Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study

Use of Commonly Available Technologies for Diabetes Information and Self-Management Among Adolescents With Type 1 Diabetes and Their Parents: A Web-Based Survey Study

BACKGROUND

For individuals with Type 1 diabetes (T1D), following a complicated daily medical regimen is critical to maintaining optimal health. Adolescents in particular struggle with regimen adherence. Commonly available technologies (eg, diabetes websites, apps) can provide diabetes-related support, yet little is known about how many adolescents with T1D use them, why they are used, or relationships between use and self-management.

OBJECTIVE

This study examined adolescent and parent use of 5 commonly available technologies for diabetes, including proportions who use each technology, frequency of use, and number of different technologies used for diabetes. Analyses also investigated the reasons adolescents reported for using or not using technologies for diabetes, and factors correlated with adolescents' technology use. Finally, this study examined relationships between the type and number of technologies adolescents use for diabetes and their self-management and glycemic control.

METHODS

Adolescents (12-17 years) and their parents (N=174 pairs), recruited from a pediatric diabetes clinic (n=134) and the Children with Diabetes community website (n=40), participated in this Web-based survey study. Glycosylated hemoglobin (A1C) values were obtained from medical records for pediatric clinic patients. Adolescents reported their use of 5 commonly available technologies for diabetes (ie, social networking, diabetes websites, mobile diabetes apps, text messaging, and glucometer/insulin pump software), reasons for use, and self-management behavior (Self-Care Inventory-Revised, SCI-R).

RESULTS

Most adolescents and parents used at least one of the 5 technologies for diabetes. Among adolescents, the most commonly used technology for diabetes was text messaging (53%), and the least commonly used was diabetes websites (25%). Most adolescents who used diabetes apps, text messaging, or pump/glucometer software did so more frequently (≥2 times per week), compared to social networking and website use (≤1 time per week). The demographic, clinical, and parent-technology use factors related to adolescents' technology use varied by technology. Adolescents who used social networking, websites, or pump/glucometer software for diabetes had better self-management behavior (SCI-R scores: beta=.18, P=.02; beta=.15, P=.046; beta=.15, P=.04, respectively), as did those who used several technologies for diabetes (beta=.23, P=.003). However, use of diabetes websites was related to poorer glycemic control (A1C: beta=.18, P=.01).

CONCLUSIONS

Adolescents with T1D may be drawn to different technologies for different purposes, as individual technologies likely offer differing forms of support for diabetes self-management (eg, tracking blood glucose or aiding problem solving). Findings suggest that technologies that are especially useful for adolescents' diabetes problem solving may be particularly beneficial for their self-management. Additional research should examine relationships between the nature of technology use and adolescents' T1D self-management over time.

Apps and Adolescents: A Systematic Review of Adolescents' Use of Mobile Phone and Tablet Apps That Support Personal Management of Their Chronic or Long-Term Physical Conditions

Background

The prevalence of physical chronic or long-term conditions in adolescents aged 10-24 years is rising. Mobile phone and tablet mobile technologies featuring software program apps are widely used by these adolescents and their healthy peers for social networking or gaming. Apps are also used in health care to support personal condition management and they have considerable potential in this context. There is a growing body of literature on app use in health contexts, thereby making a systematic review of their effectiveness very timely.

Objective

To systematically review the literature on the effectiveness of mobile apps designed to support adolescents’ management of their physical chronic or long-term conditions.

Methods

We conducted a review of the English-language literature published since 2003 in five relevant bibliographical databases using key search terms. Two independent reviewers screened titles and abstracts using data extraction and quality assessment tools.

Results

The search returned 1120 hits. Of the 19 eligible full-text papers, four met our review criteria, reporting one pilot randomized controlled trial and three pretest/post-test studies. Samples ranged from 4 to 18 participants, with a combined sample of 46 participants. The apps reported were targeted at type 1 diabetes, asthma, and cancer. Two papers provided data for calculating effect size. Heterogeneity in terms of study design, reported outcomes, follow-up times, participants’ ages, and health conditions prevented meta-analyses. There was variation in whether adolescents received guidance in using the app or were solely responsible for navigating the app. Three studies reported some level of patient involvement in app design, development, and/or evaluation. Health professional involvement in the modelling stages of apps was reported in all studies, although it was not always clear whether specific clinical (as opposed to academic) expertise in working with adolescents was represented. The dearth of studies and the small overall sample size emphasizes the need for future studies of the development, evaluation, use, and effectiveness of mobile apps to support adolescents’ personal management of their conditions.

Conclusions

A key finding of the review is the paucity of evidence-based apps that exist, in contrast to the thousands of apps available on the app market that are not evidence-based or user or professional informed. Although we aimed to assess the effectiveness of apps, the dearth of studies meeting our criteria meant that we were unable to be conclusive in this regard. Based on the available evidence, apps may be considered feasible health interventions, but more studies involving larger sample sizes, and with patient and health professional input at all stages, are needed to determine apps’ acceptability and effectiveness. This review provides valuable findings and paves the way for future rigorous development and evaluation of health apps for adolescents with chronic or long-term conditions.

Smartphone Apps for Schizophrenia: A Systematic Review

Background

There is increasing interest in using mobile technologies such as smartphones for improving the care of patients with schizophrenia. However, less is known about the current clinical evidence for the feasibility and effectiveness of smartphone apps in this population.

Objective

To review the published literature of smartphone apps applied for the care of patients with schizophrenia and other psychotic disorders.

Methods

An electronic database search of Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Allied and Complementary Medicine, Health and Psychosocial Instruments, PsycINFO, and Embase was conducted on May 24, 2015. All eligible studies were systematically reviewed, and proportional meta-analyses were applied to pooled data on recruitment, retention, and adherence to examine the overall feasibility of smartphone interventions for schizophrenia.

Results

Our search produced 226 results from which 7 eligible articles were identified, reporting on 5 studies of smartphone apps for patients with schizophrenia. All examined feasibility, and one assessed the preliminary efficacy of a smartphone intervention for schizophrenia. Study lengths varied between 6 and 130 days. Overall retention was 92% (95% CI 82-98%). Participants consistently used the smartphone apps on more than 85% of days during the study period, averaging 3.95 interactions per person per day. Furthermore, participants responded to 71.9% of automated prompts (95% CI 65.7-77.8%). Participants reported a range of potential benefits from the various interventions, and user experience was largely positive.

Conclusions

Although small, the current published literature demonstrates strong evidence for the feasibility of using smartphones to enhance the care of people with schizophrenia. High rates of engagement and satisfaction with a broad range of apps suggest the nascent potential of this mobile technology. However, there remains limited data on the efficacy of such interventions.

Adherence in adolescents with Type 1 diabetes: strategies and considerations for assessment in research and practice

Suboptimal adherence remains a significant concern for adolescents with Type 1 diabetes, the treatment regimen for which is complex and includes numerous behaviors. Accurate assessment of adherence is critical for effective healthcare and to measure trial outcomes. Without a valid biomarker of adherence, assessment strategies must rely on measuring management behaviors. This paper provides an overview of approaches to measure adherence, with an emphasis on contemporary, validated measures that are appropriate for current diabetes care. Objective measures include electronic data from diabetes management devices. Subjective measures include self/parent-report questionnaires, structured interviews and diaries/logbooks. Practical strategies for selecting measurement approaches for clinical and research purposes are reviewed, and implications of adherence assessment for clinical care delivery and adherence-promotion are discussed.

Chronic care management of globesity: promoting healthier lifestyles in traditional and mHealth based settings

Obesity and being overweight could be real chronic conditions above all if there are other complications such as type 2 diabetes, cardiovascular diseases, hypertension, dyslipidemia, hypercholesterolemia, cancer, and various psychosocial and psychopathological disorders. Due to the multifactorial etiology of obesity, evidence-based interventions to improve weight loss, maintain a healthy weight, and reduce related comorbidities combine different treatment approaches: dietetic, nutritional, physical, behavioral, psychological, and, in some situations, pharmacological and surgical. There are significant limitations in this multidisciplinary chronic care management of obesity, most notably those regarding costs and long-term adherence and efficacy. Programs including eHealth platforms and new technologies could overcome limitations connected to the traditional in-patient chronic care management of obesity, thus providing promising opportunities in enhancing weight reduction and reducing complications in terms of long-term efficacy and effectiveness across clinical, organizational, and economic perspectives.

The Systematic Design of a Behavioural Mobile Health Application for the Self-Management of Type 2 Diabetes

Patients with diabetes often face serious complications due to limited self-management skills, the inability to adhere to care regimens, and psychosocial factors. Although regular self-monitoring of blood glucose is known to benefit patients receiving insulin therapy, its role in patients not treated with insulin has been unclear. However, recent studies have demonstrated that structured self-monitoring of blood glucose can significantly benefit patients who are not taking insulin, facilitating improved self-awareness and clinical decision making. We hypothesize that effective self-management by patients with type 2 diabetes who do not need insulin requires a behavioural intervention that enables the association between lifestyle behaviours, such as dietary intake and physical activity, and overall glycemic control. Mobile health applications (apps), coupled with wireless medical peripheral devices, can facilitate self-monitoring; deliver tailored, actionable knowledge; elicit positive behaviour changes and promote effective self-management of diabetes. Although existing apps incorporate tracking and feedback from healthcare providers, few attempt to elicit positive behaviour changes for the purposes of developing patients' self-care skills. The purpose of this article is to present a systematic approach to the design and development a diabetes self-management mobile app, which included 1) a scoping review of literature; 2) the development of an overarching theoretical approach and 3) validation of the app features through user-centred design methods. The resulting app, bant II, facilitates 1) self-monitoring of blood glucose, physical activity, diet and weight; 2) identification of glycemic patterns in relation to lifestyle; 3) remedial decision making and 4) positive behaviour change through incentives.

Mobile Phone App Aimed at Improving Iron Intake and Bioavailability in Premenopausal Women: A Qualitative Evaluation

BACKGROUND

Low iron intake can lead to iron deficiency, which can result in impaired health and iron-deficiency anemia. A mobile phone app, combining successful dietary strategies to increase bioavailable iron with strategies for behavior change, such as goal setting, monitoring, feedback, and resources for knowledge acquisition, was developed with the aim to increase bioavailable iron intake in premenopausal women.

OBJECTIVE

To evaluate the content, usability, and acceptability of a mobile phone app designed to improve intake of bioavailable dietary iron.

METHODS

Women aged 18-50 years with an Android mobile phone were invited to participate. Over a 2-week period women were asked to interact with the app. Following this period, semistructured focus groups with participants were conducted. Focus groups were audio recorded and analyzed via an inductive open-coding method using the qualitative analysis software NVivo 10. Themes were identified and frequency of code occurrence was calculated.

RESULTS

Four focus groups (n=26) were conducted (age range 19-36 years, mean 24.7, SD 5.2). Two themes about the app's functionality were identified (frequency of occurrence in brackets): interface and design (134) and usability (86). Four themes about the app's components were identified: goal tracker (121), facts (78), photo diary (40), and games (46). A number of suggestions to improve the interface and design of the app were provided and will inform the ongoing development of the app.

CONCLUSIONS

This research indicates that participants are interested in iron and their health and are willing to use an app utilizing behavior change strategies to increase intake of bioavailable iron. The inclusion of information about the link between diet and health, monitoring and tracking of the achievement of dietary goals, and weekly reviews of goals were also seen as valuable components of the app and should be considered in mobile health apps aimed at adult women.

Using mobile technology to motivate adolescents with type 1 diabetes mellitus: A systematic review of recent literature

Introduction

Behavioural interventions have been shown to improve outcomes in patients with type 1 diabetes mellitus (T1DM). There are a small number of studies that suggest text-messages (TM), native mobile applications (NMAs), and other mobile tools may be useful platforms for delivering behavioural interventions to adolescents.

Aim

The aim of this study was to explore, by way of a systematic review of available literature, (a) the outcomes of interventions using mobile technology for youth with T1DM and (b) what mobile technologies, functional design elements and aesthetic design elements have the best evidence to support their use.

Methods

A search of six online databases returned 196 unique results, of which 13 met the inclusion criteria.

Results

Four studies were randomised controlled trials (RCTs), and all others prospective cohort studies. TM (10) was the most common intervention technology, while NMAs were used in four studies. The most common outcome measured was HbA1c (9); however, only three studies showed a significant decrease. Similarly, the results reported for other outcome measures were mixed. The studies included in this review suggest that interventions which have data collection and clinician support functionality may be more effective in improving adherence and glycaemic control, but more evidence is needed. Further, the evidence base supporting the use of NMAs in T1DM management for adolescents is weak, with most studies adopting TM as the intervention tool. Overall, the studies lack adequate descriptions of their methodology, and better quality studies are required to inform future intervention design.

Games and Diabetes: A Review Investigating Theoretical Frameworks, Evaluation Methodologies, and Opportunities for Design Grounded in Learning Theories

Here we review 18 articles that describe the design and evaluation of 1 or more games for diabetes from technical, methodological, and theoretical perspectives. We undertook searches covering the period 2010 to May 2015 in the ACM, IEEE, Journal of Medical Internet Research, Studies in Health Technology and Informatics, and Google Scholar online databases using the keywords "children," "computer games," "diabetes," "games," "type 1," and "type 2" in various Boolean combinations. The review sets out to establish, for future research, an understanding of the current landscape of digital games designed for children with diabetes. We briefly explored the use and impact of well-established learning theories in such games. The most frequently mentioned theoretical frameworks were social cognitive theory and social constructivism. Due to the limitations of the reported evaluation methodologies, little evidence was found to support the strong promise of games for diabetes. Furthermore, we could not establish a relation between design features and the game outcomes. We argue that an in-depth discussion about the extent to which learning theories could and should be manifested in the design decisions is required.

Engaging Teens with Asthma in Designing a Patient-Centered Mobile App to Aid Disease Self-Management

BACKGROUND

Despite the growing market of e-health disease self-management tools, few studies have reported the presence of teen patients in all phases of product design. While rates of American teens using mobile Internet grow, an opportunity to deliver disease self-management targeted for teen patients exists. Building on findings from previous investigations with teens with asthma, we explored teens' insights on the development of a patient-centered asthma management application (app).

MATERIALS AND METHODS

Two existing asthma apps were used by 16 teen asthmatics for 7-10 days. At the end of the trial period, in-depth interviews were conducted with each participant to gather insights about the user experience.

RESULTS

Participants requested more asthma-related content that educates them about their condition. Suggested improvements to currently available apps included a longer list of selectable symptoms to track, medication tracking, and more compelling interface features.

CONCLUSIONS

Participants showed interest in using apps for managing their asthma, yet recommended improvements on current design. Whereas national figures point to a more ubiquitous mobile device environment, implementation efforts must respond to participants' recommendations while minding lingering digital divides. Currently available apps lack appealing components that teens seek or desire. Subsequent development should include teens' participation in component design insights.

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes

Only 21 % of adolescents with type 1 diabetes (T1D) meet glycemic goals set forth by the American Diabetes Association. Adherence to therapy is a particular concern in this population, and the association between poor adherence and worsening glycemic control indicates that there is a critical need to improve adherence to therapy in adolescents with T1D. In this article, we review barriers to adherence in adolescents with T1D and discuss interventions aimed at improving adherence to therapy and glycemic control. Interventions include technology-based applications, family-based therapies, motivational interviewing, and others. Notably, less than 10 % of the interventions reviewed are provider-led, clinic-based interventions, and few have focused on regimen-related aspects of adherence. This article also outlines the importance of provider communication and the role of providers in facilitating adherence behaviors in adolescents with T1D. Finally, we suggest future directions of research to improve adherence to therapy in adolescents with T1D.

Technology Use for Diabetes Problem Solving in Adolescents with Type 1 Diabetes: Relationship to Glycemic Control

BACKGROUND

This study examines technology use for problem solving in diabetes and its relationship to hemoglobin A1C (A1C).

SUBJECTS AND METHODS

A sample of 112 adolescents with type 1 diabetes completed measures assessing use of technologies for diabetes problem solving, including mobile applications, social technologies, and glucose software. Hierarchical regression was performed to identify the contribution of a new nine-item Technology Use for Problem Solving in Type 1 Diabetes (TUPS) scale to A1C, considering known clinical contributors to A1C.

RESULTS

Mean age for the sample was 14.5 (SD 1.7) years, mean A1C was 8.9% (SD 1.8%), 50% were female, and diabetes duration was 5.5 (SD 3.5) years. Cronbach's α reliability for TUPS was 0.78. In regression analyses, variables significantly associated with A1C were the socioeconomic status (β = -0.26, P < 0.01), Diabetes Adolescent Problem Solving Questionnaire (β = -0.26, P = 0.01), and TUPS (β = 0.26, P = 0.01). Aside from the Diabetes Self-Care Inventory--Revised, each block added significantly to the model R(2). The final model R(2) was 0.22 for modeling A1C (P < 0.001).

CONCLUSIONS

Results indicate a counterintuitive relationship between higher use of technologies for problem solving and higher A1C. Adolescents with poorer glycemic control may use technology in a reactive, as opposed to preventive, manner. Better understanding of the nature of technology use for self-management over time is needed to guide the development of technology-mediated problem solving tools for youth with type 1 diabetes.

Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App

Background

The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children’s weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users’ engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process.

Objective

The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community.

Methods

The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app.

Results

Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents’ capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents’ preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users’ preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app.

Conclusions

Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users’ preferences to help maximize its engagement with the target population.

Self-management interventions for young people with chronic conditions: A systematic overview

OBJECTIVE

To provide a systematic overview of self-management interventions (SMI) for young people with chronic conditions with respect to content, formats, theories, and evaluated outcomes.

METHODS

Embase, Medline, PsycINFO, Web-of-Science, CINAHL, and Cochrane were searched. Reviews' reference lists were scrutinized. Selected studies were: Original research articles in English published between 2003 and March 2014; about the evaluation of SMI for 7 to 25-year-olds with somatic chronic conditions/physical disabilities; with clear outcomes and intervention descriptions. The classification of medical, role and emotion management served to review content. Formats, theories, and evaluated outcomes were summarized.

RESULTS

86 studies were reviewed. Most aimed at medical management and were unclear about theoretical bases. Although a variety of outcomes was evaluated and the distribution over self-management domains was quite unpredictable, outcomes conceptually related to specific content. A content-based framework for the evaluation of self-management interventions is presented.

CONCLUSIONS AND PRACTICE IMPLICATIONS

SMI relate to self-management tasks and skill-building. Yet, conceptualizations of self-management support often remained unclear and content focuses predominantly on the medical domain, neglecting psycho-social challenges for chronically ill young people. Future evaluations should match outcomes/themes to content and characteristics. Our framework and overview of SMI characteristics and outcomes may assist clinicians in providing self-management support.

The Use of Videogames, Gamification, and Virtual Environments in the Self-Management of Diabetes: A Systematic Review of Evidence

The use of videogames in healthcare interventions is gaining popularity, but there is still a gap in the understanding on how these types of interventions are used for the management of diabetes. The purpose of this review is to examine published research on the use of videogames for diabetes management. With the increased use of mobile technology, the review was expanded to understand whether games, gamification, and virtual environments can be used for diabetes self-management. Out of the 307 articles identified, only 10 articles met the inclusion criteria of the study. The duration of most studies was short, with small sample sizes. All interventions targeted behavioral changes examining risk reduction of diabetes-related risk and promotion of healthy behavior among study participants. Videogames appeared to be helpful tools for education in some interventions, whereas gamification and virtual environments increased extrinsic motivation and provided positive reinforcement. This review concludes by discussing the potential of using videogames and gamification for the self-management of diabetes.

Virtues, ecological momentary assessment/intervention and smartphone technology

Virtues, broadly understood as stable and robust dispositions for certain responses across morally relevant situations, have been a growing topic of interest in psychology. A central topic of discussion has been whether studies showing that situations can strongly influence our responses provide evidence against the existence of virtues (as a kind of stable and robust disposition). In this review, we examine reasons for thinking that the prevailing methods for examining situational influences are limited in their ability to test dispositional stability and robustness; or, then, whether virtues exist. We make the case that these limitations can be addressed by aggregating repeated, cross-situational assessments of environmental, psychological and physiological variables within everyday life-a form of assessment often called ecological momentary assessment (EMA, or experience sampling). We, then, examine how advances in smartphone application (app) technology, and their mass adoption, make these mobile devices an unprecedented vehicle for EMA and, thus, the psychological study of virtue. We, additionally, examine how smartphones might be used for virtue development by promoting changes in thought and behavior within daily life; a technique often called ecological momentary intervention (EMI). While EMA/I have become widely employed since the 1980s for the purposes of understanding and promoting change amongst clinical populations, few EMA/I studies have been devoted to understanding or promoting virtues within non-clinical populations. Further, most EMA/I studies have relied on journaling, PDAs, phone calls and/or text messaging systems. We explore how smartphone app technology provides a means of making EMA a more robust psychological method, EMI a more robust way of promoting positive change, and, as a result, opens up new possibilities for studying and promoting virtues.

Adherence to glycemic monitoring in diabetes

Glucose monitoring either by self-monitoring of blood glucose (SMBG) or continuous glucose monitoring (CGM) plays an important role in diabetes management and in reducing risk for diabetes-related complications. However, despite evidence supporting the role of glucose monitoring in better patient health outcomes, studies also reveal relatively poor adherence rates to SMBG and CGM use and numerous patient-reported barriers. Fortunately, some promising intervention strategies have been identified that promote at least short-term improvements in patients' adherence to SMBG. These include education, problem solving, contingency management, goal setting, cognitive behavioral therapy, and motivational interviewing. Specific to CGM, interventions to promote greater use among patients are currently under way, yet one pilot study provides data suggesting better maintenance of CGM use in patients showing greater readiness for behavior change. The purpose of this review is to summarize the literature specific to glucose monitoring in patients with diabetes focusing specifically on current adherence rates, barriers to monitoring, and promising intervention strategies that may be ready to deploy now in the clinic setting to promote greater patient adherence to glucose monitoring. Yet, to continue to help patients with diabetes adhere to glucose monitoring, future research is needed to identify the treatment strategies and the intervention schedules that most likely lead to long-term maintenance of optimal glycemic monitoring levels.

Health and social media: perfect storm of information

Objectives

The use of Internet in the health domain is becoming a major worldwide trend. Millions of citizens are searching online health information and also publishing content about their health. Patients are engaging with other patients in online communities using different types of social media. The boundaries between mobile health, social media, wearable, games, and big data are becoming blurrier due the integration of all those technologies. In this paper we provide an overview of the major research challenges with the area of health social media.

Methods

We use several study cases to exemplify the current trends and highlight future research challenges.

Results

Internet is exploding and is being used for health purposes by a great deal of the population. Social networks have a powerful influence in health decisions. Given the lack of knowledge on the use of health social media, there is a need for complex multidisciplinary research to help us understand how to use social networks in favour of public health. A bigger understanding of social media will give health authorities new tools to help decision-making at global, national, local, and corporate level.

Conclusions

There is an unprecedented amount of data that can be used in public health due the potential combination of data acquired from mobile phones, Electronic Health Records, social media, and other sources. To identify meaningful information from those data sources it is not trial. Moreover, new analytics tools will need to be developed to analyse those sources of data in a way that it can benefit healthcare professionals and authorities.

Development testing of mobile health interventions for cancer patient self-management: A review

As the vision of mobile health (mHealth) is beginning to be realized, rigorous intervention development protocols are needed in order to draw optimal efficacy and effectiveness to support patient-centered oncology care. The purpose of the current study was to conduct a review of published articles that describe the development process of mHealth interventions for patients' cancer care self-management. The review search yielded 11 interventions, reported by 14 manuscripts. The following trends emerged: importance of stakeholder engagement during the development process, addressing the unique needs and experiences of cancer patients and care providers, ensuring user satisfaction with the system, and identifying perceived benefits and limitations of the system. This review provides practical suggestions for mHealth intervention development. Assessments of user perceptions should be both qualitative and quantitative, and researchers should follow an established framework when developing a randomized controlled trial employing mHealth.

Telehealth interventions to reduce management complications in type 1 diabetes: A review

Type 1 diabetes is a chronic illness with a high burden of care. While effective interventions and recommendations for diabetes care exist, the intensive nature of diabetes management makes compliance difficult. This is especially true in children and adolescents as they have unique psychosocial and diabetes needs. Despite the development of effective in-person interventions targeting improving self-management and ameliorating psychosocial difficulties there are still a number of barriers to implementing these interventions, namely time, cost, and access. Telehealth interventions allow for the dissemination of these interventions to a broader audience. Self-management and psychosocial telehealth interventions are reviewed with a special emphasis on mobile phone and internet based technology use. While efficacy has been demonstrated in a number of telehealth interventions with improved cost effectiveness over in-person interventions, many challenges remain including high participant attrition and difficulties with receiving reimbursement for services rendered. These and other challenges are discussed with recommendations for researchers and telehealth providers provided.

Use of mobile device applications in Canadian dietetic practice

PURPOSE

A cross-sectional web-based survey of dietitians was used to explore topics related to mobile devices and their applications (apps) in Canadian dietetic practice.

METHODS

A survey was drafted, posted on SurveyMonkey, and pretested with dietitians and dietetic interns. Dietitians of Canada (DC), a supporter of this work, promoted the survey to members through its monthly electronic newsletters from January 2012 to April 2012.

RESULTS

Of 139 dietitians who answered some survey questions, 118 finished the survey; this represents a response rate of approximately 3%. Overall, 57.3% of respondents reported app use in practice, and 54.2% had a client ask about or use a nutrition/food app. About 40.5% of respondents had recommended nutrition/food apps to clients. Respondents were enthusiastic about apps, but many described challenges with use. From the survey data, three themes emerged that can affect dietitians' use of apps and whether they recommend apps to clients: mobile device and app factors (access to information/tools, content quality, usability, accessibility/compatibility, and cost), personal factors (knowledge, interest, suitability, and willingness/ability to pay), and workplace factors.

CONCLUSIONS

Apps are now infiltrating dietetic practice. Several factors can affect dietitians' use of apps and whether they recommend them to clients. These findings will help guide future development and use of apps in practice.

Digital games for type 1 and type 2 diabetes: underpinning theory with three illustrative examples

Digital games are an important class of eHealth interventions in diabetes, made possible by the Internet and a good range of affordable mobile devices (eg, mobile phones and tablets) available to consumers these days. Gamifying disease management can help children, adolescents, and adults with diabetes to better cope with their lifelong condition. Gamification and social in-game components are used to motivate players/patients and positively change their behavior and lifestyle. In this paper, we start by presenting the main challenges facing people with diabetes—children/adolescents and adults—from a clinical perspective, followed by three short illustrative examples of mobile and desktop game apps and platforms designed by Ayogo Health, Inc. (Vancouver, BC, Canada) for type 1 diabetes (one example) and type 2 diabetes (two examples). The games target different age groups with different needs—children with type 1 diabetes versus adults with type 2 diabetes. The paper is not meant to be an exhaustive review of all digital game offerings available for people with type 1 and type 2 diabetes, but rather to serve as a taster of a few of the game genres on offer today for both types of diabetes, with a brief discussion of (1) some of the underpinning psychological mechanisms of gamified digital interventions and platforms as self-management adherence tools, and more, in diabetes, and (2) some of the hypothesized potential benefits that might be gained from their routine use by people with diabetes. More research evidence from full-scale evaluation studies is needed and expected in the near future that will quantify, qualify, and establish the evidence base concerning this gamification potential, such as what works in each age group/patient type, what does not, and under which settings and criteria.

Perspectives on the evolution of mobile (mHealth) technologies and application to rehabilitation

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often require complex habilitative and rehabilitative services to prevent and treat these complications. This perspective article reviews the evolution of mHealth technologies and presents insights as to how this evolution informed our development of a novel mHealth system, iMHere (interactive mobile health and rehabilitation), and other technologies, including those used by the Veterans Administration. This article will explain the novel applications of mHealth for rehabilitation and specifically physical therapy. Perspectives on the roles of rehabilitation professionals in the delivery of health care using mHealth systems are included. Challenges to mHealth, including regulatory and funding issues, are discussed. This article also describes how mHealth can be used to improve patient satisfaction and delivery of care and to promote health and wellness.

Behavioral functionality of mobile apps in health interventions: a systematic review of the literature

BACKGROUND

Several thousand mobile phone apps are available to download to mobile phones for health and fitness. Mobile phones may provide a unique means of administering health interventions to populations.

OBJECTIVE

The purpose of this systematic review was to systematically search and describe the literature on mobile apps used in health behavior interventions, describe the behavioral features and focus of health apps, and to evaluate the potential of apps to disseminate health behavior interventions.

METHODS

We conducted a review of the literature in September 2014 using key search terms in several relevant scientific journal databases. Only English articles pertaining to health interventions using mobile phone apps were included in the final sample.

RESULTS

The 24 studies identified for this review were primarily feasibility and pilot studies of mobile apps with small sample sizes. All studies were informed by behavioral theories or strategies, with self-monitoring as the most common construct. Acceptability of mobile phone apps was high among mobile phone users.

CONCLUSIONS

The lack of large sample studies using mobile phone apps may signal a need for additional studies on the potential use of mobile apps to assist individuals in changing their health behaviors. Of these studies, there is early evidence that apps are well received by users. Based on available research, mobile apps may be considered a feasible and acceptable means of administering health interventions, but a greater number of studies and more rigorous research and evaluations are needed to determine efficacy and establish evidence for best practices.

Effective strategies for encouraging behavior change in people with diabetes

Behavioral management of diabetes leads to better health outcomes. This paper reviews the available literature on facilitators of behavior change in people with diabetes and highlights approaches and strategies diabetes care providers can utilize. The research and clinical evidence points to the critical nature of considering the content and structure of recommendations, and utilizing problem solving and teamwork approaches. Furthermore, close attention to individual and community factors will optimize behavior change. These factors include health literacy, community infrastructure, support within the family, and whether there are co-occurring eating and mood issues. Recommendations are provided to optimize communication and embed behavior change approaches in clinical and community encounters.

The diabetes app challenge: user-led development and piloting of internet applications enabling young people with diabetes to set the focus for their diabetes consultations

Background

Traditionally, some teenagers and young adults with diabetes have not engaged well at diabetes appointments, giving rise to concerns about long-term health risks. We considered that apps might help this group of patients to improve preparation for, and therefore engagement at their appointments. Although there are already many apps for young people with type 1 diabetes (YPD), we thought that by supporting YPD themselves to develop apps, the resulting products would have greater “authenticity” and relevance.

Objective

To test the feasibility of an online competition to (1) recruit and support YPD to develop apps (mobile or Internet based) to help prepare for clinic appointments, and (2) for these apps to be tested and rated by YPD.

Methods

The “Diabetes App Challenge” was a United Kingdom (UK) national competition, run between June and October 2012 for teams including at least one YPD (aged 16-25) to pilot the design and development of apps for use by other YPD prior to clinic appointments. The competition was advertised by social media, email, AdWords and postings on the Diabetes UK website. Registrants for the competition were supported via email and discussion forum. After app development, other YPD were invited (November 2012-February 2013) to trial the apps, choose and use one prior to a clinic appointment, and review their experiences.

Results

Of 56 people (including 28 YPD) who expressed interest in the competition, 6 teams (14 people) developed and submitted an app. Two apps aimed to facilitate agenda setting in clinic consultations, 2 enabled data logging and 2 helped insulin dose calculation. Of 135 YPD who registered to trial the apps, 83 (61.5%) took part (mean age 18.98, 37/83 male). Agenda setting apps were considered most useful for preparing for and setting the focus of clinic appointments (P=.02). Just over half (46/83, 55%) said they would use their chosen app again and 4/5 (67/83, 81%) would recommend it to a friend.

Conclusions

This competition to engage YPD in developing and reviewing apps proved successful. App designers and testers saw a need for a range of functions. However, this may, in part, reflect a lack of detailed knowledge of all existing apps and be limited by the technical skills of YPD. App competitions appear worth applying to other patient groups, but future competitions should include a review stage and perhaps focus on ideas for app design for subsequent professional implementation.

Dietary Approaches to Stop Hypertension: Lessons Learned From a Case Study on the Development of an mHealth Behavior Change System

Background

Evidence-based solutions for changing health behaviors exist but problems with feasibility, sustainability, and dissemination limit their impact on population-based behavior change and maintenance.

Objective

Our goal was to overcome the limitations of an established behavior change program by using the inherent capabilities of smartphones and wireless sensors to develop a next generation mobile health (mHealth) intervention that has the potential to be more feasible.

Methods

In response to the clinical need and the growing capabilities of smartphones, our study team decided to develop a behavioral hypertension reduction mHealth system inspired by Dietary Approaches to Stop Hypertension (DASH), a lifestyle modification program. We outline the key design and development decisions that molded the project including decisions about behavior change best practices, coaching features, platform, multimedia content, wireless devices, data security, integration of systems, rapid prototyping, usability, funding mechanisms, and how all of these issues intersect with clinical research and behavioral trials.

Results

Over the 12 months, our study team faced many challenges to developing our prototype intervention. We describe 10 lessons learned that will ultimately stimulate more effective and sustainable approaches.

Conclusions

The experiences presented in this case study can be used as a reference for others developing mHealth behavioral intervention development projects by highlighting the benefits and challenges facing mHealth research.

Understanding usage of a hybrid website and smartphone app for weight management: a mixed-methods study

Background

Advancements in mobile phone technology offer huge potential for enhancing the timely delivery of health behavior change interventions. The development of smartphone-based health interventions (apps) is a rapidly growing field of research, yet there have been few longitudinal examinations of how people experience and use these apps within their day-to-day routines, particularly within the context of a hybrid Web- and app-based intervention.

Objective

This study used an in-depth mixed-methods design to examine individual variation in (1) impact on self-reported goal engagement (ie, motivation, self-efficacy, awareness, effort, achievement) of access to a weight management app (POWeR Tracker) when provided alongside a Web-based weight management intervention (POWeR) and (2) usage and views of POWeR Tracker.

Methods

Thirteen adults were provided access to POWeR and were monitored over a 4-week period. Access to POWeR Tracker was provided in 2 alternate weeks (ie, weeks 1 and 3 or weeks 2 and 4). Participants’ goal engagement was measured daily via self-report. Mixed effects models were used to examine change in goal engagement between the weeks when POWeR Tracker was and was not available and whether the extent of change in goal engagement varied between individual participants. Usage of POWeR and POWeR Tracker was automatically recorded for each participant. Telephone interviews were conducted and analyzed using inductive thematic analysis to further explore participants’ experiences using POWeR and POWeR Tracker.

Results

Access to POWeR Tracker was associated with a significant increase in participants’ awareness of their eating (β₁=0.31, P=.04) and physical activity goals (β₁=0.28, P=.03). The level of increase varied between individual participants. Usage data showed that participants used the POWeR website for similar amounts of time during the weeks when POWeR Tracker was (mean 29 minutes, SD 31 minutes) and was not available (mean 27 minutes, SD 33 minutes). POWeR Tracker was mostly accessed in short bursts (mean 3 minutes, SD 2 minutes) during convenient moments or moments when participants deemed the intervention content most relevant. The qualitative data indicated that nearly all participants agreed that it was more convenient to access information on-the-go via their mobiles compared to a computer. However, participants varied in their views and usage of the Web- versus app-based components and the informational versus tracking tools provided by POWeR Tracker.

Conclusions

This study provides evidence that smartphones have the potential to improve individuals’ engagement with their health-related goals when used as a supplement to an existing online intervention. The perceived convenience of mobile access to information does not appear to deter use of Web-based interventions or strengthen the impact of app access on goal engagement. A mixed-methods design enabled exploration of individual variation in daily usage of the app-based tools.

Getting a technology-based diabetes intervention ready for prime time: a review of usability testing studies

Consumer health technologies can educate patients about diabetes and support their self-management, yet usability evidence is rarely published even though it determines patient engagement, optimal benefit of any intervention, and an understanding of generalizability. Therefore, we conducted a narrative review of peer-reviewed articles published from 2009 to 2013 that tested the usability of a web- or mobile-delivered system/application designed to educate and support patients with diabetes. Overall, the 23 papers included in our review used mixed (n = 11), descriptive quantitative (n = 9), and qualitative methods (n = 3) to assess usability, such as documenting which features performed as intended and how patients rated their experiences. More sophisticated usability evaluations combined several complementary approaches to elucidate more aspects of functionality. Future work pertaining to the design and evaluation of technology-delivered diabetes education/support interventions should aim to standardize the usability testing processes and publish usability findings to inform interpretation of why an intervention succeeded or failed and for whom.

Fostering adherence to injectable disease-modifying therapies in multiple sclerosis

Multiple sclerosis requires long-term management, often with disease-modifying therapies. Poor medication adherence, especially to injectables, can increase relapse and hospitalisation rates and consume healthcare resources. We discuss adherence definitions and terminology and its prevalence in multiple sclerosis (MS). Typical causes of poor adherence in patients with MS include: insufficient efficacy or tolerability, concurrent disorders, and consequences of MS (e.g., forgetfulness, depression, fatigue and poor motor skills). Ways to improve adherence rates are reviewed, focusing on interdisciplinary healthcare teams, good communication between healthcare workers and patients (and their families), ongoing support and digital tools to promote adherence. We consider open communication and continuing education to be key, and that MS nurses have a pivotal role in ensuring patients' adherence to MS medicines.

Human Factors and Usability in Mobile Health Design – Factors for Sustained Patient Engagement in Diabetes Care

The degree of health care resource consumption within the United States is significant, even with the passage of the Patient Protection and Affordable Care Act (PPACA), with annual expenditures expected to reach 14% of the US gross domestic product by 2016. This suggests the need for population-level solutions that cover the spectrum of both clinical and non-clinical care for the primary prevention of chronic disease, in particular diabetes, which affects over eight percent of the population and costs over $100 billion annually. Over the past decade, there have been an abundance of technological solutions that provide the potential of mitigating the risk issues associated with diabetes and improving self-management practices. One such technology in particular is emerging that may become very important to the delivery of health care: mobile phones. In 2012, a study undertook a comprehensive assessment of the use of mobile health (mHealth) in the management and treatment of diabetes. This study encompassed the review of over 514 articles, as well as series of key informant interviews and site visits, to determine the effectiveness and utility of mHealth in managing and treating diabetes. The research suggested that the usability of mHealth applications could be understood and assessed according to four major factors: user-friendliness, user design, user satisfaction and user confidence. The first two primarily deal with the type of technology and the design of the interface. The last two concern user perception and are crucial in appropriately evaluating how well the application meets a patient’s expectations, which is a critical component of both quality of care and patient outcomes.

Obesity and outpatient rehabilitation using mobile technologies: the potential mHealth approach

Obesity is currently an important public health problem of epidemic proportions (globesity). Inpatient rehabilitation interventions that aim at improving weight-loss, reducing obesity-related complications and changing dysfunctional behaviors, should ideally be carried out in a multidisciplinary context with a clinical team composed of psychologists, dieticians, psychiatrists, endocrinologists, nutritionists, physiotherapists, etc. Long-term outpatient multidisciplinary treatments are likely to constitute an essential aspect of rehabilitation. Internet-based technologies can improve long-term obesity rehabilitation within a collaborative approach by enhancing the steps specified by psychological and medical treatment protocols. These outcomes may be augmented further by the mHealth approach, through creating new treatment delivery methods to increase compliance and engagement. mHealth (m-health, mobile health) can be defined as the practice of medicine and public health, supported by mobile communication devices for health services and information. mHealth applications which can be implemented in weight loss protocols and obesity rehabilitation are discussed, taking into account future research directions in this promising area.

Mobile applications for diabetics: a systematic review and expert-based usability evaluation considering the special requirements of diabetes patients age 50 years or older

BACKGROUND

A multitude of mhealth (mobile health) apps have been developed in recent years to support effective self-management of patients with diabetes mellitus type 1 or 2.

OBJECTIVE

We carried out a systematic review of all currently available diabetes apps for the operating systems iOS and Android. We considered the number of newly released diabetes apps, range of functions, target user groups, languages, acquisition costs, user ratings, available interfaces, and the connection between acquisition costs and user ratings. Additionally, we examined whether the available applications serve the special needs of diabetes patients aged 50 or older by performing an expert-based usability evaluation.

METHODS

We identified relevant keywords, comparative categories, and their specifications. Subsequently, we performed the app review based on the information given in the Google Play Store, the Apple App Store, and the apps themselves. In addition, we carried out an expert-based usability evaluation based on a representative 10% sample of diabetes apps.

RESULTS

In total, we analyzed 656 apps finding that 355 (54.1%) offered just one function and 348 (53.0%) provided a documentation function. The dominating app language was English (85.4%, 560/656), patients represented the main user group (96.0%, 630/656), and the analysis of the costs revealed a trend toward free apps (53.7%, 352/656). The median price of paid apps was €1.90. The average user rating was 3.6 stars (maximum 5). Our analyses indicated no clear differences in the user rating between free and paid apps. Only 30 (4.6%) of the 656 available diabetes apps offered an interface to a measurement device. We evaluated 66 apps within the usability evaluation. On average, apps were rated best regarding the criterion "comprehensibility" (4.0 out of 5.0), while showing a lack of "fault tolerance" (2.8 out of 5.0). Of the 66 apps, 48 (72.7%) offered the ability to read the screen content aloud. The number of functions was significantly negative correlated with usability. The presence of documentation and analysis functions reduced the usability score significantly by 0.36 and 0.21 points.

CONCLUSIONS

A vast number of diabetes apps already exist, but the majority offer similar functionalities and combine only one to two functions in one app. Patients and physicians alike should be involved in the app development process to a greater extent. We expect that the data transmission of health parameters to physicians will gain more importance in future applications. The usability of diabetes apps for patients aged 50 or older was moderate to good. But this result applied mainly to apps offering a small range of functions. Multifunctional apps performed considerably worse in terms of usability. Moreover, the presence of a documentation or analysis function resulted in significantly lower usability scores. The operability of accessibility features for diabetes apps was quite limited, except for the feature "screen reader".

Telemedicine for Adolescents With Type 1 Diabetes

Diabetes is the third most common chronic disease in the pediatric population and diabetes management in adolescents presents a unique challenge for health care providers. The purpose of this article is to define telemedicine, review a variety of telemedicine intervention studies in the adolescent population, and interpret those results in the context of the current health care climate. Clinicians and researchers will be provided with education related to adolescent needs and telemedicine interventions so that telemedicine can be used effectively to promote the health of adolescents with diabetes. Because telemedicine has yet to demonstrate consistent and significant positive outcomes in this population, further research and continued development of technology are essential to improve diabetes control in adolescents and prevent the long-term complications of this disease.

A smartphone-based pain management app for adolescents with cancer: establishing system requirements and a pain care algorithm based on literature review, interviews, and consensus

BACKGROUND

Pain that occurs both within and outside of the hospital setting is a common and distressing problem for adolescents with cancer. The use of smartphone technology may facilitate rapid, in-the-moment pain support for this population. To ensure the best possible pain management advice is given, evidence-based and expert-vetted care algorithms and system design features, which are designed using user-centered methods, are required.

OBJECTIVE

To develop the decision algorithm and system requirements that will inform the pain management advice provided by a real-time smartphone-based pain management app for adolescents with cancer.

METHODS

A systematic approach to algorithm development and system design was utilized. Initially, a comprehensive literature review was undertaken to understand the current body of knowledge pertaining to pediatric cancer pain management. A user-centered approach to development was used as the results of the review were disseminated to 15 international experts (clinicians, scientists, and a consumer) in pediatric pain, pediatric oncology and mHealth design, who participated in a 2-day consensus conference. This conference used nominal group technique to develop consensus on important pain inputs, pain management advice, and system design requirements. Using data generated at the conference, a prototype algorithm was developed. Iterative qualitative testing was conducted with adolescents with cancer, as well as pediatric oncology and pain health care providers to vet and refine the developed algorithm and system requirements for the real-time smartphone app.

RESULTS

The systematic literature review established the current state of research related to nonpharmacological pediatric cancer pain management. The 2-day consensus conference established which clinically important pain inputs by adolescents would require action (pain management advice) from the app, the appropriate advice the app should provide to adolescents in pain, and the functional requirements of the app. These results were used to build a detailed prototype algorithm capable of providing adolescents with pain management support based on their individual pain. Analysis of qualitative interviews with 9 multidisciplinary health care professionals and 10 adolescents resulted in 4 themes that helped to adapt the algorithm and requirements to the needs of adolescents. Specifically, themes were overall endorsement of the system, the need for a clinical expert, the need to individualize the system, and changes to the algorithm to improve potential clinical effectiveness.

CONCLUSIONS

This study used a phased and user-centered approach to develop a pain management algorithm for adolescents with cancer and the system requirements of an associated app. The smartphone software is currently being created and subsequent work will focus on the usability, feasibility, and effectiveness testing of the app for adolescents with cancer pain.

Web-based apps for reflection: a longitudinal study with hospital staff

BACKGROUND

Reflection is an important cognitive process in workplace learning; however, it occurs only rarely on its own and therefore needs additional support.

OBJECTIVE

In this study, we investigated the effect of software applications (apps) that aim to support reflection on hospital staff's actual reflection behavior. In doing so, we also analyzed the relationship between reflection and the job satisfaction of health care professionals.

METHODS

Reflective learning was introduced in the ward of a neurological hospital by providing apps that aimed to foster particular aspects of individual and collaborative reflection. Data were collected repeatedly: once before the introduction of the apps and again 2 years after the initial measure. We used a questionnaire with subjective ratings of reflection and job satisfaction. Response rates were 34.4% (167/485) for the first and 40.6% (210/517) for the second measure.

RESULTS

Collaborative reflection was increased (P=.047) after the provision of the apps (2010: mean 2.84, SD 0.72; 2012: mean 3.06, SD 0.63) in contrast to a control group of other wards of the same hospital (2010: mean 2.68, SD 0.67; 2012: mean 2.63, SD 0.68). In addition, we revealed a positive correlation between collaborative reflection and job satisfaction (r=.61, P<.001).

CONCLUSIONS

The findings provide evidence for an effect of the apps on hospital employees' reflection behavior. Apps that foster reflective learning can increase health care professionals' reflection about work experiences and support them in discussing experiences in teams or with their supervisors. The relationship between collaborative reflection and job satisfaction suggests that opportunities for joint reflection on work experiences in a hospital have further impact over and above fostering reflective learning per se. We discuss the limitations of our study and provide suggestions for both future research and the development of Web-based apps.

The regulation of mobile medical applications

The rapidly expanding number of mobile medical applications have the potential to transform the patient-healthcare provider relationship by improving the turnaround time and reducing costs. In September 2013, the U.S. Food and Drug Administration (FDA) issued guidance to regulate these applications and protect consumers by minimising the risks associated with their unintended use. This guidance distinguishes between the subset of mobile medical apps which may be subject to regulation and those that are not. The marketing claims of the application determine the intent. Areas of concern include compliance with regular updates of the operating systems and of the mobile medical apps themselves. In this article, we explain the essence of this FDA guidance by providing examples and evaluating the impact on academia, industry and other key stakeholders, such as patients and clinicians. Our assessment indicates that awareness and incorporation of the guidelines into product development can hasten the commercialisation and market entry process. Furthermore, potential obstacles have been discussed and directions for future development suggested.

Challenging recruitment of youth with type 2 diabetes into clinical trials

PURPOSE

To better understand and overcome difficulties with recruitment of adolescents with type 2 diabetes into clinical trials at three United States institutions, we reviewed recruitment and retention strategies in clinical trials of youth with various chronic conditions. We explored whether similar strategies might be applicable to pediatric patients with type 2 diabetes.

METHODS

We compiled data on recruitment and retention of adolescents with type 2 diabetes at three centers (National Institutes of Health, Bethesda, Maryland; Baylor College of Medicine, Houston, Texas; and Children's National Medical Center, Washington, DC) from January 2009 to December 2011. We also conducted a thorough literature review on recruitment and retention in adolescents with chronic health conditions.

RESULTS

The number of recruited patients was inadequate for timely completion of ongoing trials. Our review of recruitment strategies in adolescents included monetary and material incentives, technology-based advertising, word-of-mouth referral, and continuous patient-research team contact. Cellular or Internet technology appeared promising in improving participation among youths in studies of various chronic conditions and social behaviors.

CONCLUSIONS

Adolescents with type 2 diabetes are particularly difficult to engage in clinical trials. Monetary incentives and use of technology do not represent "magic bullets," but may presently be the most effective tools. Future studies should be conducted to explore motivation in this population. We speculate that (1) recruitment into interventional trials that address the main concerns of the affected youth (e.g., weight loss, body image, and stress management) combined with less tangible outcomes (e.g., blood glucose control) may be more successful; and (2) study participation and retention may be improved by accommodating patients' and caregivers' schedules, by scheduling study visits before and after working hours, and in more convenient locations than in medical facilities.

Mobile medical and health apps: state of the art, concerns, regulatory control and certification

This paper examines the state of the art in mobile clinical and health-related apps. A 2012 estimate puts the number of health-related apps at no fewer than 40,000, as healthcare professionals and consumers continue to express concerns about the quality of many apps, calling for some form of app regulatory control or certification to be put in place. We describe the range of apps on offer as of 2013, and then present a brief survey of evaluation studies of medical and health-related apps that have been conducted to date, covering a range of clinical disciplines and topics. Our survey includes studies that highlighted risks, negative issues and worrying deficiencies in existing apps. We discuss the concept of ‘apps as a medical device’ and the relevant regulatory controls that apply in USA and Europe, offering examples of apps that have been formally approved using these mechanisms. We describe the online Health Apps Library run by the National Health Service in England and the calls for a vetted medical and health app store. We discuss the ingredients for successful apps beyond the rather narrow definition of ‘apps as a medical device’. These ingredients cover app content quality, usability, the need to match apps to consumers’ general and health literacy levels, device connectivity standards (for apps that connect to glucometers, blood pressure monitors, etc.), as well as app security and user privacy. ‘Happtique Health App Certification Program’ (HACP), a voluntary app certification scheme, successfully captures most of these desiderata, but is solely focused on apps targeting the US market. HACP, while very welcome, is in ways reminiscent of the early days of the Web, when many “similar” quality benchmarking tools and codes of conduct for information publishers were proposed to appraise and rate online medical and health information. It is probably impossible to rate and police every app on offer today, much like in those early days of the Web, when people quickly realised the same regarding informational Web pages. The best first line of defence was, is, and will always be to educate consumers regarding the potentially harmful content of (some) apps.

Smartphone medication adherence apps: potential benefits to patients and providers

OBJECTIVES

To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps.

PRACTICE DESCRIPTION

Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful.

PRACTICE INNOVATION

Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior.

MAIN OUTCOME MEASURES

Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen. RESULTS 160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.

CONCLUSION

Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.

I PLAY AT WORK-ten principles for transforming work processes through gamification

Gamified workplaces could be a positive and innovative solution to addressing contemporary problems in organizations. Such problems include high levels of stress, reduced sense of community, reduced loyalty and rapid changes in the workforce. To better prepare organizations for the future it may be helpful to identify and understand the potential advantages, disadvantages and areas for future research in relationship to the use of gamification for personal and organizational wellbeing. An analysis of research literature across disciplines in combination with expert opinion identified gamified workplaces as a promising strategy for promoting wellbeing. Furthermore, this paper proposes a set of 10 principles (I PLAY AT WORK) that may support gamification efforts. In addition to the value of mapping the present for the benefit of the future, there is also considerable value in reshaping core ideas related to the workplaces. Gamified workplaces can provide opportunities for a more vigorous and strategic inter-disciplinary research agenda that can stimulate investments in the area.