to identify if applications where gamification is applied do respect users’ privacy. For the accomplishment of this aim, two main steps have been implemented. Since the main principle of gamification is the existence of game elements, the first step was to identify the set of game elements recorded in the literature that are commonly applied in various applications. Afterwards, an examination of the relationship between these elements and privacy requirements was implemented in order to identify which elements conflict with the privacy requirements leading to potential privacy violations and which elements do not. Α conceptual model according to the results of this examination was designed, which presents how elements conflict with requirements. Based on the results, there are indeed game elements which can lead to privacy violations. The results of this work provide valuable guidance to software developers, especially during the design stages of gamified applications since it helps them to consider the protection of users’ privacy in parallel from the early stages of the application development onwards.
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159
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Lopes S, Pereira A, Magalhães P, Oliveira A, Rosário P. Gamification: focus on the strategies being implemented in interventions: a systematic review protocol. BMC Res Notes 2019; 12:100. [PMID: 30795806 PMCID: PMC6387509 DOI: 10.1186/s13104-019-4139-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/19/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Gamification broadly refers to the use of game design elements in non-game contexts with the goal of promoting users' engagement. Gamification strategies appear as an advantageous tool to increase the motivation and involvement of users. The purpose of this systematic review is to identify studies using gamification strategies in distinct intervention contexts and to describe their impact in each type of intervention. Thus, the focus is on the construct (gamification) rather than on a particular area or population. RESULTS To achieve this goal, Scopus, IEEE, Web of Science, MEDLINE, ERIC, and PsycINFO databases will be used to gather data for the systematic review. Both the research and report of results will be based on Cochrane's recommendations and PRISMA guidelines. Data, including the assessment on the quality of the articles, will be conducted by two members of the team independently. Findings will be reported narratively. The ethical approval is not required as the research does not involve data collection. Findings will be submitted to a peer-review journal and the results will be presented on international congresses. Future reviews could consider investigating particular areas of intervention in which gamification strategies are being employed. Trial registration Systematic Review Registration: PROSPERO CRD42017070508.
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Affiliation(s)
- Sílvia Lopes
- School of Psychology, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal.
| | - Armanda Pereira
- School of Psychology, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
| | - Paula Magalhães
- School of Psychology, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
| | - André Oliveira
- School of Psychology, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
| | - Pedro Rosário
- School of Psychology, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal
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160
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Moore G, Wilding H, Gray K, Castle D. Participatory Methods to Engage Health Service Users in the Development of Electronic Health Resources: Systematic Review. J Particip Med 2019; 11:e11474. [PMID: 33055069 PMCID: PMC7434099 DOI: 10.2196/11474] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/29/2018] [Accepted: 12/10/2018] [Indexed: 02/06/2023] Open
Abstract
Background When health service providers (HSP) plan to develop electronic health (eHealth) resources for health service users (HSU), the latter’s involvement is essential. Typically, however, HSP, HSU, and technology developers engaged to produce the resources lack expertise in participatory design methodologies suited to the eHealth context. Furthermore, it can be difficult to identify an established method to use, or determine how to work stepwise through any particular process. Objective We sought to summarize the evidence about participatory methods and frameworks used to engage HSU in the development of eHealth resources from the beginning of the design process. Methods We searched for studies reporting participatory processes in initial development of eHealth resources from 2006 to 2016 in 9 bibliographic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Emcare, Cochrane Library, Web of Science, ACM Guide to Computing Literature, and IEEE Xplore. From 15,117 records initially screened on title and abstract for relevance to eHealth and early participatory design, 603 studies were assessed for eligibility on full text. The remaining 90 studies were rated by 2 reviewers using the Mixed Methods Appraisal Tool Version 2011 (Pluye et al; MMAT) and analyzed with respect to health area, purpose, technology type, and country of study. The 30 studies scoring 90% or higher on MMAT were included in a detailed qualitative synthesis. Results Of the 90 MMAT-rated studies, the highest reported (1) health areas were cancer and mental disorders, (2) eHealth technologies were websites and mobile apps, (3) targeted populations were youth and women, and (4) countries of study were the United States, the United Kingdom, and the Netherlands. Of the top 30 studies the highest reported participatory frameworks were User-Centered Design, Participatory Action Research Framework, and the Center for eHealth Research and Disease Management (CeHRes) Roadmap, and the highest reported model underpinning development and engagement was Social Cognitive Theory. Of the 30 studies, 4 reported on all the 5 stages of the CeHRes Roadmap. Conclusions The top 30 studies yielded 24 participatory frameworks. Many studies referred to using participatory design methods without reference to a framework. The application of a structured framework such as the CeHRes Roadmap and a model such as Social Cognitive Theory creates a foundation for a well-designed eHealth initiative that ensures clarity and enables replication across participatory design projects. The framework and model need to be clearly articulated and address issues that include resource availability, responsiveness to change, and the criteria for good practice. This review creates an information resource for future eHealth developers, to guide the design of their eHealth resource with a framework that can support further evaluation and development. Trial Registration PROSPERO CRD42017053838; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=53838
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Affiliation(s)
- Gaye Moore
- Mental Health Executive Services, St Vincent's Hospital, Melbourne, Fitzroy, Australia.,Department of Nursing, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Helen Wilding
- Mental Health Executive Services, St Vincent's Hospital, Melbourne, Fitzroy, Australia.,Library Service, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Kathleen Gray
- Health and Biomedical Informatics Centre, University of Melbourne, Melbourne, Australia
| | - David Castle
- Mental Health Executive Services, St Vincent's Hospital, Melbourne, Fitzroy, Australia.,Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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161
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Wang X, Shu W, Du J, Du M, Wang P, Xue M, Zheng H, Jiang Y, Yin S, Liang D, Wang R, Hou L. Mobile health in the management of type 1 diabetes: a systematic review and meta-analysis. BMC Endocr Disord 2019; 19:21. [PMID: 30760280 PMCID: PMC6375163 DOI: 10.1186/s12902-019-0347-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/25/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND As an insulin-dependent disease, type 1 diabetes requires paying close attention to the glycemic control. Studies have shown that mobile health (mHealth) can improve the management of chronic diseases. However, the effectiveness of mHealth in controlling the glycemic control remains uncertain. The objective of this study was to carry out a systematic review and meta-analysis using the available literature reporting findings on mHealth interventions, which may improve the management of type 1 diabetes. METHODS We performed a systematic literature review of all studies in the PubMed, Web of Science, and EMbase databases that used mHealth (including mobile phones) in diabetes care and reported glycated hemoglobin (HbA1c) values as a measure of glycemic control. The fixed effects model was used for this meta-analysis. RESULTS This study analyzed eight studies, which involved a total of 602 participants. In the meta-analysis, the fixed effects model showed a statistically significant decrease in the mean of HbA1c in the intervention group: - 0.25 (95% confidence interval: - 0.41, - 0.09; P = 0.003, I2 = 12%). Subgroup analyses indicated that the patient's age, the type of intervention, and the duration of the intervention influenced blood glucose control. Funnel plots showed no publication bias. CONCLUSIONS Mobile health interventions may be effective among patients with type 1 diabetes. A significant reduction in HbA1c levels was associated with adult age, the use of a mobile application, and the long-term duration of the intervention.
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Affiliation(s)
- Xuemei Wang
- Department of Nutrition and Food Hygiene, School of Public Health, Peking University Health Science Center, Beijing, 100191 China
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Wei Shu
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
- Clinical Center on TB Control, Beijing Tuberculosis and Thoracic Tumor Research Institute/Beijing Chest Hospital, Capital Medical University, Beijing, 101149 China
| | - Jian Du
- Clinical Center on TB Control, Beijing Tuberculosis and Thoracic Tumor Research Institute/Beijing Chest Hospital, Capital Medical University, Beijing, 101149 China
| | - Maolin Du
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Peiyu Wang
- Department of Social Medicine and Health Education, School of Public Health, Peking University Health Science Center, Beijing, 100191 China
| | - Mingming Xue
- School of Basic Medicine, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Huiqiu Zheng
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Yufeng Jiang
- Diabetes Centre, The 306th Hospital of PLA, Beijing, 100101 China
| | - Shaohua Yin
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Danyan Liang
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Ruiqi Wang
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
| | - Lina Hou
- Department of Health Statistics, School of Public Health, Inner Mongolia Medical University, Hohhot, 010110 China
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162
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Abstract
The Wellbeing Game uses game design elements to promote wellbeing. Players document their daily activities in the game and categorize them to one or more of five wellbeing-related factors. The users join teams and can create team events to work together and improve their wellbeing status. The present study aims to review the application and the theoretical base of ‘The Wellbeing Game’, to adapt it to the German context, and to evaluate its health effects in different settings. Additional aims are to analyze the current state of research regarding the links between health, wellbeing, and gamification and to identify crucial game design elements that have to be implemented in the application in order to address the needs of competence, autonomy, and social relatedness according to the self-determination theory.
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163
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Liew MS, Zhang J, See J, Ong YL. Usability Challenges for Health and Wellness Mobile Apps: Mixed-Methods Study Among mHealth Experts and Consumers. JMIR Mhealth Uhealth 2019; 7:e12160. [PMID: 30698528 PMCID: PMC6372932 DOI: 10.2196/12160] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND By 2019, there will be an estimated 4.68 billion mobile phone users globally. This increase comes with an unprecedented proliferation in mobile apps, a plug-and-play product positioned to improve lives in innumerable ways. Within this landscape, medical apps will see a 41% compounded annual growth rate between 2015 and 2020, but paradoxically, prevailing evidence indicates declining downloads of such apps and decreasing "stickiness" with the intended end users. OBJECTIVE As usability is a prerequisite for success of health and wellness mobile apps, this paper aims to provide insights and suggestions for improving usability experience of the mobile health (mHealth) app by exploring the degree of alignment between mHealth insiders and consumers. METHODS Usability-related major themes were selected from over 20 mHealth app development studies. The list of themes, grouped into 5 categories using the Nielsen usability model, was then used as a framework to identify and classify the responses from mHealth expert (insider) interviews. Responses from the qualitative phase were integrated into some questions for a quantitative consumer survey. Subsequently, categorical data from qualitative mHealth insider interviews and numerical data from a quantitative consumer survey were compared in order to identify common usability themes and areas of divergence. RESULTS Of the 5 usability attributes described in Nielsen model, Satisfaction ranked as the top attribute for both mHealth insiders and consumers. Satisfaction refers to user likability, comfort, and pleasure. The consumer survey yielded 451 responses. Out of 9 mHealth insiders' top concerns, 5 were similar to those of the consumers. On the other hand, consumers did not grade themes such as Intuitiveness as important, which was deemed vital by mHealth insiders. Other concerns of the consumers include in-app charges and advertisements. CONCLUSIONS This study supports and contributes to the existing pool of mixed-research studies. Strengthening the connectivity between suppliers and users (through the designed research tool) will help increase uptake of mHealth apps. In a holistic manner, this will have a positive overall outcome for the mHealth app ecosystem.
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Affiliation(s)
- Mei Shan Liew
- Alliance Manchester Business School, Manchester, United Kingdom
| | - Jian Zhang
- Alliance Manchester Business School, Manchester, United Kingdom
| | - Jovis See
- Alliance Manchester Business School, Manchester, United Kingdom
| | - Yen Leng Ong
- Alliance Manchester Business School, Manchester, United Kingdom
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164
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McPherson AC, Oake M, Stinson J. "Don't sweat it buddy, it's OK": an exploration of the needs of adolescents with disabilities when designing a mobile application for weight management and healthy lifestyles. Disabil Rehabil 2019; 42:1569-1577. [PMID: 30689451 DOI: 10.1080/09638288.2018.1530804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose: Adolescents with disabilities often demonstrate higher sedentary behaviours, lower physical activity levels, poorer quality diets, and higher rates of overweight and obesity than typically developing youth. This study had two objectives: 1) To understand the needs and priorities of adolescents with disabilities, parents, and the healthcare professionals who work with them around healthy lifestyles and weight management; and 2) To explore whether and how a mobile application could address these needs.Methods: Multiple perspectives were gathered through separate qualitative focus groups with adolescents with disabilities (12-17 years), parents, and rehabilitation healthcare professionals. Data were analysed using descriptive thematic analysis.Results: Parents (n = 6) and healthcare professionals (n = 9) described the complex needs of adolescents with disabilities around weight management and healthy lifestyles, including balancing differing priorities and a lack of appropriate resources. Adolescents (n = 7) endorsed the potential for technology to enhance their health through empowerment and having a virtual support system. All stakeholder groups endorsed taking a holistic, wellness approach.Conclusions: Adolescents with disabilities have a complex lifestyle and weight management needs, but mobile applications have the potential to provide individualized support. It is critical that anyone developing mobile applications engage a range of stakeholders as co-designers.Implications for rehabilitationAdolescents with disabilities have complex support needs and priorities around weight management and healthy lifestyles.Existing resources do not take into account the wide-ranging abilities of adolescents with disabilities.Mobile applications have the potential to empower adolescents and provide tailored support around healthy lifestyles.Including user input when designing technologies is critical.
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Affiliation(s)
- Amy C McPherson
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Michelle Oake
- Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
| | - Jennifer Stinson
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
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165
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Beintner I, Jacobi C. Internet-based aftercare for women with bulimia nervosa following inpatient treatment: The role of adherence. Internet Interv 2019; 15:67-75. [PMID: 30723692 PMCID: PMC6350217 DOI: 10.1016/j.invent.2018.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 11/03/2022] Open
Abstract
Facing poor long-term outcome and high relapse rates in the treatment of bulimia nervosa, we developed an Internet-based aftercare program for women with severe and chronic bulimia nervosa following inpatient treatment based on previous experiences with self-directed targeted prevention and early intervention programs delivered online. The aim of the present study was to examine adherence to the program in detail, to explore potential variables that predict adherence and to analyze whether adherence affects outcomes. We analyzed data from 126 women in the intervention group of a randomized controlled trial. 107 women (85%) logged on to the program platform at least once. These women opened on average 42.8% (SD = 31.9%) of all assigned program pages. Adherence declined during the course of the intervention. Adherence was not associated with the number of outpatient treatment sessions received during the intervention period. Adherence was not related to overall illness severity or duration at baseline. However, excessive exercise at hospital discharge (which may be a sign of insufficient motivation to change eating disorder related behaviors) seems to play some small role in adherence. Adherence did not affect intervention outcomes. Based on our findings, we would like to advocate further research on online aftercare interventions for women with severe and chronic bulimia nervosa.
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Affiliation(s)
| | - Corinna Jacobi
- Chair of Clinical Psychology, E-Mental-Health, Technische Universität Dresden, 01062 Dresden, Germany
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166
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Klaprat N, MacIntosh A, McGavock JM. Gaps in Knowledge and the Need for Patient-Partners in Research Related to Physical Activity and Type 1 Diabetes: A Narrative Review. Front Endocrinol (Lausanne) 2019; 10:42. [PMID: 30787908 PMCID: PMC6372552 DOI: 10.3389/fendo.2019.00042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
Regular physical activity (PA) is a cornerstone in the management of complications associated with type 1 diabetes (T1D). Most national guidelines advocate for regular PA for persons living with T1D, however the evidence to support these recommendations has not be reviewed recently. Additionally, in an era of patient-centered care and patient oriented research, the role of patient partners in the area of PA and T1D interventions has never been explored. The purpose of this narrative review is to overcome these two gaps in the literature. Here we review selected epidemiological evidence and identify gaps in research that would add important information to guide practitioners and future guidelines. We also provide an overview of patient-oriented research projects co-developed with persons living with T1D. Significant gaps in the field include: (1) a lack of adequately powered prospective cohort studies using serial measures of PA and hard chronic disease end-points; (2) no multi-centered, highly powered, randomized controlled trials of PA, and long-term health outcomes; (3) little data on the role of new technologies to support PA-related behavior change, and (4) no trials that involved patients in the design and execution of PA-based clinical trials. This review provides a template for scientists and patient partners to develop future research priorities and agendas in the field.
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Affiliation(s)
- Nika Klaprat
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Andrea MacIntosh
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan M. McGavock
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Action Canada SPOR Network, Toronto, ON, Canada
- *Correspondence: Jonathan M. McGavock
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167
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Gholami Farashah MS, Pasbakhsh P, Omidi A, Nekoonam S, Aryanpour R, Regardi Kashani I. Preconditioning with SDF-1 Improves Therapeutic Outcomes of Bone marrow-derived Mesenchymal Stromal Cells in a Mouse Model of STZ-induced Diabetes. Avicenna J Med Biotechnol 2019; 11:35-42. [PMID: 30800241 PMCID: PMC6359696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Nowadays, transplantation of Bone marrow-derived Mesenchymal Stromal Cells (BMSCs) is currently an important alternative therapy for patient's type 1 diabetes mellitus. But a number of critical obstacles lie ahead of this new strategy including reducing stem cell homing to the damaged tissue due to oxidative stress. The purpose of the present study was to investigate whether preconditioning of BMSCs with SDF-1 could enhance their homing to the pancreas and promote regeneration of the pancreatic β cells after being intravenously injected. METHODS Mice BMSCs were isolated and expanded. Cell proliferation was assayed by MTT Assay. Preconditioning was performed with 10 ng/ml SDF-1α for 24 hr. Male NMRI mice were injected with high-dose STZ (150 mg/kg). The preconditioned or un-preconditioned BMSCs at a dose of 1×106 cells were infused via the tail vein. Blood and pancreatic tissue samples were taken from all mice for flow cytometry, biochemical and histological studies. RESULTS Proliferation and homing of BMSCs to the pancreas were significantly increased in the BMSCs with SDF-1α preconditioning. Differentiation of transplanted BMSCs, were significantly increased in preconditioning group. Although BMSCs without SDF-1 preconditioning exhibited remarkable recovery of pancreatic islets structure but this recovery were significantly increased in the BMSCs with SDF-1α preconditioning. CONCLUSION Our results showed the effectiveness of SDF-1α preconditioning in BMSCs transplantation of STZ induced diabetes mice which might be achieved through improvement of BMSCs homing into the injured pancreas.
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Affiliation(s)
| | - Parichehr Pasbakhsh
- Department of Anatomical Sciences, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ameneh Omidi
- Department of Anatomical Sciences, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Saied Nekoonam
- Department of Anatomical Sciences, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Aryanpour
- Department of Anatomical Sciences, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Iraj Regardi Kashani
- Department of Anatomical Sciences, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author: Iraj Ragerdi Kashani, Ph.D., Department of Anatomical Sciences, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran, Tel: +98 21 64053410, 09127019141, Fax: +98 21 66419072, E-mail:
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168
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Kordonouri O, Riddell MC. Use of apps for physical activity in type 1 diabetes: current status and requirements for future development. Ther Adv Endocrinol Metab 2019; 10:2042018819839298. [PMID: 31037216 PMCID: PMC6475849 DOI: 10.1177/2042018819839298] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 02/19/2019] [Indexed: 01/02/2023] Open
Abstract
Smartphone technologies, and the applications (apps) that they host, are developing rapidly mainly with regard to communication, information processing, design, features and connectivity with other devices. Technologies used in modern treatment modalities and monitoring of type 1 diabetes are also rapidly evolving and can communicate with smartphones and apps. Therefore, numerous web-based and smartphone apps aim to provide information and various patient data metrics (e.g. caloric intake, activity levels, glucose monitoring) that can be accessed and processed for decision support by smartphone apps. In this narrative review, we highlight current information about the effectiveness of interventions through smartphone apps with a focus on apps designed to give guidance to patients with type 1 diabetes on physical activity monitoring and glucose control during and after structured exercise sessions, as these patients are experiencing huge therapeutic challenges during exercise. Furthermore, we propose a number of critical elements for future apps designed for people with type 1 diabetes.
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Affiliation(s)
| | - Michael C. Riddell
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada; School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
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169
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Abstract
We live in a heavily technologized global society. It is therefore not surprising that efforts are being made to integrate current information technology into the treatment of diabetes mellitus. This paper is dedicated to improving the treatment of this disease through the use of well-designed mobile applications. Our analysis of relevant literature sources and existing solutions has revealed that the current state of mobile applications for diabetics is unsatisfactory. These limitations relate both to the content and the Graphical User Interface (GUI) of existing applications. Following the analysis of relevant studies, there are four key elements that a diabetes mobile application should contain. These elements are: (1) blood glucose levels monitoring; (2) effective treatment; (3) proper eating habits; and (4) physical activity. As the next step in this study, three prototypes of new mobile applications were designed. Each of the prototypes represents one group of applications according to a set of given rules. The most optimal solution based on the users’ preferences was determined by using a questionnaire survey conducted with a sample of 30 respondents participating in a questionnaire after providing their informed consent. The age of participants was from 15 until 30 years old, where gender was split to 13 males and 17 females. As a result of this study, the specifications of the proposed application were identified, which aims to respond to the findings discovered in the analytical part of the study, and to eliminate the limitations of the current solutions. All of the respondents expressed preference for an application that includes not only the key functions, but a number of additional functions, namely synchronization with one of the external devices for measuring blood glucose levels, while five-sixths of them found suggested additional functions as being sufficient.
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170
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Jessen S, Mirkovic J, Ruland CM. Creating Gameful Design in mHealth: A Participatory Co-Design Approach. JMIR Mhealth Uhealth 2018; 6:e11579. [PMID: 30552080 PMCID: PMC6315237 DOI: 10.2196/11579] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Gameful designs (gamification), using design pieces and concepts typically found in the world of games, is a promising approach to increase users' engagement with, and adherence to, electronic health and mobile health (mHealth) tools. Even though both identifying and addressing users' requirements and needs are important steps of designing information technology tools, little is known about the users' requirements and preferences for gameful designs in the context of self-management of chronic conditions. OBJECTIVE This study aimed to present findings as well as the applied methods and design activities from a series of participatory design workshops with patients with chronic conditions, organized to generate and explore user needs, preferences, and ideas to the implementation of gameful designs in an mHealth self-management app. METHODS We conducted three sets of two consecutive co-design workshops with a total of 22 participants with chronic conditions. In the workshops, we applied participatory design methods to engage users in different activities such as design games, scenario making, prototyping, and sticky notes exercises. The workshops were filmed, and the participants' interactions, written products, ideas, and suggestions were analyzed thematically. RESULTS During the workshops, the participants identified a wide range of requirements, concerns, and ideas for using the gameful elements in the design of an mHealth self-management app. Overall inputs on the design of the app concerned aspects such as providing a positive user experience by promoting collaboration and not visibly losing to someone or by designing all feedback in the app to be uplifting and positive. The participants provided both general inputs (regarding the degree of competitiveness, use of rewards, or possibilities for customization) and specific inputs (such as being able to customize the look of their avatars or by having rewards that can be exchanged for real-world goods in a gift shop). However, inputs also highlighted the importance of making tools that provide features that are meaningful and motivating on their own and do not only have to rely on gameful design features to make people use them. CONCLUSIONS The main contribution in this study was users' contextualized and richly described needs and requirements for gamefully designed mHealth tools for supporting chronic patients in self-management as well as the methods and techniques used to facilitate and support both the participant's creativity and communication of ideas and inputs. The range, variety, and depth of the inputs from our participants also showed the appropriateness of our design approach and activities. These findings may be combined with literature and relevant theories to further inform in the selection and application of gameful designs in mHealth apps, or they can be used as a starting point for conducting more participatory workshops focused on co-designing gameful health apps.
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Affiliation(s)
- Stian Jessen
- Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jelena Mirkovic
- Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, Oslo, Norway
| | - Cornelia M Ruland
- Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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171
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Liang WH, Madan-Swain A, Cronin RM, Jackson GP. Development of a Technology-Supported, Lay Peer-to-Peer Family Engagement Consultation Service in a Pediatric Hospital. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2018; 2018:730-739. [PMID: 30815115 PMCID: PMC6371240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Patient and caregiver engagement in making decisions and taking actions to promote health are critically important for improving outcomes, enhancing healthcare experience satisfaction, and reducing costs. Patients and caregivers have a wealth of expertise in illness self-management and can aid others in attaining high levels of activation through peer-to-peer social support. We describe the development of a technology-supported, family engagement consultation service at Children's of Alabama that integrates parent volunteers as front-line, peer-to-peer support consultants with a multidisciplinary team of informatics professionals in the pediatric hospital setting. This service was adapted from an existing engagement consultation service with a traditional medical consultation model at Vanderbilt Children's Hospital. The unique features of the new model are articulated, along with plans for a shared knowledge database of consumer health resources to meet needs. The layperson peer-to-peer design is highly innovative and relevant as healthcare transitions towards increasingly participatory and personalized medicine.
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Affiliation(s)
- Wayne H Liang
- University of Alabama at Birmingham, Birmingham, Alabama
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172
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Martinez-Millana A, Jarones E, Fernandez-Llatas C, Hartvigsen G, Traver V. App Features for Type 1 Diabetes Support and Patient Empowerment: Systematic Literature Review and Benchmark Comparison. JMIR Mhealth Uhealth 2018; 6:e12237. [PMID: 30463839 PMCID: PMC6282013 DOI: 10.2196/12237] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/12/2018] [Accepted: 11/01/2018] [Indexed: 12/26/2022] Open
Abstract
Background Research in type 1 diabetes management has increased exponentially since the irruption of mobile health apps for its remote and self-management. Despite this fact, the features affect in the disease management and patient empowerment are adopted by app makers and provided to the general population remain unexplored. Objective To study the gap between literature and available apps for type 1 diabetes self-management and patient empowerment and to discover the features that an ideal app should provide to people with diabetes. Methods The methodology comprises systematic reviews in the scientific literature and app marketplaces. We included articles describing interventions that demonstrated an effect on diabetes management with particular clinical endpoints through the use of mobile technologies. The features of these apps were gathered in a taxonomy of what an ideal app should look like to then assess which of these features are available in the market. Results The literature search resulted in 231 matches. Of these, 55 met the inclusion criteria. A taxonomy featuring 3 levels of characteristics was designed based on 5 papers which were selected for the synthesis. Level 1 includes 10 general features (Personalization, Family support, Agenda, Data record, Insulin bolus calculator, Data management, Interaction, Tips and support, Reminders, and Rewards) Level 2 and Level 3 included features providing a descriptive detail of Level 1 features. Eighty apps matching the inclusion criteria were analyzed. None of the assessed apps fulfilled the features of the taxonomy of an ideal app. Personalization (70/80, 87.5%) and Data record (64/80, 80.0%) were the 2 top prevalent features, whereas Agenda (5/80, 6.3%) and Rewards (3/80, 3.8%) where the less predominant. The operating system was not associated with the number of features (P=.42, F=.81) nor the type of feature (P=.20, χ2=11.7). Apps were classified according to the number of level 1 features and sorted into quartiles. First quartile apps had a regular distribution of the ten features in the taxonomy whereas the other 3 quartiles had an irregular distribution. Conclusions There are significant gaps between research and the market in mobile health for type 1 diabetes management. While the literature focuses on aspects related to gamification, rewarding, and social communities, the available apps are focused on disease management aspects such as data record and appointments. Personalized and tailored empowerment features should be included in commercial apps for large-scale assessment of potential in the self-management of the disease.
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Affiliation(s)
| | - Elena Jarones
- ITACA, Universitat Politècnica de València, Valencia, Spain
| | | | - Gunnar Hartvigsen
- Department of Computer Science, University of Tromsø, Tromsø, Norway
| | - Vicente Traver
- ITACA, Universitat Politècnica de València, Valencia, Spain
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173
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Chib A, Lin SH. Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps. JOURNAL OF HEALTH COMMUNICATION 2018; 23:909-955. [PMID: 30449261 DOI: 10.1080/10810730.2018.1544676] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
There are now few hundred thousand healthcare apps, yet there is a gap in our understanding of the theoretical mechanisms for which, and how, technological features translate into improved healthcare outcomes. In particular, the technological convergence, within mobile health (mHealth) apps, of the processes of mass and interpersonal communication, and human-computer interaction requires greater parsing in the literature. This paper analyzed 85 empirical studies on mHealth apps using the Input-Mechanism-Output model. We found in the literature that, firstly, there is a greater emphasis on technological inputs (87%) of accessibility, usability, usage, and data quality, than health outputs (52%) such as system process efficiencies and individual level behavioral or health outcomes. Secondly, there is little evidence of explanatory mechanisms (19%) of how the effects of mHealth apps are achieved. While we believe that successful apps would require research that incorporates technological inputs, theoretical mechanisms and health outputs, such studies are a rarity (n = 3). There is a minor increase in rigor with randomized control trials (n = 5), and a preponderance of discussion around social influence (n = 8) and gamification (n = 7), albeit in a scattered manner. We discuss the implications of the trend towards socialization and gamification findings in terms of future research, particularly in terms of study design guided by theoretical mechanisms.
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Affiliation(s)
- Arul Chib
- a Wee Kim Wee School of Communication and Information , Nanyang Technological University , Singapore
| | - Sapphire H Lin
- a Wee Kim Wee School of Communication and Information , Nanyang Technological University , Singapore
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174
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Jupp JCY, Sultani H, Cooper CA, Peterson KA, Truong TH. Evaluation of mobile phone applications to support medication adherence and symptom management in oncology patients. Pediatr Blood Cancer 2018; 65:e27278. [PMID: 29943893 DOI: 10.1002/pbc.27278] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 01/19/2023]
Abstract
Mobile phone applications (apps), may support pediatric oncology patients with medication and disease management. A scoping review of the literature, a search of the iTunes App and Google Play Stores, was conducted to identify medication and symptom management apps for adult and pediatric oncology patients. Pooled results yielded 28 apps which were assessed for quality using the Mobile Application Rating Scale, with mean overall scores ranging from 2.8 to 4.3. Most apps received low scores in the Engagement domain. Our study assessed the quality of available mobile oncology apps and identified areas for improvement in design and function.
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Affiliation(s)
- Jennifer C Y Jupp
- Division of Pediatric Oncology, Blood and Marrow Transplant, Alberta, Children's Hospital, Alberta, Canada.,Pharmacy Services, Alberta Health Services, Alberta, Canada
| | | | - Cassandra A Cooper
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Alberta, Canada
| | | | - Tony H Truong
- Division of Pediatric Oncology, Blood and Marrow Transplant, Alberta, Children's Hospital, Alberta, Canada.,Department of Oncology and Pediatrics, University of Calgary, Alberta, Canada
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175
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Palermo TM, Zempsky WT, Dampier CD, Lalloo C, Hundert AS, Murphy LK, Bakshi N, Stinson JN. iCanCope with Sickle Cell Pain: Design of a randomized controlled trial of a smartphone and web-based pain self-management program for youth with sickle cell disease. Contemp Clin Trials 2018; 74:88-96. [PMID: 30316999 PMCID: PMC6218943 DOI: 10.1016/j.cct.2018.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022]
Abstract
Many adolescents with sickle cell disease (SCD) experience recurrent and chronic pain, which has a negative impact on their health-related quality of life (HRQL). Cognitive-behavioral therapy (CBT) interventions can lead to improvement in pain and HRQL, yet due to barriers to care, most youth with SCD will not receive these interventions. To address this need for innovative programs targeting youth with SCD pain, we developed iCanCope, a tailored smartphone and web-based program that delivers a pain self-management intervention to youth with SCD. We describe the rationale, design, and implementation of a three-site parallel group randomized controlled trial with a sample of 160 adolescents with SCD and their parent caregivers. The iCanCope program includes pain self-management skills training (personalized CBT-based coping skills such as deep breathing, relaxation, and cognitive skills), goal setting, and social support. The attention control group is provided with access to a self-guided website with education about SCD. Assessments will occur at baseline (T1), immediately after completion of the intervention (12 weeks; T2) and at 6 months post-intervention (T3). Primary outcomes include coping strategies and pain intensity; secondary outcomes include physical, social, and emotional functioning, treatment satisfaction, health service use and caregiver response to youth pain behavior. Potential mediators (goal setting, self-management, and perceptions of social support) and moderators (e.g., demographic factors) will also be tested. The objective is to offer an effective, convenient, and low-cost psychosocial intervention to youth with SCD to enhance their self-management of pain.
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Affiliation(s)
- Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, USA; Seattle Children's Research Institute, USA.
| | - William T Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, University of Connecticut School of Medicine, USA
| | | | - Chitra Lalloo
- The Hospital for Sick Children, Child Health Evaluative Sciences, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Canada
| | - Amos S Hundert
- The Hospital for Sick Children, Child Health Evaluative Sciences, Canada
| | | | | | - Jennifer N Stinson
- The Hospital for Sick Children, Child Health Evaluative Sciences, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Canada
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176
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Bellei EA, Biduski D, Cechetti NP, De Marchi ACB. Diabetes Mellitus m-Health Applications: A Systematic Review of Features and Fundamentals. Telemed J E Health 2018; 24:839-852. [DOI: 10.1089/tmj.2017.0230] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ericles Andrei Bellei
- Graduate Program in Applied Computing, Institute of Exact Sciences and Geosciences, University of Passo Fundo, Passo Fundo, Brazil
| | - Daiana Biduski
- Graduate Program in Applied Computing, Institute of Exact Sciences and Geosciences, University of Passo Fundo, Passo Fundo, Brazil
| | - Nathália Pinto Cechetti
- Graduate Program in Applied Computing, Institute of Exact Sciences and Geosciences, University of Passo Fundo, Passo Fundo, Brazil
| | - Ana Carolina Bertoletti De Marchi
- Graduate Program in Applied Computing, Institute of Exact Sciences and Geosciences, University of Passo Fundo, Passo Fundo, Brazil
- Graduate Program in Human Aging, College of Physical Education and Physiotherapy, University of Passo Fundo, Passo Fundo, Brazil
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177
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Stålberg A, Sandberg A, Söderbäck M. Child-centred Care - Health Professionals' Perceptions of What Aspects are Meaningful When Using Interactive Technology as a Facilitator in Healthcare Situations. J Pediatr Nurs 2018; 43:e10-e17. [PMID: 30056996 DOI: 10.1016/j.pedn.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/10/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Anna Stålberg
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden.
| | - Anette Sandberg
- School of Education, Culture and Communication, Mälardalen University, Västerås, Sweden
| | - Maja Söderbäck
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
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178
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McClure C, Cunningham M, Bull S, Berman S, Allison MA. Using Mobile Health to Promote Early Language Development: A Narrative Review. Acad Pediatr 2018; 18:850-854. [PMID: 30098442 DOI: 10.1016/j.acap.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/13/2018] [Accepted: 07/23/2018] [Indexed: 12/21/2022]
Abstract
In this narrative review, we first present a brief overview of known disparities in children's language development based on socioeconomic status and efforts in the primary care setting to promote children's language development. Next, we define mobile health (m-health) and review the limited, published literature regarding the effectiveness of m-health interventions in promoting children's health, in general, and language development, in particular. Finally, we discuss the potential role of smartphone applications to increase parental behaviors that promote their children's language development, as well as challenges that should be addressed as the field of m-health continues to grow.
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Affiliation(s)
- Catherine McClure
- Department of Pediatrics , University of Colorado Anschutz Medical Campus, Aurora
| | - Maureen Cunningham
- Department of Pediatrics , University of Colorado Anschutz Medical Campus, Aurora; Center for Global Health , Colorado School of Public Health, Aurora
| | - Sheana Bull
- Department of Community and Behavioral Health , Colorado School of Public Health, Aurora; Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS) (M Allison), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Stephen Berman
- Department of Pediatrics , University of Colorado Anschutz Medical Campus, Aurora; Center for Global Health , Colorado School of Public Health, Aurora
| | - Mandy A Allison
- Department of Pediatrics , University of Colorado Anschutz Medical Campus, Aurora.
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179
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Jiaojiao Y, Sun C, Wei Y, Wang C, Dave B, Cao F, Liandong H. Applying emerging technologies to improve diabetes treatment. Biomed Pharmacother 2018; 108:1225-1236. [PMID: 30372824 DOI: 10.1016/j.biopha.2018.09.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/18/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022] Open
Abstract
Insulin, as the most important drug for the treatment of diabetes, can effectively control the blood glucose concentration in humans. Due to its instability, short half-life, easy denaturation and side effects, the administration way of insulin are limited to subcutaneous injection accompany with poor glucose control and low patient compliance. In recent years, emerging insulin delivery systems have been developed in diabetes research. In this review, a variety of stimuli-responsive insulin delivery systems with their response mechanism and regulation principle are described. Further, the introduction of stem cell transplantation and mobile application based delivery technologies are prudent for the diabetes treatment. This article also discusses the advantages and limitations of current strategies, along with the opportunities and challenges for future insulin therapy.
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Affiliation(s)
- Yu Jiaojiao
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China
| | - Caifeng Sun
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China
| | - Yuli Wei
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China
| | - Chaoying Wang
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China
| | | | - Fei Cao
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China
| | - Hu Liandong
- School of Pharmaceutical Sciences, Hebei University, Baoding, China; Key Laboratory of Pharmaceutical Quality Control of Hebei Province, Hebei University, Baoding, China.
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180
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Holtz BE, Mitchell KM, Hershey DD, Cotten SR, Holmstrom AJ, Richman J, Dunneback JK, Wood MA. Using an mHealth App to Transition Care of Type 1 Diabetes from Parents to Teens: Protocol for a Pilot Study. JMIR Res Protoc 2018; 7:e10803. [PMID: 30377142 PMCID: PMC6234347 DOI: 10.2196/10803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/20/2018] [Accepted: 08/14/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Type 1 diabetes mellitus (T1DM) afflicts approximately 154,000 people under the age of 20 in the United States. Most people with T1DM are diagnosed at a young age, and parents have to take on the responsibility of T1DM management. Eventually, the child must begin to transition to self-management. Adolescents often struggle to take on responsibility for all the necessary tasks to successfully self-manage their T1DM. In fact, approximately three-quarters of adolescents are not achieving American Diabetes Association-recommended glycated hemoglobin (HbA1c) targets. This lack of adherence can lead to negative health outcomes. OBJECTIVE The goals of this interdisciplinary proposal are as follows: (1) to develop a unique and theory-driven technology using a mobile phone app to promote self-management behaviors for adolescents aged 10-15 years with T1DM and their parents and (2) to explore the feasibility and impact of the self-management mobile app. METHODS This study has two phases: app development and pilot testing. In the app development phase, the app will be conceptualized and a prototype will be tested. In Phase 2, the mobile app will undergo pilot testing to determine its feasibility and impact on diabetes self-management. RESULTS The pilot test was launched in September 2017. Data collection for the final pilot test is underway, and results are forthcoming. CONCLUSIONS Adolescents with T1DM and their parents can have a difficult time managing the transition of diabetes care. It is hoped that this app can help. The focus groups and prototype testing have indicated promising outcomes of app use. TRIAL REGISTRATION ClinicalTrials.gov NCT03436628; https://clinicaltrials.gov/ct2/show/NCT03436628 (Archived by WebCite at http://www.webcitation.org/72tHXTE2Z). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/10803.
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Affiliation(s)
- Bree E Holtz
- Department of Advertising and Public Relations, Michigan State University, East Lansing, MI, United States
| | - Katharine M Mitchell
- Department of Advertising and Public Relations, Michigan State University, East Lansing, MI, United States
| | - Denise D Hershey
- College of Nursing, Michigan State University, East Lansing, MI, United States
| | - Shelia R Cotten
- Department of Media and Information, Michigan State University, East Lansing, MI, United States
| | - Amanda J Holmstrom
- Department of Communication, Michigan State University, East Lansing, MI, United States
| | - Joshua Richman
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, United States
| | - Julie K Dunneback
- Department of Pediatric Endocrinology, Sparrow Health System, Lansing, MI, United States
| | - Michael A Wood
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States
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181
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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182
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Kulandaivelu Y, Lalloo C, Ward R, Zempsky WT, Kirby-Allen M, Breakey VR, Odame I, Campbell F, Amaria K, Simpson EA, Nguyen C, George T, Stinson JN. Exploring the Needs of Adolescents With Sickle Cell Disease to Inform a Digital Self-Management and Transitional Care Program: Qualitative Study. JMIR Pediatr Parent 2018; 1:e11058. [PMID: 31518307 PMCID: PMC6716437 DOI: 10.2196/11058] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/16/2018] [Accepted: 08/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Accessible self-management interventions are critical for adolescents with sickle cell disease to better cope with their disease, improve health outcomes and health-related quality of life, and promote successful transition to adult health care services. However, very few comprehensive self-management and transitional care programs have been developed and tested in this population. Internet and mobile phone technologies can improve accessibility and acceptability of interventions to promote disease self-management in adolescents with sickle cell disease. OBJECTIVE The aim of this study was to qualitatively explore the following from the perspectives of adolescents, parents, and their health care providers: (1) the impact of sickle cell disease on adolescents to identify challenges to their self-management and transitional care and (2) determine the essential components of a digital self-management and transitional care program as the first phase to inform its development. METHODS A qualitative descriptive design utilizing audio-recorded, semistructured interviews was used. Adolescents (n=19, aged 12-19 years) and parents (n=2) participated in individual interviews, and health care providers (n=17) participated in focus group discussions and were recruited from an urban tertiary care pediatric hospital. Audio-recorded data were transcribed verbatim and organized into categories inductively, reflecting emerging themes using simple content analysis. RESULTS Data were categorized into 4 major themes: (1) impact of sickle cell disease, (2) experiences and challenges of self-management, (3) recommendations for self-management and transitional care, and (4) perceptions about a digital self-management program. Themes included subcategories and the perspectives of adolescents, parents, and health care providers. Adolescents discussed more issues related to self-management, whereas health care providers and parents discussed issues related to transition to adult health services. CONCLUSIONS Adolescents, parents, and health care providers described the continued challenges youth with sickle cell disease face in terms of psychosocial impacts and stigmatization. Participants perceived a benefit to alleviating some of these challenges through a digital self-management tool. They recommended that an effective digital self-management program should provide appropriate sickle cell disease-related education; guidance on developing self-advocacy and communication skills; empower adolescents with information for planning for their future; provide options for social support; and be designed to be engaging for both adolescents and parents to use. A digital platform to deliver these elements is an accessible and acceptable way to address the self-management and transitional care needs of adolescents.
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Affiliation(s)
- Yalinie Kulandaivelu
- Department of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Chitra Lalloo
- Department of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Richard Ward
- Division of Haematology, University Health Network, Toronto, ON, Canada
| | - William T Zempsky
- Division of Pain and Palliative Medicine, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, CT, United States
| | - Melanie Kirby-Allen
- Departments of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vicky R Breakey
- Department of Pediatrics, McMaster Children's Hospital, Hamilton, ON, Canada.,Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Isaac Odame
- Departments of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Fiona Campbell
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Khush Amaria
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ewurabena A Simpson
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Cynthia Nguyen
- Department of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Tessy George
- Department of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer N Stinson
- Department of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
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183
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Backman C, Harley A, Peyton L, Kuziemsky C, Mercer J, Monahan MA, Schmidt S, Singh H, Gravelle D. Development of a Path to Home Mobile App for the Geriatric Rehabilitation Program at Bruyère Continuing Care: Protocol for User-Centered Design and Feasibility Testing Studies. JMIR Res Protoc 2018; 7:e11031. [PMID: 30249591 PMCID: PMC6231760 DOI: 10.2196/11031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 07/22/2018] [Accepted: 07/23/2018] [Indexed: 01/16/2023] Open
Abstract
Background As the population ages, the need for appropriate geriatric rehabilitation services will also increase. Pressures faced by hospitals to reduce length of stay and reduce costs have driven the need for more complex care being delivered in the home or community setting. As a result, a multifaceted approach that can provide geriatric rehabilitation patients with safe and effective person- and family-centered care during transitions from hospital to home is required. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to safely manage their personalized needs during care transitions from hospital to home. Objective The purpose of this study is to design and test the feasibility of a novel Path to Home mobile app to manage the personalized needs of geriatric rehabilitation patients during their transitions from hospital to home. Methods This study will consist of (1) codesigning a patient- and provider-tailored mobile app, and (2) feasibility pilot testing of the mobile app to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we will follow a user-centered design process integrated with a modern agile software development methodology to iteratively codesign the personalized care transition Path to Home mobile app. In phase 2, we will conduct a single-arm feasibility pilot test with geriatric rehabilitation patients using the personalized care transition Path to Home mobile app to manage their needs during the transition from hospital to home. Results The project was funded in May 2018, and enrollment and data analysis are underway. First results are expected to be submitted for publication in 2019. Conclusions Our findings will help validate the use of this technology for geriatric rehabilitation patients discharged from the hospital to home. Future research will more rigorously evaluate the health and economic benefits to inform wide-scale adoption of the technology. Registered Report Identifier RR1-10.2196/11031
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Affiliation(s)
- Chantal Backman
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Liam Peyton
- School of Electrical Engineering and Computer Science, Faculty of Engineering, University of Ottawa, Ottawa, ON, Canada
| | - Craig Kuziemsky
- Telfer School of Management, University of Ottawa, Ottawa, ON, Canada
| | - Jay Mercer
- Bruyère Continuing Care, Ottawa, ON, Canada
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184
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Zhang Y, Li X, Luo S, Liu C, Liu F, Zhou Z. Exploration of Users' Perspectives and Needs and Design of a Type 1 Diabetes Management Mobile App: Mixed-Methods Study. JMIR Mhealth Uhealth 2018; 6:e11400. [PMID: 30249580 PMCID: PMC6231832 DOI: 10.2196/11400] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/13/2018] [Accepted: 09/04/2018] [Indexed: 12/17/2022] Open
Abstract
Background With the popularity of mobile phones, mobile apps have great potential for the management of diabetes, but the effectiveness of current diabetes apps for type 1 diabetes mellitus (T1DM) is poor. No study has explored the reasons for this deficiency from the users’ perspective. Objective The aims of this study were to explore the perspectives and needs of T1DM patients and diabetes experts concerning a diabetes app and to design a new T1DM management mobile app. Methods A mixed-methods design combining quantitative surveys and qualitative interviews was used to explore users’ needs and perspectives. Experts were surveyed at 2 diabetes conferences using paper questionnaires. T1DM patients were surveyed using Sojump (Changsha ran Xing InfoTech Ltd) on a network. We conducted semistructured, in-depth interviews with adult T1DM patients or parents of child patients who had ever used diabetes apps. The interviews were audio-recorded, transcribed, and coded for theme identification. Results The expert response rate was 63.5% (127/200). The respondents thought that the reasons for app invalidity were that patients did not continue using the app (76.4%, 97/127), little guidance was received from health care professionals (HCPs; 73.2%, 93/127), diabetes education knowledge was unsystematic (52.8%, 67/127), and the app functions were incomplete (44.1%, 56/127). A total of 245 T1DM patient questionnaires were collected, of which 21.2% (52/245) of the respondents had used diabetes apps. The reasons for their reluctance to use an app were limited time (39%, 20/52), complicated operations (25%, 13/52), uselessness (25%, 13/52), and cost (25%, 13/52). Both the experts and patients thought that the most important functions of the app were patient-doctor communication and the availability of a diabetes diary. Two themes that were useful for app design were identified from the interviews: (1) problems with patients’ diabetes self-management and (2) problems with current apps. In addition, needs and suggestions for a diabetes app were obtained. Patient-doctor communication, diabetes diary, diabetes education, and peer support were all considered important by the patients, which informed the development of a prototype multifunctional app. Conclusions Patient-doctor communication is the most important function of a diabetes app. Apps should be integrated with HCPs rather than stand-alone. We advocate that doctors follow up with their patients using a diabetes app. Our user-centered method explored comprehensively and deeply why the effectiveness of current diabetes apps for T1DM was poor and what T1DM patients needed for a diabetes app and provided meaningful guidance for app design.
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Affiliation(s)
- Yiyu Zhang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, China.,National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Xia Li
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, China.,National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Shuoming Luo
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, China.,National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Chaoyuan Liu
- Department of Oncology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Fang Liu
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China.,Key Laboratory of Diabetes Immunology, Ministry of Education, Changsha, China.,National Clinical Research Center for Metabolic Diseases, Changsha, China
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185
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Customization of the TRU-PBMT App (Technology Recordings to better Understand Pediatric Blood and Marrow Transplant). J Pediatr Nurs 2018; 42:86-91. [PMID: 30219304 DOI: 10.1016/j.pedn.2018.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/10/2018] [Accepted: 07/04/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE Our investigative team is integrating mobile health technologies into pediatric blood and marrow transplant (PBMT) care. We aim to evaluate whether patient-generated health data can be used to monitor health status and enhance symptom management. While there are numerous health-related apps, none address the symptoms or care needs specific to PBMT patients. This article describes development of the Technology Recording to better Understand Pediatric Blood and Marrow Transplant (TRU-PBMT) mobile application. DESIGN AND METHODS A one-time survey was distributed to PBMT clinicians, caregivers, and outpatients to elicit feedback and suggestions for the app's design. RESULTS Feedback from clinicians (n = 23), caregivers (n = 5), and PBMT outpatients (n = 4) indicated the app would be acceptable and useable with this group of patients between eight and eighteen years of age. Suggestions from respondents included: making the app language and graphics more child-friendly; adding symptoms such as fatigue, mucositis, bleeding; and a visual stool chart. CONCLUSION Patient, caregiver, and clinician feedback was valuable in creation of the TRU-PBMT app. We designed a pediatric friendly, PBMT-symptom-specific app, which we will test in future studies. IMPLICATIONS FOR PRACTICE This app facilitates patient-generated health data collection and informs health care plans.
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186
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Irfan Khan A, Gill A, Cott C, Hans PK, Steele Gray C. mHealth Tools for the Self-Management of Patients With Multimorbidity in Primary Care Settings: Pilot Study to Explore User Experience. JMIR Mhealth Uhealth 2018; 6:e171. [PMID: 30154073 PMCID: PMC6134226 DOI: 10.2196/mhealth.8593] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 05/20/2018] [Accepted: 06/21/2018] [Indexed: 12/19/2022] Open
Abstract
Background Given the complex and evolving needs of individuals with multimorbidity, the adoption of mHealth tools to support self-management efforts is increasingly being explored, particularly in primary care settings. The electronic patient-reported outcomes (ePRO) tool was codeveloped with patients and providers in an interdisciplinary primary care team in Toronto, Canada, to help facilitate self-management in community-dwelling adults with multiple chronic conditions. Objective The objective of study is to explore the experience and expectations of patients with multimorbidity and their providers around the use of the ePRO tool in supporting self-management efforts. Methods We conducted a 4-week pilot study of the ePRO tool. Patients’ and providers’ experiences and expectations were explored through focus groups that were conducted at the end of the study. In addition, thematic analyses were used to assess the shared and contrasting perspectives of patients and providers on the role of the ePRO tool in facilitating self-management. Coded data were then mapped onto the Individual and Family Self-Management Theory using the framework method. Results In this pilot study, 12 patients and 6 providers participated. Both patients and providers emphasized the need for a more explicit recognition of self-management context, including greater customizability of content to better adapt to the complexity and fluidity of self-management in this particular patient population. Patients and providers highlighted gaps in the extent to which the tool enables self-management processes, including how limited progress toward self-management goals and the absence of direct provider engagement through the ePRO tool inhibited patients from meeting their self-management goals. Providers highlighted proximal outcomes based on their experience of the tool and specifically, they indicated that the tool offered valuable insights into the broader patient context, which helps to inform the self-management approach and activities they recommend to patients, whereas patients recognized the tool’s potential in helping to improve access to different providers in a team-based primary care setting. Conclusions This study identifies a more explicit recognition of the contextual factors that influence patients’ ability to self-manage and greater adaptability to accommodate patient complexity and provider workflow as next steps in refining the ePRO tool to better support self-management efforts in primary care ahead of its application in a full-scale randomized pragmatic trial.
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Affiliation(s)
- Anum Irfan Khan
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ashlinder Gill
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cheryl Cott
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Parminder Kaur Hans
- Bridgepoint Campus, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
| | - Carolyn Steele Gray
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Bridgepoint Campus, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
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187
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Giunti G. 3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study. JMIR Serious Games 2018; 6:e11631. [PMID: 30143476 PMCID: PMC6128959 DOI: 10.2196/11631] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 01/30/2023] Open
Abstract
Background Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider. Objective The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification. Methods This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions. Results The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process. Conclusions This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.
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Affiliation(s)
- Guido Giunti
- Salumedia Tecnologias, Seville, Spain.,University of Oulu, Oulu, Finland
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188
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Araújo-Soares V, Hankonen N, Presseau J, Rodrigues A, Sniehotta FF. Developing Behavior Change Interventions for Self-Management in Chronic Illness: An Integrative Overview. EUROPEAN PSYCHOLOGIST 2018; 24:7-25. [PMID: 31496632 PMCID: PMC6727632 DOI: 10.1027/1016-9040/a000330] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 02/21/2018] [Accepted: 04/19/2018] [Indexed: 12/24/2022]
Abstract
More people than ever are living longer with chronic conditions such as obesity, type 2 diabetes, and heart disease. Behavior change for effective self-management can improve health outcomes and quality of life in people living with such chronic illnesses. The science of developing behavior change interventions with impact for patients aims to optimize the reach, effectiveness, adoption, implementation, and maintenance of interventions and rigorous evaluation of outcomes and processes of behavior change. The development of new services and technologies offers opportunities to enhance the scope of delivery of interventions to support behavior change and self-management at scale. Herein, we review key contemporary approaches to intervention development, provide a critical overview, and integrate these approaches into a pragmatic, user-friendly framework to rigorously guide decision-making in behavior change intervention development. Moreover, we highlight novel emerging methods for rapid and agile intervention development. On-going progress in the science of intervention development is needed to remain in step with such new developments and to continue to leverage behavioral science's capacity to contribute to optimizing interventions, modify behavior, and facilitate self-management in individuals living with chronic illness.
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Affiliation(s)
- Vera Araújo-Soares
- Institute of Health & Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,School of Psychology, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Nelli Hankonen
- Faculty of Social Sciences, University of Tampere, Finland
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Canada.,School of Psychology, University of Ottawa, Canada
| | - Angela Rodrigues
- Institute of Health & Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Fuse. The UK Clinical Research Collaboration Centre for Translational Research in Public Health
| | - Falko F Sniehotta
- Institute of Health & Society, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Fuse. The UK Clinical Research Collaboration Centre for Translational Research in Public Health
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189
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Phone-Based Interventions to Control Obesity in Children Under Six Years of Age: A Systematic Review on Features and Effects. ACTA ACUST UNITED AC 2018. [DOI: 10.5812/compreped.66571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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190
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Breton MD, Patek SD, Lv D, Schertz E, Robic J, Pinnata J, Kollar L, Barnett C, Wakeman C, Oliveri M, Fabris C, Chernavvsky D, Kovatchev BP, Anderson SM. Continuous Glucose Monitoring and Insulin Informed Advisory System with Automated Titration and Dosing of Insulin Reduces Glucose Variability in Type 1 Diabetes Mellitus. Diabetes Technol Ther 2018; 20:531-540. [PMID: 29979618 PMCID: PMC6080127 DOI: 10.1089/dia.2018.0079] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Glucose variability (GV) remains a key limiting factor in the success of diabetes management. While new technologies, for example, accurate continuous glucose monitoring (CGM) and connected insulin delivery devices, are now available, current treatment standards fail to leverage the wealth of information generated. Expert systems, from automated insulin delivery to advisory systems, are a key missing element to richer, more personalized, glucose management in diabetes. METHODS Twenty four subjects with type 1 diabetes mellitus (T1DM), 15 women, 37 ± 11 years of age, hemoglobin A1c 7.2% ± 1%, total daily insulin (TDI) 46.7 ± 22.3 U, using either an insulin pump or multiple daily injections with carbohydrate counting, completed two randomized crossover 48-h visits at the University of Virginia, wearing Dexcom G4 CGM, and using either usual care or the UVA decision support system (DSS). DSS consisted of a combination of automated insulin titration, bolus calculation, and CHO treatment advice. During each admission, participants were exposed to a variety of meal sizes and contents and two 45-min bouts of exercise. GV and glucose control were assessed using CGM. RESULTS The use of DSS significantly reduced GV (coefficient of variation: 0.36 ± 08. vs. 0.33 ± 0.06, P = 0.045) while maintaining glycemic control (average CGM: 155.2 ± 27.1 mg/dL vs. 155.2 ± 23.2 mg/dL), by reducing hypoglycemia exposure (%<70 mg/dL: 3.8% ± 4.6% vs. 1.8% ± 2%, P = 0.018), with nonsignificant trends toward reduction of significant hyperglycemia overnight (%>250 mg/dL: 5.3% ± 9.5% vs. 1.9% ± 4.6%) and at mealtime (11.3% ± 14.8% vs. 5.8% ± 9.1%). CONCLUSIONS A CGM/insulin informed advisory system proved to be safe and feasible in a cohort of 24 T1DM subjects. Use of the system may result in reduced GV and improved protection against hypoglycemia.
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Affiliation(s)
- Marc D. Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
- Address correspondence to:Marc D. Breton, PhDCenter for Diabetes TechnologyUniversity of VirginiaCharlottesville, VA 22908-4888PO Box 400888
| | - Stephen D. Patek
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Dayu Lv
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Elaine Schertz
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Jessica Robic
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Jennifer Pinnata
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Laura Kollar
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Charlotte Barnett
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Christian Wakeman
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Mary Oliveri
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Chiara Fabris
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Daniel Chernavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Boris P. Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - Stacey M. Anderson
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
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191
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Tauschmann M, Hovorka R. Technology in the management of type 1 diabetes mellitus - current status and future prospects. Nat Rev Endocrinol 2018; 14:464-475. [PMID: 29946127 DOI: 10.1038/s41574-018-0044-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Type 1 diabetes mellitus (T1DM) represents 5-10% of diabetes cases worldwide. The incidence of T1DM is increasing, and there is no immediate prospect of a cure. As such, lifelong management is required, the burden of which is being eased by novel treatment modalities, particularly from the field of diabetes technologies. Continuous glucose monitoring has become the standard of care and includes factory-calibrated subcutaneous glucose monitoring and long-term implantable glucose sensing. In addition, considerable progress has been made in technology-enabled glucose-responsive insulin delivery. The first hybrid insulin-only closed-loop system has been commercialized, and other closed-loop systems are under development, including dual-hormone glucose control systems. This Review focuses on well-established diabetes technologies, including glucose sensing, pen-based insulin delivery, data management and data analytics. We also cover insulin pump therapy, threshold-based suspend, predictive low-glucose suspend and single-hormone and dual-hormone closed-loop systems. Clinical practice recommendations for insulin pump therapy and continuous glucose monitoring are presented, and ongoing research and future prospects are highlighted. We conclude that the management of T1DM is improved by diabetes technology for the benefit of the majority of people with T1DM, their caregivers and guardians and health-care professionals treating patients with T1DM.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
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192
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Stubberud A, Linde M. Digital Technology and Mobile Health in Behavioral Migraine Therapy: a Narrative Review. Curr Pain Headache Rep 2018; 22:66. [PMID: 30066141 DOI: 10.1007/s11916-018-0718-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This article reviews the recent research and development of electronic health (eHealth) and, in particular, mobile health (mHealth) strategies to deliver behavioral treatment for migraine. Prospects for future development and research of mobile health in migraine are suggested. RECENT FINDINGS Advances in digital technology and mobile technology have led to an era where electronic and mobile approaches are applied to several aspects of healthcare. Electronic behavioral interventions for migraine seem to be acceptable and feasible, but efficacy measures are uncertain. Clinical trials on mHealth-based classical behavioral therapies, such as relaxation, biofeedback, and cognitive behavioral therapy are missing in the literature. Within mHealth, headache diaries are the most researched and scientifically developed. Still, there is a gap between commercially available apps and scientifically validated and developed apps. Digital technology and mobile health has not yet lived out its potential in behavioral migraine therapy. Application of proper usability and functionality designs towards the right market, together with appraisal of medical and technological recommendations, may facilitate rapid development of eHealth and mHealth, while also establishing scientific evidence.
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Affiliation(s)
- Anker Stubberud
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, NO-7489, Trondheim, Norway.
| | - Mattias Linde
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, NO-7489, Trondheim, Norway.,Norwegian Advisory Unit on Headache, Department of Neurology and Clinical Neurophysiology, St. Olavs Hospital, NO-7006, Trondheim, Norway
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193
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Larsson I, Staland-Nyman C, Svedberg P, Nygren JM, Carlsson IM. Children and young people's participation in developing interventions in health and well-being: a scoping review. BMC Health Serv Res 2018; 18:507. [PMID: 29954392 PMCID: PMC6027768 DOI: 10.1186/s12913-018-3219-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 05/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Greater interest is being shown in participatory approaches, especially in research on interventions that concern children and young people's health and well-being. Although participatory approaches have user involvement in common, they differ in terms of the explicit guidance on how to actually involve and engage children and young people in health research. The aim of this scoping review was to systematically map recent research involving children and young people in the development of interventions targeting issues of health and well-being. METHODS An interpretative scoping literature review based on: a scientific literature search in (health and social science) databases, reference lists, a manual search in key journals and contact with existing networks was conducted. A total of 4458 references were identified through the literature search, of which 41 studies published between 2000 and 2017 were included in the review. The target population was children and young people under 25 years old. Level of participation was categorized according to Shier's Pathways to Participation Model. RESULTS The review showed that participatory approaches were most often used in the development of interventions in school settings and in community and healthcare settings and on issues concerning support in lifestyle or in managing illness or disease. The level of participation varied from children and young people taking part just as active informants, through stages of greater participation both in quantitative and qualitative terms, to children and young people becoming an active agent involved as a co-researcher where the research process was shaped by views of a higher level of mutuality. Most of the studies were categorised at a medium level and only three studies were judged to involve the children and young people at the highest level. CONCLUSIONS This scoping review showed that work remains in enabling children and young people to influence the development of interventions targeting health and well-being. In relation to level of sustainability in the interventions, it is relevant that goals, strategies and processes are formulated by those who can gain from the interventions. Participatory approaches aiming for a higher level of participation where children and young people work together with the researchers in partnerships are thus warranted.
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Affiliation(s)
- Ingrid Larsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden.
| | - Carin Staland-Nyman
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | - Petra Svedberg
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | - Jens M Nygren
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
| | - Ing-Marie Carlsson
- School of Health and Welfare, Halmstad University, Box 823, S-30118, Halmstad, Sweden
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194
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Santos CMVT, Andrade JAD, Amorim ADC, Garcia PA, Carvalho GA, Vilaça KHC. Application on mobile platform “Idoso Ativo” (Active Aging): exercises for lower limbs combining technology and health. FISIOTERAPIA EM MOVIMENTO 2018. [DOI: 10.1590/1980-5918.031.ao17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract Introduction: The introduction of a healthy lifestyle for the elderly from regular physical exercise is linked to physical independence and social wellness. The increasing integration of technology, including in the elderly’s health area, extends an innovative and interactive approach towards the specific aspects of aging. Objective: To report the development of the application "Idoso Ativo” (Active Aging) with proposed exercises for the elderly population’s lower limbs. Methods: The study belongs to the type ‘original paper’ which describes the development and accomplishment of the application for the health of the elderly. The study had the participation of an elderly model to perform exercises and video recording. The study was approved by the Research Ethics Committee of UCB and supported by CNPQ. Results: The Software development proposal involved interdisciplinary work for the selection of exercises for posture, balance and gait, development of the application and the use of a specific programming language with presentation of exercises on screens for easy understanding for the elderly public. Conclusion: The application developed can be adopted as a proposal in scientific studies in the physical therapy area and applied as an innovative resource combining health promotion and disease prevention.
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195
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Hannon TS, Yazel-Smith LG, Hatton AS, Stanton JL, Moser EAS, Li X, Carroll AE. Advancing diabetes management in adolescents: Comparative effectiveness of mobile self-monitoring blood glucose technology and family-centered goal setting. Pediatr Diabetes 2018; 19:776-781. [PMID: 29504207 PMCID: PMC6476179 DOI: 10.1111/pedi.12648] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/22/2017] [Accepted: 01/03/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND As adolescents gain autonomy, it remains important for parents to be involved with diabetes management to avoid deterioration in glycemic control. Technologies for self-monitoring of blood glucose (SMBG) allow for remote monitoring in real-time by parents. This research compared 3 strategies for improving SMBG and diabetes self-care in the short-term. These strategies were: (1) health information technology (HIT)-enhanced blood glucose meter that shared blood glucose data among patients, their parent, and care providers, and allowed for text messaging; (2) family-centered goal setting; and (3) a combination of (1) and (2). METHODS One hundred twenty-eight participants enrolled; 97 adolescent-parent pairs attended clinic at 3-month intervals during the 6-month intervention. Differences between treatment groups were evaluated using analysis of variance (ANOVAs) for continuous variables and χ2 tests for frequencies. Within patient changes were evaluated using paired t tests. RESULTS Participants in the HIT-enhanced SMBG group had no change in mean glycosylated hemoglobin (HbA1c). Participants assigned to family-centered goal setting had a non-significant decrease in HbA1c of -0.3% (P = .26) from baseline to 6 months. Participants in the combined approach had a significant decrease in HbA1c of -0.6% (P = .02) from baseline to 3 months, but the decrease of -0.4% at 6 months was non-significant (P = .51). The change in HbA1c from baseline to 3 months was greater for the combined approach than for the HIT-enhanced SMBG (P = .05) or family-centered goal setting (P = .01). CONCLUSIONS Our data suggest that utilizing the family-centered goal setting strategy when implementing HIT-enhanced diabetes technology deserves further study.
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Affiliation(s)
- Tamara S. Hannon
- Indiana University School of Medicine, Department of Pediatrics, 410 W. 10 Street, Suite 2000A, Indianapolis, IN 46202
| | - Lisa G. Yazel-Smith
- Indiana University School of Medicine, Section of Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, Suite 2000A, Indianapolis, IN 46202
| | - Amy S. Hatton
- Riley Hospital for Children, 705 Riley Hospital Dr. Rm. 3039, Indianapolis, IN 46202
| | - Jennifer L. Stanton
- Indiana University School of Medicine, Indiana Children’s Health Services Research, 410 W. 10th Street, Suite 2000, Indianapolis, IN 46202
| | - Elizabeth A. S. Moser
- Indiana University School of Medicine, Richard M. Fairbanks School of Public Health, Department of Biostatistics, 410 W. 10 Street, Suite 3000, Indianapolis, IN 46202
| | - Xiaochun Li
- Indiana University Purdue University Indianapolis, Richard M. Fairbanks School of Public Health, Department of Biostatistics, 410 W. 10 Street, Suite 3000, Indianapolis, IN 46202
| | - Aaron E. Carroll
- Indiana University School of Medicine, Department of Pediatrics, Section of Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, Suite 2000A, Indianapolis, IN 46202
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Stewart AC, Gannon KN, Beresford F, Fleming L. Adolescent and caregivers' experiences of electronic adherence assessment in paediatric problematic severe asthma. J Child Health Care 2018; 22:238-250. [PMID: 29325420 DOI: 10.1177/1367493517753082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study explored the experiences of adolescents and their caregivers regarding adherence to inhaled corticosteroids which are assessed through an electronic monitoring device (EMD). These devices are increasingly being used for assessing medication adherence, yet there is little information about patient's experience of these tools. Semi-structured interviews were conducted with eight adolescents with severe asthma, aged 11-15 years, who were electronically monitored as part of their care, along with their caregivers. Interviews were analysed using thematic analysis. Three themes were identified: 'they were trying to help me get better', 'checking up and catching out' and 'who is responsible?' The themes highlighted differences in priorities between participant groups, the impact of monitoring on the healthcare relationship and the dilemma of transferring responsibility for asthma management to adolescents. The findings suggest it is important for healthcare professionals to engage with patient's preferences and priorities when introducing EMDs.
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Affiliation(s)
- Amy C Stewart
- 1 Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | | | - Fran Beresford
- 3 Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- 3 Respiratory Paediatrics, Royal Brompton Hospital, London, UK
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197
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Pramana G, Parmanto B, Lomas J, Lindhiem O, Kendall PC, Silk J. Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial. JMIR Serious Games 2018; 6:e9. [PMID: 29748165 PMCID: PMC5968217 DOI: 10.2196/games.8902] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 03/03/2018] [Accepted: 03/14/2018] [Indexed: 11/16/2022] Open
Abstract
Background Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment.
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Affiliation(s)
- Gede Pramana
- Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bambang Parmanto
- Department of Health Information Management, University of Pittsburgh, Pittsburgh, PA, United States
| | - James Lomas
- The Design Lab, University of California, San Diego, CA, United States
| | - Oliver Lindhiem
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, United States
| | - Jennifer Silk
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, United States
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198
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Jordan S, McSwiggan J, Parker J, Halas GA, Friesen M. An mHealth App for Decision-Making Support in Wound Dressing Selection (WounDS): Protocol for a User-Centered Feasibility Study. JMIR Res Protoc 2018; 7:e108. [PMID: 29691213 PMCID: PMC5941095 DOI: 10.2196/resprot.9116] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/01/2018] [Accepted: 03/09/2018] [Indexed: 11/23/2022] Open
Abstract
Background Primary care health professionals, especially family physicians, see a variety of wounds, and yet—despite the frequency of providing wound care—many family physicians do not feel confident in wound care management. This is partly due to a lack of formal wound education in Family Medicine programs. While there are numerous electronic wound care resources available in the UK and North America, none were identified that address the specific need in supporting clinical decision-making in wound dressing selection. At the same time, healthcare providers are increasingly using technology in personal and professional contexts, and a logical extension is to use technology for knowledge translation strategies. Objective This work developed a prototype mobile health software application named WounDS, designed to support clinical decision-making in selecting wound dressings. This article presents the development and evaluation plan for the WounDS app. Methods WounDS has been developed on the iOS platform. The primary specification included ease of use, in that one of the primary influences in user adoption would be the ability to receive a wound dressing recommendation in under 30 seconds and under 5 taps on the screen. The WounDS app guides users through a series of binary decisions for assessing the wound and provides a wound dressing recommendation. The selection algorithm is based in best practices using the Wound Bed Preparation Paradigm. Results Current work is underway to examine the implementation needs for WounDS to be most effectively utilized and to pilot test its feasibility and use in clinical care. Data will be collected through user trials, focus groups, and user metadata will be collected within the app. Optimizing these preconditions will enable a subsequent phase of study to determine effects on clinical decision-making and clinical outcomes. Conclusions WounDS is designed for knowledge translation, use of technology in clinical decision-making, and continuity of care. The benefits of WounDS include the potential to improve healthcare providers’ competency in wound management and to improve wound healing through better alignment with evidence-based best practices in wound dressing selection, consistency in care from primary to community care, and subsequent downstream impacts in quality of life for patients.
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Affiliation(s)
- Scott Jordan
- Department of Electrical & Computer Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Jane McSwiggan
- Wound Care, Nursing Initiatives, Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Joanne Parker
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Gayle A Halas
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marcia Friesen
- Department of Electrical & Computer Engineering, University of Manitoba, Winnipeg, MB, Canada
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Iacobelli F, Adler RF, Buitrago D, Buscemi J, Corden ME, Perez-Tamayo A, Penedo FJ, Rodriguez M, Yanez BR. Designing an mHealth application to bridge health disparities in Latina breast cancer survivors: a community-supported design approach. ACTA ACUST UNITED AC 2018; 2:58-76. [PMID: 30506017 DOI: 10.1080/24735132.2018.1452871] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Latina breast cancer patients in the USA report significantly worse cancer-related symptom burden and health-related quality of life than non-Hispanic whites. However, health literacy (e.g. knowledge about cancer, coping skills and communication) has been found to improve quality of life. In this paper, we present a case study of the methodology used to design Mi Guía (My Guide), a mobile application that aims to improve symptom burden and health-related quality of life among Hispanic women who have completed active treatment for breast cancer by increasing their health literacy. We developed a community-supported approach to building the application, which involved: (1) eliciting feedback from community leaders such as support group organizers and facilitators who are bilingual in Spanish and English, prioritize patients' preferences and best interests and have a unique knowledge of the women and their needs;(2) conducting a formal evaluation of design principles based on previous interaction design research and user responses;(3) incorporating feedback from potential future users. In this paper, we discuss our methodology, and the challenges and benefits of this approach. We believe that future studies that aim to develop mobile technologies for underserved populations may benefit from a community-supported approach to design.
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Affiliation(s)
- Francisco Iacobelli
- Department of Computer Science, Northeastern Illinois University, Chicago, IL, USA
| | - Rachel F Adler
- Department of Computer Science, Northeastern Illinois University, Chicago, IL, USA
| | - Diana Buitrago
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joanna Buscemi
- Department of Psychology, DePaul University, Chicago, IL, USA.,institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Marya E Corden
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Frank J Penedo
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melinda Rodriguez
- Department of Computer Science, Northeastern Illinois University, Chicago, IL, USA
| | - Betina R Yanez
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Mobile Application vs Paper Pictorial Blood Assessment Chart to Track Menses in Young Women: A Randomized Cross-over Design. J Pediatr Adolesc Gynecol 2018; 31:84-88. [PMID: 29030160 DOI: 10.1016/j.jpag.2017.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 09/01/2017] [Accepted: 09/27/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE Heavy menstrual bleeding is a common symptom reported by approximately 30% of women. The Pictorial Blood Assessment Chart (PBAC) score is often used to quantify severity of menstrual bleeding. However, the traditional PBAC paper diary might be subject to recall bias and compliance issues, especially in adolescents. We developed a mobile application (app) version of the PBAC score and evaluated patient satisfaction and compliance with app reporting vs paper reporting. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study was a randomized cross-over study of 25 postmenarchal female adolescents and young women ages 13-21 years. Participants agreed to track bleeding in 2 consecutive menstrual cycles and were randomized to use the PBAC paper diary or mobile app format first. At the end of each cycle, a satisfaction survey and system usability scale (app only) was used to assess the acceptability of the format used. RESULTS Twenty-five participants had a median age of 15 years. Cross-over analysis showed that satisfaction level was significantly higher for the app (P < .001). Twenty of 25 (80%) participants preferred the app over the paper diary. For the app, 20 of 25 participants (80%) had high compliance for reporting bleeding, with a mean of 2 app entries per day. Participants' PBAC scores did not vary significantly between the paper diary (median, 95) and mobile app (median, 114). All paper diaries met definition for high compliance. There was no significant period or carryover effect. CONCLUSION This study showed that a PBAC app compared with the paper diary was the preferred method of recording menstrual bleeding in adolescents and showed feasibility as a research data collection tool.
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