Developing and implementing a gamification method to improve user engagement: A case study with an m-Health application for hypertension monitoring

An approach to boost adherence to self-data reporting in mHealth applications for users without specific health conditions

BACKGROUND

The popularization of mobile health (mHealth) apps for public health or medical care purposes has transformed human life substantially, improving lifestyle behaviors and chronic condition management. The objective of this study is to evaluate the effect of gamification features in a mHealth app that includes the most common categories of behavior change techniques for the self-report of lifestyle data. The data reported by the user can be manual (i.e., diet, activity, and weight) and automatic (Fitbit wearable devices). As a secondary objective, this work aims to explore the differences in the adherence when considering a longer study duration and make a comparative analysis of the gamification effect.

METHODS

In this study, the effectiveness of various behavior change techniques strategies is evaluated through the analysis of two user groups. With a first group of users, we perform a comparative analysis in terms of adherence and system usability scale of two versions of the app, both including the most common categories of behavior change techniques but the second version having added gamification features. Then, with a second group of participants and the best mHealth app version, a longer study is carried out and user adherence, the system usability scale and user feedback are analyzed.

RESULTS

In the first stage study, results have shown that the app version with gamification features has achieved a higher adherence, as the percentage of days active was higher for most of the users and the system usability scale score is 80.67, which is categorized as rank A. The app also exceeded the expectations of the users by about 70% for the app version with gamification functionalities. In the second stage of the study, an adherence of 76.25% is reported after 8 weeks and 58% at the end of the pilot for the mHealth app. Similarly, for the wearable device, an adherence of 74.32% is achieved after 8 weeks and 81.08% is obtained at the end of the pilot. We hypothesize that these specific wearable devices have contributed to a decreased system usability scale score, reaching 62.89 which is ranked as C.

CONCLUSION

This study evidences the effectiveness of the gamification category of behavior change techniques in increasing the overall user adherence, expectations, and perceived usability. In addition, the results provide quantitative results on the effect of the most common categories of behavior change techniques for the self-report of lifestyle data. Therefore, a higher duration in the study has shown several limitations when capturing lifestyle data, especially when including wearable devices such as Fitbit.

Developing a mobile exercise program for individuals with Spinal Cord Injury: Stakeholder perceptions of app features and implementation determinants

BACKGROUND

Individuals with Spinal Cord Injury (SCI) often experience physical deconditioning, leading to long-term health challenges. While regular exercise can offer substantial health benefits, adherence to exercise guidelines among individuals with SCI is hindered by barriers such as inaccessibility. Exercise programs using the mobile application (App) tailored to individual needs present a promising solution for promoting exercise adherence among individuals with SCI.

OBJECTIVE

This study aimed to identify factors contributing to the successful implementation of an app-based home exercise program for individuals with SCI and gather user feedback on app preferences, functionality, and features.

METHODS

Guided by the Consolidated Framework for Implementation Research (CFIR), twenty-six clinicians completed an expert panel survey to rank factors influencing the implementation of an app-based intervention for increasing exercise adherence for individuals with SCI. CFIR-selected factors and app quality features obtained from the Mobile Application Rating Scale (MARS) framework were discussed in seven focus groups with 23 individuals with SCI, 6 caregivers, and 6 clinicians.

RESULTS

The expert survey identified adaptability, complexity, evidence strength/quality, relative advantage, knowledge/beliefs about the initiative, and execution as the key CFIR factors that affected the intervention's success. Major themes emerging from focus groups with individuals with SCI and caregivers included usability, instruction and guidelines, user-friendly interface, and clinician interaction. In contrast, clinicians mentioned themes such as the representation of the SCI population, time commitment, accessibility, and equipment.

CONCLUSIONS

The study highlights the significance of incorporating these determinants into future designs to develop app-based home exercise interventions for individuals with SCI.

Unlocking knowledge: a meta-analysis assessing the efficacy of educational escape rooms in health sciences education

Educational escape rooms within health sciences education are gaining traction as a unique and engaging game-based strategy for reviewing instructional content. Educational escape rooms cultivate valuable skills such as teamwork, communication, creativity, attention to detail, and the ability to apply knowledge under time pressures. While several studies have independently assessed learners' knowledge gains after educational escape room interventions, the present work meta-analyzes the efficacy of educational escape rooms across studies and student learners within health sciences education. A systematic search across seven databases was performed by a health sciences librarian from inception to March 24, 2023. Record screenings, full-text reviews, and data extractions were managed within Covidence. MERSQI criteria were used to assess study quality. Pooled effect sizes (Standardized Mean Differences = SMD) were estimated through meta-analysis to summarize learner performance outcomes after educational escape room interventions. Eleven studies followed a longitudinal pretest-posttest design, and five studies followed a control-treatment group design. Learners' posttest scores after participating in an educational escape room were statistically higher than their pretest scores as indicated by a large positive summary effect size (SMD ≥ 0.893; p <0.001). Educational escape rooms were also effective for treatment group participants (n = 508), who significantly outperformed (SMD = 0.616; p <0.001) control group participants (n = 555). Most escape rooms were employed as a mechanism for reviewing educational content. This meta-analytic review suggests escape rooms are effective educational interventions for increasing knowledge gains among health sciences learners and highlights common implementation practices to help guide educators interested in this game-based learning approach.

Gamification in personal health record systems: a regulatory fit perspective

OBJECTIVE

It has been known that individuals' regulatory focus differences (prevention orientation or promotion orientation) influence health-related behaviors. However, in the gamification literature, when classical and gamified applications are discussed, the gain frame is predominantly included, whereas the loss frame is not sufficiently considered. In this study, individuals' evaluations of gamified and non-gamified personal health record systems with different frames were examined.

METHODS

A 2 (type of personal health record system application: gamified vs. non-gamified) X 2 (frame: gain vs. loss) between-subject design was implemented, and users' regulatory foci were tested in this study. We predicted that systems that are gamified and aligned with users' regulatory foci will be evaluated more favorably than systems that are not aligned with users' regulatory foci.

RESULTS

Contrary to what the gamification literature suggests, we found that individuals do not always prefer gamified systems over non-gamified ones. Participants' regulatory focus might play a crucial role in their attitudes toward gamified platforms.

CONCLUSION

The findings might contribute to the design of personal health record systems by bearing the individual motivational differences of users in mind.

How can we reward you? A compliance and reward ontology (CaRO) for eliciting quantitative reward rules for engagement in mHealth app and healthy behaviors

OBJECTIVE

When developing mHealth apps with point reward systems, knowledge engineers and domain experts should define app requirements capturing quantitative reward patterns that reflect patient compliance with health behaviors. This is a difficult task, and they could be aided by an ontology that defines systematically quantitative behavior goals that address more than merely the recommended behavior but also rewards for partial compliance or practicing the behavior more than recommended. No ontology and algorithm exist for defining point rewards systematically.

METHODS

We developed an OWL ontology for point rewards that leverages the Basic Formal Ontology, the Behaviour Change Intervention Ontology and the Gamification Domain Ontology. This Compliance and Reward Ontology (CaRO) allows defining temporal elementary reward patterns for single and multiple sessions of practicing a behavior. These could be assembled to define more complex temporal patterns for persistence behavior over longer time intervals as well as logical combinations of simpler reward patterns. We also developed an algorithm for calculating the points that should be rewarded to users, given data regarding their actual performance. A natural language generation algorithm generates from ontology instances app requirements in the form of user stories. To assess the usefulness of the ontology and algorithms, information system students who are trained to be system analysts/knowledge engineers evaluated whether the ontology and algorithms can improve the requirement elicitation of point rewards for compliance patterns more completely and correctly.

RESULTS

For single-session rewards, the ontology improved formulation of two of the six requirements as well as the total time for specifying them. For multi-session rewards, the ontology improved formulation of five of the 11 requirements.

CONCLUSION

CaRO is a first attempt of its kind, and it covers all of the cases of compliance and reward pattern definitions that were needed for a full-scale system that was developed as part of a large European project. The ontology and algorithm are available at https://github.com/capable-project/rewards.

A fusion architecture to deliver multipurpose mobile health services

Mobile Health (mHealth) services typically make use of customized software architectures, leading to development-dependent fragmentation. Nevertheless, irrespective of their specific purpose, most mHealth services share common functionalities, where standard pieces could be reused or adapted to expedite service deployment and even extend the follow-up of appearing conditions under the same service. To harness compatibility and reuse, this article presents a data fusion architecture proposing a common design framework for mHealth services. An exhaustive mapping of mHealth functionalities identified in the literature serves as starting point. The architecture is then conceptualized making use of the Joint Directors of Laboratories (JDL) data fusion model. The aim of the architecture is to exploit the multi-source data acquisition capabilities supported by smartphones and Internet of Things devices, and artificial intelligence-enabled feature fusion. A series of interconnected fusion layers ensure streamlined data management; each layer is composed of microservices which may be implemented or omitted depending on the specific goals of the healthcare service. Moreover, the architecture considers essential features related to authentication mechanisms, data sharing protocols, practitioner-patient communication, context-based notifications and tailored visualization interfaces. The effectiveness of the architecture is underscored by its instantiation for four real cases, encompassing risk assessment for youth with mental health issues, remote monitoring for SARS-CoV-2 patients, liquid intake control for kidney disease patients, and peritoneal dialysis treatment support. This breadth of applications exemplifies how the architecture can effectively serve as a guidance framework to accelerate the design of mHealth services.

Developing cue-behavior association for habit formation: A qualitative study to explore the role of avatar in hypertension

Background

Electronic health (eHealth) has been widely adopted in chronic disease management. Prior studies focused on time-based reminders as a cue to facilitate behavior change intentions, ignoring the development of automatic cue-behavior associations via other cue types.

Objective

Hence, this study utilized avatar appearance as a visual-based cue to help establish the automatic association between appearance transformation and health behavior to form habits without intention.

Methods

To better understand users' attitudes and experiences toward applying changes in avatar appearance to develop cue-behavior associations for hypertensive patients. Fifteen participants were recruited in a 14-day experiment. After excluding one participant who dropped out of the experiment, others were randomly assigned to two groups. One group consisted of a visual-based cue (a virtual plant) and basic behavior change techniques (BCTs). The other group only included basic BCTs. Attitudes and experience outcomes were collected by interview, and qualitative data were analyzed using thematic analysis.

Results

57% of participants had been diagnosed with hypertension for more than five years, and more than 50% of participants have experience using mobile apps or wearables. 66% of participants did physical activity more than three times every week. The result shows that tailored time-based reminders, blood pressure monitoring, and daily dietary intake were the most attractive features. Additionally, hypertensive participants have positive attitudes toward avatar appearance as a visual-based cue to develop cue-behavior association, which enhances self-management motivation.

Conclusion

This study proposes a visual-based cue design for habit formation and conducts a qualitative method to explore hypertensive patients' perceptions. The findings offer insights from user's perspectives into hypertensive patients' attitudes toward visual-based cues and perception of the connection between avatar appearance and health behavior for self-management. Subsequent discussions present eHealth design guidelines of habit formation from intention, automatic cue-behavior association, and self-management perspectives.

The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review

BACKGROUND

Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients' participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases.

OBJECTIVE

This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population.

METHODS

We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis.

RESULTS

We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard.

CONCLUSIONS

This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification.

Diabetes and hypertension MobileHealth systems: a review of general challenges and advancements

Mobile health (mHealth) systems are sipping into more and more healthcare functions with self-management being the foremost modus operandi. However, there has been challenges. This study explores challenges with mHealth self-management of diabetes and hypertension, two of the most comorbid chronic diseases. Existing literature present the challenges in fragments, certain subsets of the challenges at a time. Nevertheless, feedback from patient/users in extant literature depict very variegated concerns that are also interdependent. This work pursues provision of an encyclopedic, but not redundant, view of the challenges with mHealth systems for self-management of diabetes and hypertension.

Furthermore, the work identifies machine learning (ML) and self-management approaches as potential drivers of potency of diabetes and hypertension mobile health systems. The nexus between ML and diabetes and hypertension mHealth systems was found to be under-explored. For ML contributions to management of diabetes, we found that machine learning has been applied most to diabetes prediction followed by diagnosis, with therapy in distant third. For diabetes therapy research, only physical and dietary therapy were emphasized in reviewed literature. The four most considered performance metrics were accuracy, ROC-AUC, sensitivity, and specificity. Random forest was the best performing algorithm across all metrics, for all purposes covered in the literature. For hypertension, in descending order, hypertension prediction, prediction of risk factors, and prediction of prehypertension were most considered areas of hypertension management witnessing application of machine learning. SVM averaged best ML algorithm in accuracy and sensitivity, while random forest averaged best performing in specificity and ROC-AUC.

Health promotion through physical activity applications using gamification

The present study aims to examine how gamification will function in physical activity applications. Because of the stoppage of exercise centers during the epidemic of diseases like COVID-19, which caused a global crisis, and because lack of physical activity is becoming a serious health problem around the world, the present research examines how exercise applications may be used to keep users active in non- exercises contexts. The present study aims to identify the components of gamification on user attraction, involvement, and flow. The gathered data were examined using the content analysis technique, which was used to collect data using the qualitative research method. Finally, a model was constructed that can be used to create and build exercise applications. Narration, feedback, level, progress boards, and other components have been identified, and team building and sharing, as well as the social aspect of applications, have been presented and enhanced, and different aspects have been added to applications, as well as the dynamics and mechanics that affect them. Designers and developers of gamified exercises and health applications will benefit from this article. At present, many special centers for juvenile delinquency use physical activity and sports programs in order to control, prevent and correct delinquency. Sports and physical activities, as one of the important leisure activities, is considered one of the important forms of social control and has educational goals as well.

Sustainable Development for Mobile Health Apps Using the Human-Centered Design Process

Well-documented scientific evidence indicates that mobile health (mHealth) apps can improve the quality of life, relieve symptoms, and restore health for patients. In addition to improving patients' health outcomes, mHealth apps reduce health care use and the cost burdens associated with disease management. Currently, patients and health care providers have a wide variety of choices among commercially available mHealth apps. However, due to the high resource costs and low user adoption of mHealth apps, the cost-benefit relationship remains controversial. When compared to traditional expert-driven approaches, applying human-centered design (HCD) may result in more useable, acceptable, and effective mHealth apps. In this paper, we summarize current HCD practices in mHealth development studies and make recommendations to improve the sustainability of mHealth. These recommendations include consideration of factors regarding culture norms, iterative evaluations on HCD practice, use of novelty in mHealth app, and consideration of privacy and reliability across the entire HCD process. Additionally, we suggest a sociotechnical lens toward HCD practices to promote the sustainability of mHealth apps. Future research should consider standardizing the HCD practice to help mHealth researchers and developers avoid barriers associated with inadequate HCD practices.

Exploring the usability of an internet-based intervention and its providing eHealth platform in an eye-tracking study

The proliferation of online eHealth has made it much easier for users to access healthcare services and interventions from the comfort of their own homes. This study looks at how well one such platform-eSano-performs in terms of user experience when delivering mindfulness interventions. In order to assess usability and user experience, several tools such as eye-tracking technology, think-aloud sessions, a system usability scale questionnaire, an application questionnaire, and post-experiment interviews were employed. Participants were evaluated while they accessed the first module of the mindfulness intervention provided by eSano to measure their interaction with the app, and their level of engagement, and to obtain feedback on both the intervention and its overall usability. The results revealed that although users generally rated their experience with the app positively in terms of overall satisfaction, according to data collected through the system usability scale questionnaire, participants rated the first module of the mindfulness intervention as below average. Additionally, eye-tracking data showed that some users skipped long text blocks in favor of answering questions quickly while others spent more than half their time reading them. Henceforth, recommendations were put forward to improve both the usability and persuasiveness of the app-such as incorporating shorter text blocks and more engaging interactive elements-in order to raise adherence rates. Overall findings from this study provide valuable insights into how users interact with the eSano's participant app which can be used as guidelines for the future development of more effective and user-friendly platforms. Moreover, considering these potential improvements will help foster more positive experiences that promote regular engagement with these types of apps; taking into account emotional states and needs that vary across different age groups and abilities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12652-023-04635-4.

Gamifying Cognitive Behavioral Therapy Techniques on Smartphones for Bangkok's Millennials With Depressive Symptoms: Interdisciplinary Game Development

BACKGROUND

There is serious concern over the annual increase in depressive symptoms among millennials in Bangkok, Thailand. Their daily routine revolves around the use of their smartphones for work and leisure. Although accessibility to mental health care is expanding, it cannot keep up with the demand for mental health treatment. Outside Thailand, multiple projects and studies have attempted to merge gamification mechanisms and cognitive behavioral therapy (CBT) to create mobile health intervention apps and serious games with positive feedback. This presents an opportunity to explore the same approach in Thailand.

OBJECTIVE

This study investigated the development process of gamifying CBT techniques to support game mechanics in a visual narrative serious game, BlueLine. The primary target of this research is Bangkok's millennials. In the game, players play as Blue, a Bangkok millennial who struggles to live through societal norms that influence his digital life and relationships. Through in-game scenarios, players will learn and understand how to lessen the impact of depressive symptoms via gamified interactions on their smartphones.

METHODS

First, this paper follows each development step of solidifying BlueLine's game structure by integrating the Activating Events, Beliefs, Consequences, Disputation of Beliefs and Effective New Approaches (ABCDE) model and narrative in games. Second, the approach to select CBT and related therapeutic elements for gamification is based on suitability to the game structure. Throughout the process, CBT experts in Thailand have reviewed these scenarios. The approach forms the base of the player's interactions throughout the scenarios in BlueLine, broken down into 4 types of gamified mechanisms: narrative, verbal interactions, physical interactions, and social media interactions.

RESULTS

With the game structure based on the ABCDE model, BlueLine scenarios implement gamified mechanisms in conjunction with the following CBT and related therapeutic elements: behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. In each scenario, players guide Blue to overcome his triggered dysfunctional beliefs. During this process, players can learn and understand how to lessen the impact of depressive symptoms through gamified interactions.

CONCLUSIONS

This paper presents the development process of gamifying CBT and related therapeutic techniques in BlueLine game scenarios. A scenario can harbor multiple techniques, including behavioral activation, self-monitoring, interpersonal skills, positive psychology, relaxation and mindful activities, and problem-solving. BlueLine's game structure does not limit the fact that the same combination of CBT elements ties each gamified mechanism.

Escape rooms technology as a way of teaching mathematics to secondary school students

The aim of this study is to determine whether Escape Rooms can be used as an active methodological approach for the purpose of teaching mathematics. The research adapted a quantitative approach via an experimental design. Two different study groups were established, the first of which comprised the control group who were taught using conventional training methods, and the second consisted of the experimental group, who were taught using a novel approach incorporating an Escape Room activity. The participants included 80 students who were all attending secondary school within the Kingdom of Saudi Arabia. The findings revealed how the activity involving the Escape Room led to a significant enhancement in the student's motivation, achievement and autonomy. The conclusion can be drawn that using an Escape Room in mathematics teaching can enhance learning achievement, anxiety, motivation and autonomy, with students' negative attitudes regarding mathematics learning considered as an important variable, particularly with respect to autonomy and motivation. Hence, Escape Rooms can potentially be more effective than conventional methods for teaching mathematics.

A gamified approach for improving the learning performance of K-6 students using Easter eggs

Gamification is mainly used to increase user engagement and motivation, hence increasing the user base and user activity. Defined by applying game elements to non-gaming contexts, gamification is mostly integrated with software applications in order to provide a gameful experience for users. Education has been one of the areas where gamification studies have focused a lot during the last decade. Young students with the age range of 7-12 years old (K-6) require different teaching methods to use their full potential. However, the methods and principles presented in studies on gamification and its application in education are not dedicated to K-6 students. Furthermore, the evolution of video games has brought new opportunities to develop new gamification elements and principles. In this research, the easter egg element has been implemented as a gamification element. Easter eggs can trigger children's curiosity by encouraging them to find all the Easter eggs, promising special rewards and perks. Additionally, a gamified approach is proposed for implementing a gamified software application for K-6 students. Based on the proposed approach, Science Island is implemented as an online gamified web application for K-6 students. In order to assess the proposed approach, a group of 47 sixth-grade students was selected to use the application for an observation period of 2 months. Feedbacks from students showed that more than 82% of the students agreed with the effectiveness of gamification in their educational performance. Additionally, the results from the data analysis revealed that students' learning performance was improved significantly after applying gamification elements; showing an increase of 0.63 in average quiz score from the second month compared to the first month. Furthermore, the user activity rate at the end of the observation period showed increased motivation among students for using the software application.

Gamification of e-learning in higher education: a systematic literature review

In recent years, university teaching methods have evolved and almost all higher education institutions use e-learning platforms to deliver courses and learning activities. However, these digital learning environments present significant dropout and low completion rates. This is primarily due to the lack of student motivation and engagement. Gamification which can be defined as the application of game design elements in non-game activities has been used to address the issue of learner distraction and stimulate students’ involvement in the course. However, choosing the right combination of game elements remains a challenge for gamification designers and practitioners due to the lack of proven design approaches, and there is no one-size-fits-all approach that works regardless of the gamification context. Therefore, our study focused on providing a comprehensive overview of the current state of gamification in online learning in higher education that can serve as a resource for gamification practitioners when designing gamified systems. In this paper, we aimed to systematically explore the different game elements and gamification theory that have been used in empirical studies; establish different ways in which these game elements have been combined and provide a review of the state-of-the-art of approaches proposed in the literature for gamifying e-learning systems in higher education. A systematic search of databases was conducted to select articles related to gamification in digital higher education for this review, namely, Scopus and Google Scholar databases. We included studies that consider the definition of gamification as the application of game design elements in non-game activities, designed for online higher education. We excluded papers that use the term of gamification to refer to game-based learning, serious games, games, video games, and those that consider face-to-face learning environments. We found that PBL elements (points, badges, and leaderboards), levels, and feedback and are the most commonly used elements for gamifying e-learning systems in higher education. We also observed the increasing use of deeper elements like challenges and storytelling. Furthermore, we noticed that of 39 primary studies, only nine studies were underpinned by motivational theories, and only two other studies used theoretical gamification frameworks proposed in the literature to build their e-learning systems. Finally, our classification of gamification approaches reveals the trend towards customization and personalization in gamification and highlights the lack of studies on content gamification compared to structural gamification.

The feasibility of using Apple's ResearchKit for recruitment and data collection: Considerations for mental health research

In 2015, Apple launched an open-source software framework called ResearchKit. ResearchKit provides an infrastructure for conducting remote, smartphone-based research trials through the means of Apple's App Store. Such trials may have several advantages over conventional trial methods including the removal of geographic barriers, frequent assessments of participants in real-life settings, and increased inclusion of seldom-heard communities. The aim of the current study was to explore the feasibility of participant recruitment and the potential for data collection in the non-clinical population in a smartphone-based trial using ResearchKit. As a case example, an app called eMovit, a behavioural activation (BA) app with the aim of helping users to build healthy habits was used. The study was conducted over a 9-month period. Any iPhone user with access to the App Stores of The Netherlands, Belgium, and Germany could download the app and participate in the study. During the study period, the eMovit app was disseminated amongst potential users via social media posts (Twitter, Facebook, LinkedIn), paid social media advertisements (Facebook), digital newsletters and newspaper articles, blogposts and other websites. In total, 1,788 individuals visited the eMovit landing page. A total of 144 visitors subsequently entered Apple's App Store through that landing page. The eMovit product page was viewed 10,327 times on the App Store. With 79 installs, eMovit showed a conversion rate of 0.76% from product view to install of the app. Of those 79 installs, 53 users indicated that they were interested to participate in the research study and 36 subsequently consented and completed the demographics and the participants quiz. Fifteen participants completed the first PHQ-8 assessment and one participant completed the second PHQ-8 assessment. We conclude that from a technological point of view, the means provided by ResearchKit are well suited to be integrated into the app process and thus facilitate conducting smartphone-based studies. However, this study shows that although participant recruitment is technically straightforward, only low recruitment rates were achieved with the dissemination strategies applied. We argue that smartphone-based trials (using ResearchKit) require a well-designed app dissemination process to attain a sufficient sample size. Guidelines for smartphone-based trial designs and recommendations on how to work with challenges of mHealth research will ensure the quality of these trials, facilitate researchers to do more testing of mental health apps and with that enlarge the evidence-base for mHealth.

Did Usage of Mental Health Apps Change during COVID-19? A Comparative Study Based on an Objective Recording of Usage Data and Demographics

This paper aims to objectively compare the use of mental health apps between the pre-COVID-19 and during COVID-19 periods and to study differences amongst the users of these apps based on age and gender. The study utilizes a dataset collected through a smartphone app that objectively records the users' sessions. The dataset was analyzed to identify users of mental health apps (38 users of mental health apps pre-COVID-19 and 81 users during COVID-19) and to calculate the following usage metrics; the daily average use time, the average session time, the average number of launches, and the number of usage days. The mental health apps were classified into two categories: guidance-based and tracking-based apps. The results include the increased number of users of mental health apps during the COVID-19 period as compared to pre-COVID-19. Adults (aged 24 and above), compared to emerging adults (aged 15-24 years), were found to have a higher usage of overall mental health apps and guidance-based mental health apps. Furthermore, during the COVID-19 pandemic, males were found to be more likely to launch overall mental health apps and guidance-based mental health apps compared to females. The findings from this paper suggest that despite the increased usage of mental health apps amongst males and adults, user engagement with mental health apps remained minimal. This suggests the need for these apps to work towards improved user engagement and retention.

Evaluating the Implementation of a Mental Health App for Overseas Filipino Workers in Macao China: A Mixed-Methods Study of Stakeholders' Perspectives

Background

Overseas Filipino workers (OFWs) is one of the largest communities of international migrant workers. They face systemic barriers to fulfilling their health needs. The COVID-19 pandemic worsened this condition and provided a context to evaluate the utility of a digital mental health intervention delivered within a stepped-care model to address OFW mental health. Using an implementation science framework, this study aimed to evaluate stakeholders' perspectives on the implementation of Kumusta Kabayan, a mobile phone-based mental health app, for OFWs in Macao.

Methods

A mixed-methods convergent design was used by conducting two parallel steps, including quantitative and qualitative measures. The quantitative data was collected from Filipino team members and local non-governmental organization (NGO) staff members (N = 12). The qualitative data were gathered from interviews with OFWs in Macao who used the app (N = 25; 80% females, 76% domestic workers).

Results

From the online survey, the staff members of the local partner NGO and the Filipino team members strongly perceived that their organization could adapt Kumusta Kabayan to their program and generally evaluated that Kumusta Kabayan achieved its goal and was received well by OFWs. In the interviews, the OFW app users shared their experiences in using Kumusta Kabayan, which was thematically organized into six aspects of the participants' experience: (1) promotional channel and expectation; (2) when to use the app and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions.

Conclusion

Kumusta Kabayan was well accepted and shows potential to be integrated into the existing support services for OFWs in Macao. This app has the promise of being scaled-up for OFWs in other countries by collaborating with local and overseas stakeholders. Lessons learnt from this evaluation could also be implemented in wider digital mental health services in different settings.

The impact of gamification on the patient's engagement in the online health community

Purpose

Gamification has been widely implemented to improve user engagement in the online health community (OHC). While its effect on the physicians' engagement has recently been documented, whether and how gamification influences the patients' engagement in the OHC remains an untapped research area. The purpose of this study is to fill this dearth by encompassing the gamification strategy of Haodf.com, which awards the “Annual Physician” badges to the physicians, to analyze how this gamification approach motivates patients’ engagement in the OHC.

Design/methodology/approach

Real-world data are leveraged from the OHC. The Tobit model is employed for modeling the gamification-patient's engagement nexus in an OHC. Robust findings are obtained by incorporating different measures of a dependent variable, a set of control variables about the physician's characteristics and hospital's features, and alternative estimation techniques.

Findings

The results reveal that a patient's engagement in the OHC in the form of appointments and review-posting behavior is enhanced by the gamification strategy. Besides, the positive influence of gamification on the patient's engagement is further strengthened by the physician's professional capital. It is basically obtained that the gamification is an efficacious tool to accelerate not only the physicians' engagement but also of the patients in the OHC platform.

Originality/value

The study provides both theoretical and empirical discussion to enrich the understanding on how OHCs enhance patients' engagement by developing gamification techniques. The findings guide the practitioners of OHC to better understand the implications of their gamification design to optimize user engagement.

Tailoring mHealth Apps on Users to Support Behavior Change Interventions: Conceptual and Computational Considerations

Personalization is an important factor to increase the user experience (UX) and effectiveness of mHealth solutions. In this paper, we present an innovative approach to the personalization of mHealth apps. A profiling function has been developed based on the physical and psychological characteristics of users, with the final aim to cluster them acting as a guideline to the design and implementation of new functionalities to improve the overall acceptance degree of the app. A preliminary analysis case study has been proposed to evaluate the impact on user experience according to the state of the art to draw useful lessons for future works.

Exploring and Characterizing Patient Multibehavior Engagement Trails and Patient Behavior Preference Patterns in Pathway-Based mHealth Hypertension Self-Management: Analysis of Use Data

Background

Hypertension is a long-term medical condition. Mobile health (mHealth) services can help out-of-hospital patients to self-manage. However, not all management is effective, possibly because the behavior mechanism and behavior preferences of patients with various characteristics in hypertension management were unclear.

Objective

The purpose of this study was to (1) explore patient multibehavior engagement trails in the pathway-based hypertension self-management, (2) discover patient behavior preference patterns, and (3) identify the characteristics of patients with different behavior preferences.

Methods

This study included 863 hypertensive patients who generated 295,855 use records in the mHealth app from December 28, 2016, to July 2, 2020. Markov chain was used to infer the patient multibehavior engagement trails, which contained the type, quantity, time spent, sequence, and transition probability value (TP value) of patient behavior. K-means algorithm was used to group patients by the normalized behavior preference features: the number of behavioral states that a patient performed in each trail. The pages in the app represented the behavior states. Chi-square tests, Z-test, analyses of variance, and Bonferroni multiple comparisons were conducted to characterize the patient behavior preference patterns.

Results

Markov chain analysis revealed 3 types of behavior transition (1-way transition, cycle transition, and self-transition) and 4 trails of patient multibehavior engagement. In perform task trail (PT-T), patients preferred to start self-management from the states of task blood pressure (BP), task drug, and task weight (TP value 0.29, 0.18, and 0.20, respectively), and spent more time on the task food state (35.87 s). Some patients entered the states of task BP and task drug (TP value 0.20, 0.25) from the reminder item state. In the result-oriented trail (RO-T), patients spent more energy on the ranking state (19.66 s) compared to the health report state (13.25 s). In the knowledge learning trail (KL-T), there was a high probability of cycle transition (TP value 0.47, 0.31) between the states of knowledge list and knowledge content. In the support acquisition trail (SA-T), there was a high probability of self-transition in the questionnaire (TP value 0.29) state. Cluster analysis discovered 3 patient behavior preference patterns: PT-T cluster, PT-T and KL-T cluster, and PT-T and SA-T cluster. There were statistically significant associations between the behavior preference pattern and gender, education level, and BP.

Conclusions

This study identified the dynamic, longitudinal, and multidimensional characteristics of patient behavior. Patients preferred to focus on BP, medications, and weight conditions and paid attention to BP and medications using reminders. The diet management and questionnaires were complicated and difficult to implement and record. Competitive methods such as ranking were more likely to attract patients to pay attention to their own self-management states. Female patients with lower education level and poorly controlled BP were more likely to be highly involved in hypertension health education.

Playing alone: can game design elements satisfy user needs in gamified mHealth services?

Chronic health conditions have necessitated the need for behavioral interventions (such as exercise programs) outside of clinical contexts, increasingly managed through technology such as mobile health (mHealth) services. Gamification has emerged as a promising tool to facilitate greater engagement in these services; however, no studies investigate the links between specific game design elements (GDEs) and psychological or behavioral outcomes within a health context. This domain is motivationally complex and has shown resistance to the satisfaction of social (relatedness) needs, presenting a challenge to the design of gamification products for health promotion. Drawing on self-determination theory, this research demonstrates the strengths of a taxonomy based upon structural features of GDEs (such as social, narrative or reward elements) rather than the design intent definitions of these elements used in previous studies. This taxonomy is then used to assess the relationship between GDEs and psychological needs satisfaction in a survey (N = 236) of gamified exercise/fitness application users. Further qualitative interviews (N = 20) were conducted to clarify survey findings. This research demonstrates the positive association between control and presentation elements and autonomy satisfaction, and control and reward elements and competency satisfaction. However, it also suggests that player type and context may limit the ability for GDEs alone to support relatedness satisfaction in mHealth services. Implications for managers and researchers are discussed, particularly the strengths and weaknesses of using structural taxonomies in gamification assessment.

Patterns for Patient Engagement with the Hypertension Management and Effects of Electronic Health Care Provider Follow-up on These Patterns: Cluster Analysis

Background

Hypertension is a long-term medical condition. Electronic and mobile health care services can help patients to self-manage this condition. However, not all management is effective, possibly due to different levels of patient engagement (PE) with health care services. Health care provider follow-up is an intervention to promote PE and blood pressure (BP) control.

Objective

This study aimed to discover and characterize patterns of PE with a hypertension self-management app, investigate the effects of health care provider follow-up on PE, and identify the follow-up effects on BP in each PE pattern.

Methods

PE was represented as the number of days that a patient recorded self-measured BP per week. The study period was the first 4 weeks for a patient to engage in the hypertension management service. K-means algorithm was used to group patients by PE. There was compliance follow-up, regular follow-up, and abnormal follow-up in management. The follow-up effect was calculated by the change in PE (CPE) and the change in systolic blood pressure (CSBP, SBP) before and after each follow-up. Chi-square tests and z scores were used to ascertain the distribution of gender, age, education level, SBP, and the number of follow-ups in each cluster. The follow-up effect was identified by analysis of variances. Once a significant effect was detected, Bonferroni multiple comparisons were further conducted to identify the difference between 2 clusters.

Results

Patients were grouped into 4 clusters according to PE: (1) PE started low and dropped even lower (PELL), (2) PE started high and remained high (PEHH), (3) PE started high and dropped to low (PEHL), and (4) PE started low and rose to high (PELH). Significantly more patients over 60 years old were found in the PEHH cluster (P≤.05). Abnormal follow-up was significantly less frequent (P≤.05) in the PELL cluster. Compliance follow-up and regular follow-up can improve PE. In the clusters of PEHH and PELH, the improvement in PE in the first 3 weeks and the decrease in SBP in all 4 weeks were significant after follow-up. The SBP of the clusters of PELL and PELH decreased more (–6.1 mmHg and –8.4 mmHg) after follow-up in the first week.

Conclusions

Four distinct PE patterns were identified for patients engaging in the hypertension self-management app. Patients aged over 60 years had higher PE in terms of recording self-measured BP using the app. Once SBP reduced, patients with low PE tended to stop using the app, and a continued decline in PE occurred simultaneously with the increase in SBP. The duration and depth of the effect of health care provider follow-up were more significant in patients with high or increased engagement after follow-up.

Dietary Intake and Health Status of Elderly Patients With Type 2 Diabetes Mellitus: Cross-sectional Study Using a Mobile App in Primary Care

Background

Healthy dietary intake reduces the risk of complications of diabetes mellitus. Using assessment methods helps to understand these circumstances, and an electronic application may optimize this practice.

Objective

In this study, we aimed to (1) assess the dietary intake and health status of elderly patients with type 2 diabetes mellitus (T2DM) in primary care, (2) use a mobile app as a tool for data collection and analysis in the context of primary care, and (3) verify the perceptions of multidisciplinary health professionals regarding app use.

Methods

First, we developed a mobile app comprised of the questions of the Food and Nutrition Surveillance System (SISVAN) of Brazil, which includes a food frequency questionnaire of food categories with a recall of the previous 7 days. Thereafter, we used the app to collect data on the health status and dietary intake of 154 participants, aged 60-96 years, diagnosed with T2DM, and under treatment in primary care centers in the northern region of Rio Grande do Sul, Brazil. We also collected participants’ demographic, anthropometric, biochemical, and lifestyle variables. The associations between dietary intake and other variables were tested using chi-square tests with a 5% significance level. Regarding the app, we assessed usability and acceptance with 20 health professionals.

Results

Between August 2018 and December 2018, participants had an intake in line with recommended guidelines for raw salads (57.1%), fruits (76.6%), milk products (68.2%), fried foods (72.7%), savory biscuits (60.4%), cookies or sweets (72.1%), and sugary drinks (92.9%) Meanwhile, the consumption of beans (59.7%), pulses and cooked vegetables (73.4%), and processed meat products (59.7%) was not in line with the guidelines. There were statistically significant differences in meeting the recommended guidelines among participants of different genders (P=.006 and P=.035 for the intake of fried foods and sugary drinks, respectively), place of residence (P=.034 for the intake of cookies and sweets), family history of diabetes (P<.001 for the intake of beans), physical activity engagement (P=.003 for the intake fresh fruits), history of smoking (P=.001 for the intake of raw salads), and presence of coronary disease (P=.050 for the intake of pulses and cooked vegetables). The assessment of usability resulted in a mean score of 71.75 points. Similarly, the assessment of the 15 acceptance questions revealed high scores, and the qualitative questions revealed positive perceptions.

Conclusions

We identified that most participants complied with recommended intake guidelines for 7 of 10 categories in the SISVAN guidelines. However, most participants were overweight and had nutritional and clinical disorders, which justifies further investigations in this population. The app was well-rated by health professionals and considered a useful and promising tool for collecting and analyzing data in primary care settings.

Smart Health-Enhanced Early Mobilisation in Intensive Care Units

Critically ill patients that stay in Intensive Care Units (ICU) for long periods suffer from Post-Intensive Care Syndrome or ICU Acquired Weakness, whose effects can decrease patients' quality of life for years. To prevent such issues and aiming at shortening intensive care treatments, Early Mobilisation (EM) has been proposed as an encouraging technique: the literature includes numerous examples of the benefits of EM on the prevention of post-operative complications and adverse events. However, the appropriate application of EM programmes entails the use of scarce resources, both human and technical. Information and Communication Technologies can play a key role in reducing cost and improving the practice of EM. Although there is rich literature on EM practice and its potential benefits, there are some barriers that must be overcome, and technology, i.e., the use of sensors, robotics or information systems, can contribute to that end. This article reviews the literature and analyses on the use of technology in the area of EM, and moreover, it proposes a smart health-enhanced scenario.

Who is more likely to adopt and comply with the electronic patient-reported outcome measure (ePROM) mobile application? A real-world study with cancer patients undergoing active treatment

PURPOSE

This study aims to identify factors associated with the adoption and compliance of electronic patient-reported outcome measure (ePROM) use among cancer patients in a real-world setting.

METHODS

This prospective cohort study was conducted at the Samsung Medical Center in Seoul, Korea, from September 2018 to January 2019. Cancer patients aged 18 years or older who owned smartphones and who were receiving chemotherapy or radiation therapy were eligible for this study. Patients were asked to use the app to report their symptoms every 7 days for a total of 21 days (3 weeks). Logistic regression was performed to identify the factors associated with the adoption and compliance.

RESULTS

Among 580 patients, 417 (71.9%) adopted the ePROM app and 159 (27.4%) out of 417 had good compliance. Patients who had greater expectations regarding the ease of use (adjusted odds ratio [aOR] 2.67, 95% CI: 1.28-5.57) and usefulness (aOR 1.69, 95% CI: 1.05-2.72) of the ePROM app were more likely to adopt the app than those who did not. Patients who had greater satisfaction with usefulness (aOR 1.89, 95% CI 1.10-3.25) were more likely to comply with using the app, but satisfaction with ease of use was not related to the compliance.

CONCLUSION

While expectation regarding the ease of use and usefulness of the ePROM app was associated with the adoption of the app, satisfaction with ease of use was not related to compliance with the ePROM app. Satisfaction with usefulness was associated with the compliance of ePROM app use.

Using a mobile health app to improve patients' adherence to hypertension treatment: a non-randomized clinical trial

Poor adherence to hypertension treatment increases complications of the disease and is characterized by a lack of awareness and acceptance of ongoing treatment. Mobile health (mHealth) apps can optimize processes and facilitate access to health information by combining treatment methods with attractive solutions. In this study, we aimed at verifying the influence of using an mHealth app on patients' adherence to hypertension treatment, also examining how user experience toward the app influenced the outcomes. A total of 49 participants completed the study, men and women, diagnosed with hypertension and ongoing medical treatment. For 12 weeks, the control group continued with conventional monitoring, while the experimental group used an mHealth app. From the experimental group, at baseline, 8% were non-adherent, 64% were partial adherents and 28% were adherent to the treatment. Baseline in the control group indicated 4.2% non-adherents, 58.3% partial adherents, and 37.5% adherents. After follow-up, the experimental group had an increase to 92% adherent, 8% partially adherent, and 0% non-adherent (P < 0.001). In the control group, adherence after follow-up remained virtually the same (P ≥ 0.999). Results of user experience were substantially positive and indicate that the participants in the experimental group had a satisfactory perception of the app. In conclusion, this study suggests that using an mHealth app can empower patients to manage their own health and increase adherence to hypertension treatment, especially when the app provides a positive user experience.

A User-Centered Chatbot (Wakamola) to Collect Linked Data in Population Networks to Support Studies of Overweight and Obesity Causes: Design and Pilot Study

BACKGROUND

Obesity and overweight are a serious health problem worldwide with multiple and connected causes. Simultaneously, chatbots are becoming increasingly popular as a way to interact with users in mobile health apps.

OBJECTIVE

This study reports the user-centered design and feasibility study of a chatbot to collect linked data to support the study of individual and social overweight and obesity causes in populations.

METHODS

We first studied the users' needs and gathered users' graphical preferences through an open survey on 52 wireframes designed by 150 design students; it also included questions about sociodemographics, diet and activity habits, the need for overweight and obesity apps, and desired functionality. We also interviewed an expert panel. We then designed and developed a chatbot. Finally, we conducted a pilot study to test feasibility.

RESULTS

We collected 452 answers to the survey and interviewed 4 specialists. Based on this research, we developed a Telegram chatbot named Wakamola structured in six sections: personal, diet, physical activity, social network, user's status score, and project information. We defined a user's status score as a normalized sum (0-100) of scores about diet (frequency of eating 50 foods), physical activity, BMI, and social network. We performed a pilot to evaluate the chatbot implementation among 85 healthy volunteers. Of 74 participants who completed all sections, we found 8 underweight people (11%), 5 overweight people (7%), and no obesity cases. The mean BMI was 21.4 kg/m2 (normal weight). The most consumed foods were olive oil, milk and derivatives, cereals, vegetables, and fruits. People walked 10 minutes on 5.8 days per week, slept 7.02 hours per day, and were sitting 30.57 hours per week. Moreover, we were able to create a social network with 74 users, 178 relations, and 12 communities.

CONCLUSIONS

The Telegram chatbot Wakamola is a feasible tool to collect data from a population about sociodemographics, diet patterns, physical activity, BMI, and specific diseases. Besides, the chatbot allows the connection of users in a social network to study overweight and obesity causes from both individual and social perspectives.

Designing a gamified e-learning environment for teaching undergraduate ERP course based on big five personality traits

The COVID-19 pandemic forced universities to push the use of distance learning, impacting an unprecedented number of students. New norms of social distancing and lockdown had been brought in as university measures, immediately modifying student and lecturer habits, changing from the traditional classroom to e-learning platforms. However, the lack of engagement of students throughout an e-learning system is a regular concern among lecturers when creating content on a system. This study presents an applied gamification concept to e-learning focusing on improving engagement of the various types of personalities of undergraduate students in ERP courses. The gamification design was developed by implementing the pros and cons of each game element to compromise the overall performance of students. Three evaluations were conducted:1) to test whether the student has competently gained ERP knowledge; 2) web monitor to record the activity of students; 3) to evaluate the qualitative information of the game experience by interviews. According to the study, the selection of a game element based on personality traits does not necessarily improve knowledge but proves to allow better engagement in the course. In addition, our finding also provides the suggestions for designing game elements based on personality traits.

A Bowling Exergame to Improve Functional Capacity in Older Adults: Co-Design, Development, and Testing to Compare the Progress of Playing Alone Versus Playing With Peers

Background

Older people often do not meet the recommended levels of exercise required to reduce functional decline. Social interaction is mentioned by this cohort as a reason for joining group-based exercises, which does not occur when exercising alone. This perspective shows that exergames can be used as motivational resources. However, most available exergames are generic, obtained from commercial sources, and usually not specifically designed or adapted for older people.

Objective

In this study, we aim to co-design and develop a new exergame alongside older participants to (1) tailor the game mechanics and optimize participants’ adherence to and enjoyment of exercise; (2) test the participants’ functional capacity, motivation, and adherence to the exergaming program; and (3) compare these scores between those who played alone and those who played with peers.

Methods

We conducted a co-design process to develop a new exergame adapted to older people. For user testing, 23 participants were divided into 2 groups to play individually (alone group) or to compete in pairs (with peers group). They played the game twice a week, resulting in 21 exergaming sessions. We assessed the participants’ General Physical Fitness Index (GPFI) before and after the user testing. We also administered questionnaires about the gaming experience and exercise adherence with its motivators and barriers.

Results

We introduced a new bowling exergame for Xbox with a Kinect motion sensor that can be played in single or multiplayer mode. For the GPFI measurements, the sample was homogeneous in the pretest (with peers group: mean 40.5 [SD 9.6], alone group: mean 33.9 [SD 7.8]; P=.11). After the exergame testing sessions, both groups had significant gains (with peers group: mean 57.5 [SD 8.7], P=.005; alone group: mean 44.7 [SD 10.6]; P=.02). Comparing the posttest between groups, it was found that the group in which participants played with peers had better outcomes than the group in which participants played alone (P=.02). Regarding the gaming experience and exercise adherence, both groups recognized the benefits and expressed enthusiasm toward the exergame.

Conclusions

The findings suggest that the developed exergame helps in improving the functional capacity and adherence to physical exercise among older people, with even better results for those who played with peers. In addition to leading to more appropriate products, a co-design approach may positively influence the motivation and adherence of participants.

An IoT-Based Healthcare Platform for Patients in ICU Beds During the COVID-19 Outbreak

There is a global concern with the escalating number of patients at hospitals caused mainly by population aging, chronic diseases, and recently by the COVID-19 outbreak. To smooth this challenge, IoT emerges as an encouraging paradigm because it provides the scalability required for this purpose, supporting continuous and reliable health monitoring on a global scale. Based on this context, an IoT-based healthcare platform to provide remote monitoring for patients in a critical situation was proposed in the authors' previous works. Therefore, this paper aims to extend the platform by integrating wearable and unobtrusive sensors to monitor patients with coronavirus disease. Furthermore, we report a real deployment of our approach in an intensive care unit for COVID-19 patients in Brazil.

Novel Digital Technologies for Blood Pressure Monitoring and Hypertension Management

PURPOSE OF REVIEW

Hypertension is common, impacting an estimated 108 million US adults, and deadly, responsible for the deaths of one in six adults annually. Optimal management includes frequent blood pressure monitoring and antihypertensive medication titration, but in the traditional office-based care delivery model, patients have their blood pressure measured only intermittently and in a way that is subject to misdiagnosis with white coat or masked hypertension. There is a growing opportunity to leverage our expanding repository of digital technology to reimagine hypertension care delivery. This paper reviews existing and emerging digital tools available for hypertension management, as well as behavioral economic insights that could supercharge their impact.

RECENT FINDINGS

Digitally connected blood pressure monitors offer an alternative to office-based blood pressure monitoring. A number of cuffless blood pressure monitors are in development but require further validation before they can be deployed for widespread clinical use. Patient-facing hubs and applications offer a means to transmit blood pressure data to clinicians. Though artificial intelligence could allow for curation of this data, its clinical use for hypertension remains limited to assessing risk factors at this time. Finally, text-based and telemedicine platforms are increasingly being employed to translate hypertension data into clinical outcomes with promising results.

SUMMARY

The digital management of hypertension shows potential as an avenue for increasing patient engagement and improving clinical efficiency and outcomes. It is important for clinicians to understand the benefits, limitations, and future directions of digital health to optimize management of hypertension.

A methodology for the design and development of gamified mobile apps for monitoring cancer survivors

An increasing number of cancer patients is treated and recover each year, and consequently there are survivors that require specialized and coordinated follow-up. The physical, social, working, psychological and emotional aspects of these survivors have to be characterized, investigated and treated by multidisciplinary and interdisciplinary teams. Nowadays, oncology community is focused on tracking records of interest in Patient-Reported Outcome (PROs) for patients of different cancer types. In the last years, several articles have proven that PROs are an effective method to improve the management of patient symptoms and, subsequently, clinical care. In this scenario, patient engagement is one of the most relevant aspects for PROs success. In this sense, one of the most promising strategies for increasing engagement is gamification, that is, the introduction of game elements in systems that are not games. Therefore, in this work we introduce a methodology for developing gamification apps for cancer survivors that aims at increasing engagement when collecting PROs data.

Modeling Impact of Word of Mouth and E-Government on Online Social Presence during COVID-19 Outbreak: A Multi-Mediation Approach

Although social presence plays an essential role under general conditions, its role becomes significant for societal protection during the quarantine period in epidemic outbreak. In this study, we attempted to identify the role of E-government and COVID-19 word of mouth in terms of their direct impact on online social presence during the outbreak as well as their impacts mediated by epidemic protection and attitudes toward epidemic outbreaks. For this purpose, a unique multi-mediation model is proposed to provide a new direction for research in the field of epidemic outbreaks and their control. Through random sampling, an online survey was conducted and data from 683participants were analyzed. Partial least squares structural equation modeling was used to test the relationships between the variables of interest. The study results revealed that the roles of E-government and COVID-19 word of mouth are positively related to online social presence during the outbreak. Epidemic protection and attitude toward epidemic outbreak were found to positively moderate the impact of the role of E-government and COVID-19 word of mouth on online social presence during the outbreak. The key findings of this study have both practical and academic implications.

Effects of using a mobile health application on the health conditions of patients with arterial hypertension: A pilot trial in the context of Brazil's Family Health Strategy

Brazil’s Family Health Strategy (FHS) leads public health policies and actions regarding community health, addressing arterial hypertension (AH) in primary care settings. In this scenario, the use of communication technologies becomes appropriate for the monitoring of patients with AH. To preliminary verify the intervention approach and the effects of using an m-Health application on the health conditions of patients with AH for a future study, we conducted a non-randomized, controlled, non-blind trial (N = 39), comparing the use of a mobile health app (m-Health) with conventional AH monitoring over 3 months. During the study, we promoted health information workshops to engage patients from both intervention and control groups. Pre and post-intervention, we compared measurements of systolic and diastolic blood pressure; food frequency questionnaire; Appraisal of Self-Care Agency Scale; blood tests of hemogram, creatinine, uric acid, sodium, potassium, lipid profile, and glycemia. Improvements were identified in both groups due to the workshops, including the reduction in total and non-HDL cholesterol, healthier consumption of salads and sugary drinks, and increased self-care scores. Exclusively in the intervention group, which used the m-Health app, there was a change in systolic and diastolic pressure towards more adequate levels. In addition, the intervention group had improved levels of glucose and HDL cholesterol and reduced consumption of ultra-processed foods. In conclusion, the use of an m-Health app had positive effects on the health conditions of patients with AH under treatment within FHS, especially when combined with health information. On the context of FHS, the use of technology is encouraging supporting better health conditions.

An Electronic Health Platform for Monitoring Health Conditions of Patients With Hypertension in the Brazilian Public Health System: Protocol for a Nonrandomized Controlled Trial

Background

Chronic noncommunicable diseases such as arterial hypertension have a high impact in the context of public health. Previous studies have shown improvements in blood pressure due to simple lifestyle changes, which were supported by electronic health (eHealth) solutions.

Objective

The aim of this study is to develop an eHealth platform and assess the effects of its use on the health conditions of patients with hypertension, with assistance from health professionals in the public health system of a Brazilian city.

Methods

The platform will include a server that centralizes all the data and business rules, a website dashboard for health professionals, and a mobile app for patients. We will analyze the effects of its use through a controlled, nonrandomized, nonblind, prospective, monocentric clinical trial. We will enroll 68 participants diagnosed with arterial hypertension and under medical follow-up and categorize them into two groups. The participants of the intervention group will use the platform as a monitoring method, whereas the participants of the control group will use conventional methods. In both groups, we will assess and compare the evolution of blood pressure and treatment adherence before, during, and after the intervention.

Results

The project was funded at the end of 2018. We have been developing the software since 2019 with plans to complete it in 2020, and we will enroll patients between 2020 and 2021. We expect to submit the first results for publication in 2020.

Conclusions

For the primary outcome, we expect a reduction and stabilization of blood pressure. For the secondary outcomes, we hope to see improvements in treatment adherence, physical activities and dietary practices, and acceptance of the eHealth platform. In public health, the technology that favors disease control also helps reduce complications and, consequently, treatment costs. The platform might encourage the adaptation of medical assistance to incorporate this technology into patient monitoring.

International Registered Report Identifier (IRRID)

PRR1-10.2196/15299

Mobile health applications for chronic diseases: A systematic review of features for lifestyle improvement

AIMS

To identify mobile health applications with features for improving the lifestyle of patients with chronic diseases.

METHODS

We performed a systematic literature review between November 2017 and May 2018 on the Virtual Health Library's interface. A total of 816 records were identified. In the selection process, 24 studies met inclusion criteria for analysis. Study characteristics were extracted and synthesized.

RESULTS

We identified applications with similar functionalities, such as the use of reminders and medical monitoring. Most of them addressed the treatment of conditions related to an already diagnosed chronic disease, including Diabetes Mellitus, Hypertension, Cardiovascular Diseases, Asthma, Neoplasms, and chronic conditions in general. The main lifestyle changes were the reduction of body weight, promotion of healthy eating, and adherence to the regular practice of physical exercises.

CONCLUSIONS

Technology can facilitate health care with simple messages and alerts that aid in adherence to treatment. Changes in lifestyle with the use of applications are remarkable. Benefits may be even greater if more applications address the importance of prevention and not just treatment.