Theoretical Advancements in mHealth: A Systematic Review of Mobile Apps

Increasing access to mental health supports for 12-17-year-old Indigenous youth with the JoyPop mobile mental health app: study protocol for a randomized controlled trial

BACKGROUND

Indigenous youth in Northwestern Ontario who need mental health supports experience longer waits than non-Indigenous youth within the region and when compared to youth in urban areas. Limited access and extended waits can exacerbate symptoms, prolong distress, and increase risk for adverse outcomes. Innovative approaches are urgently needed to provide support for Indigenous youth in Northwestern Ontario. Using a randomized controlled trial design, the primary objective of this study is to determine the effectiveness of the JoyPop app compared to usual practice (UP; monitoring) in improving emotion regulation among Indigenous youth (12-17 years) who are awaiting mental health services. The secondary objectives are to (1) assess change in mental health difficulties and treatment readiness between youth in each condition to better understand the app's broader impact as a waitlist tool and (2) conduct an economic analysis to determine whether receiving the app while waiting for mental health services reduces other health service use and associated costs.

METHODS

A pragmatic, parallel arm randomized controlled superiority trial will be used. Participants will be randomly allocated in a 1:1 ratio to the control (UP) or intervention (UP + JoyPop) condition. Stratified block randomization will be used to randomly assign participants to each condition. All participants will be monitored through existing waitlist practices, which involve regular phone calls to check in and assess functioning. Participants in the intervention condition will receive access to the JoyPop app for 4 weeks and will be asked to use it at least twice daily. All participants will be asked to complete outcome measures at baseline, after 2 weeks, and after 4 weeks.

DISCUSSION

This trial will evaluate the effectiveness of the JoyPop app as a tool to support Indigenous youth waiting for mental health services. Should findings show that using the JoyPop app is beneficial, there may be support from partners and other organizations to integrate it into usual care pathways.

TRIAL REGISTRATION

https://clinicaltrials.gov/study/NCT05898516 [registered on June 1, 2023].

The role of mHealth intervention to improve maternal and child health: A provider-based qualitative study in Southern Ethiopia

INTRODUCTION

Maternal and child mortality remained higher in developing regions such as Southern Ethiopia due to poor maternal and child health. Technologies such as mobile applications in health may be an opportunity to reduce maternal and child mortality because they can improve access to information. Therefore, the main aim of this study was to explore the role of mHealth in improving maternal and child health in Southern Ethiopia.

METHODS

This study employed a qualitative study design to explore the role of mHealth in improving maternal and child health among health professionals in Southern Ethiopia from December 2022 to March 2023. We conducted nine in-depth interviews, six key informants' in-depth interviews, and four focused group discussions among health professionals. This is followed by thematic analyses to synthesize the collected evidence.

RESULTS

The results are based on 226 quotations, 5 major themes, and 24 subthemes. The study participants discussed the possible acceptance of mHealth in terms of its fitness in the existing health system, its support to health professionals, and its importance in improving maternal and child health. The participants ascertained the importance of awareness creation before the implementation of mHealth among women, families, communities, and providers. They reported the importance of mHealth for mothers and health professionals and the effectiveness of mHealth services. The participants stated that the main challenges related to acceptance, awareness, negligence, readiness, and workload. However, they also suggested strategic solutions such as using family support, provider support, mothers' forums, and community forums.

CONCLUSION

The evidence generated during this analysis is important information for program implementations and can inform policy-making. The planned intervention needs to introduce mHealth in Southern Ethiopia. Planners, decision-makers, and researchers can use it in mobile technology-related interventions. For challenges identified, we recommend solution-identified-based interventions and quality studies.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

The Effect of Mobile eHealth Education to Improve Knowledge, Skills, Self-Care, and Mobile eHealth Literacies Among Patients With Diabetes: Development and Evaluation Study

BACKGROUND

The promotion of mobile health (mHealth) and eHealth technologies as tools for managing chronic diseases, particularly diabetes mellitus, is on the rise. Nevertheless, individuals with diabetes frequently face a literacy gap that hinders their ability to fully leverage the benefits offered by these resources. Enhancing technology literacy to facilitate the adoption of mobile eHealth services poses a significant challenge in numerous countries.

OBJECTIVE

This study aims to develop an educational mobile eHealth literacy (eHL) program for patients with diabetes and to evaluate its effect on patients' outcomes.

METHODS

This study designed a mobile eHL education program comprising 2 modules specifically tailored for individuals with type 2 diabetes (T2D). These modules focused on guiding participants through the process of effectively navigating reliable health websites and utilizing diabetes-related apps. Using a pre- and posttest experimental design, the study featured an intervention group and a control group. Participants were recruited from 3 outpatient departments in hospitals, and assessments were conducted both before and after the intervention, along with a follow-up measure at the 3-month mark. The evaluation encompassed sociodemographic characteristics, computer and internet proficiency, mobile app usage, mobile eHL, and patient outcomes such as self-care behaviors and glycated hemoglobin (HbA1c) levels.

RESULTS

The analysis included a total of 132 eligible participants. Significant differences were observed in the mean scores of knowledge (P<.001) and skills (P<.001) related to computers, the web, and mobile devices at the initiation of the study and after the intervention. During the 3-month follow-up, the findings indicated a significant improvement in mobile eHL (t114=3.391, P=.001) and mHealth literacy (mHL, a subconcept of mobile eHL; t114=3.801, P<.001) within the intervention group, whereas no such improvement was observed in the control group. The chi-square values from the McNemar test underscored that individuals with uncontrolled diabetes (HbA1c≥7%) in the intervention group exhibited more improvement compared with the control group. The generalized estimating equations model unveiled a significant difference in the change of general mHL in the intervention group (β=1.91, P=.047) and self-care behavior in the control group from T0 to T2 (β=-8.21, P=.015). Despite being small, the effect sizes for mobile eHL (d=0.49) and HbA1c (d=0.33) in the intervention group were greater than those in the control group (d=0.14 and d=0.16, respectively).

CONCLUSIONS

The implementation of a mobile eHL education intervention demonstrates a positive influence on the familiarity of patients with T2D regarding health technology, leading to favorable glycemic outcomes. While additional studies are warranted for a more comprehensive understanding, this program emerges as a promising solution for enhancing patients' uptake of digital health technology.

Co-Designing a Mobile-Based Game to Improve Misinformation Resistance and Vaccine Knowledge in Uganda, Kenya, and Rwanda

Misinformation can decrease public confidence in vaccines, and reduce vaccination intent and uptake. One strategy for countering these negative impacts comes from inoculation theory. Similar to biological vaccination, inoculation theory posits that exposure to a weakened form of misinformation can develop cognitive immunity, reducing the likelihood of being misled. Online games offer an interactive, technology-driven, and scalable solution using an active form of inoculation that engages and incentivizes players to build resilience against misinformation. We document the development of the critical thinking game Cranky Uncle Vaccine. The game applies research findings from inoculation theory, critical thinking, humor in science communication, and serious games. The game content was iterated through a series of co-design workshops in Kampala (Uganda), Kitale (Kenya), and Kigali (Rwanda). Workshop participants offered feedback on cartoon character design, gameplay experience, and the game's content, helping to make the game more culturally relevant and avoid unintended consequences in East African countries. Our co-design methodology offers an approach for further adaptation of the Cranky Uncle Vaccine game to other regions, as well as a template for developing locally relevant interventions to counter future infodemics.

Unpacking the Drivers of Dissatisfaction and Satisfaction in a Fitness Mobile Application

This research investigates the factors influencing user satisfaction and dissatisfaction in fitness mobile applications. It employs Herzberg's two-factor model through text mining to classify Fitbit mobile app attributes into satisfiers and dissatisfiers. The Fitbit app was chosen due to its prevalence in the United States. The study analyzes 100,000 English reviews from the Fitbit app on the Google Play Store, categorizing attributes. It identifies three dissatisfying categories (functional, compatibility, paid services) and three satisfying categories (gratification, self-monitoring, self-regulation), comprising 25 sub-attributes. This classification offers in-depth insights into what drives user contentment or discontent with fitness apps. The findings contribute to the fitness app domain by applying text-mining and Herzberg's model. Researchers can build upon this foundation, and practitioners can use it to enhance app experiences. However, this research relies on user reviews, often lacking comprehensive explanations. This limitation may hinder a profound understanding of the underlying psychological aspects in user sentiments. Nonetheless, this study takes strides toward optimizing fitness apps for users and developers.

Mobile Apps Aimed at Preventing and Handling Unintentional Injuries in Children Aged <7 Years: Systematic Review

BACKGROUND

Despite various global health crises, the prevention and handling of unintentional childhood injuries remains an important public health objective. Although several systematic reviews have examined the effectiveness of different child injury prevention measures, these reviews did not address the evaluation of mobile communication intervention tools. Whether and how mobile apps were evaluated provides information on the extent to which communication theories, models, and evidence-based knowledge were considered. Previous studies have shown that the effectiveness of mobile apps increases when theories and evidence are considered during their development.

OBJECTIVE

This systematic review aimed to identify research on mobile apps dealing with the prevention and handling of unintentional injuries in children and examine the theoretical and methodological approaches thereof. In addition, this review analyzed the different needs of various target groups of the mobile apps described in the articles.

METHODS

In total, 8 electronic databases, ranging from interdisciplinary to medical and technical as well as social sciences databases, were searched for original research articles or brief reports in peer-reviewed journals or conference proceedings. Moreover, this review encompassed a systematic scan of articles published in the BMJ journal Injury Prevention. These steps were followed by a snowball search based on the literature references in the articles identified through the initial screening. The articles had to be written in English or German, published between 2008 and 2021, and evaluate mobile apps dealing with the prevention and handling of unintentional child injuries. The identified 5 studies were analyzed by 5 independent researchers using an inductive approach. Furthermore, the quality of the studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 5 articles were included and assessed with regard to overall quality of theoretical and methodological foundations, assessed variables, the focal app's architecture, and the needs of the study participants. The overall study quality was moderate, although part of this classification was due to a lack of details reported in the studies. Each study examined 1 mobile app aimed at parents and other caregivers. Each study assessed at least 1 usability- or user experience-related variable, whereas the needs of the included study participants were detailed in only 20% (1/5) of the cases. However, none of the studies referred to theories such as the Technology Acceptance Model during the development of the apps.

CONCLUSIONS

The future development and evaluation of apps dealing with the prevention and handling of child injuries should combine insights into existing models on user experience and usability with established theories on mobile information behavior. This theory-based approach will increase the validity of such evaluation studies.

Perspective of Artificial Intelligence in Disease Diagnosis: A Review of Current and Future Endeavours in the Medical Field

Artificial intelligence (AI) has demonstrated significant promise for the present and future diagnosis of diseases. At the moment, AI-powered diagnostic technologies can help physicians decipher medical pictures like X-rays, magnetic resonance imaging, and computed tomography scans, resulting in quicker and more precise diagnoses. In order to make a prospective diagnosis, AI algorithms may also examine patient information, symptoms, and medical background. The application of AI in disease diagnosis is anticipated to grow as the field develops. In the future, AI may be used to find patterns in enormous volumes of medical data, aiding in disease prediction and prevention before symptoms appear. Additionally, by combining genetic data, lifestyle data, and environmental variables, AI may help in the diagnosis of complicated diseases. It is crucial to remember that while AI can be a powerful tool, it cannot take the place of qualified medical personnel. Instead, AI ought to support and improve diagnostic procedures, enhancing patient care and healthcare results. Future research and the use of AI for disease diagnosis must take ethical issues, data protection, and ongoing model validation into account.

A tale of two applications: lessons learned from national LMIC COVID applications

Mobile health (mHealth) technologies in low- and middle-income countries (LMICs) have received increased attention for the significant potential benefits they can bring to underserved populations. As smartphones are becoming increasingly accessible, many stakeholders in the mHealth space have begun exploring smartphone applications as a means to impact individuals living within LMICs. With the COVID-19 pandemic straining healthcare systems around the world, many governments in LMICs turned to use smartphone applications to help support and manage their pandemic responses. By analyzing national COVID-19 applications created and launched by the Indian and Vietnamese governments, we highlight effective application functions and strategies, summarizing best practices for future LMIC application development.

Fact or Fiction? The Development and Evaluation of a Tobacco Virtual Health Tool

The virtual setting is an important setting for health promotion as individuals increasingly go online for health information and support. Yet, users can have difficulty finding valid, trustworthy, and user-friendly health information online. In 2022, we launched an interactive Fact or Fiction Tobacco virtual health tool. The virtual health tool uses evidence-informed tailored content to engage users and refer them to local tobacco cessation resources. The present paper describes the development, user testing, and evaluation of this tool. The Fact or Fiction virtual health tool was designed by tobacco cessation and health marketing experts and informed by health behaviour theories of change. The tool captures data on who is seeking health information, the user's stage of readiness to quit tobacco products, and whether they act by accessing referred resources. In 2021, we conducted two phases of user testing prior to marketing the tool publicly. After 7 weeks of marketing, we collected data on user interactions with the tool and evaluated the reach of the tool. Results from user testing found the tool to be engaging, easy to use, and quick to complete. Adaptations were made to simplify and condense text and include additional animations. During the first seven weeks of the tool being live, it reached 2306 users, and 38.7% of those users were current or occasional tobacco users. Users were classified based on their intention to quit. Bivariate analysis found that the tool was successful in driving tobacco users towards action as 21.2% tobacco users who were looking to quit and 8.8% of tobacco users who were not looking to quit clicked on local tobacco cessation resources. This virtual health tool is reaching the targeted population and providing tailored information needed at each stage of the continuum of health behaviour change. Among tobacco users looking to quit, this virtual health tool acts as a quick referral to local tobacco cessation resources.

Enjoyment or Indulgence? Social Media Service Usage, Social Gratification, Self-Control Failure and Emotional Health

Social networking site smartphone applications have been widely used among Chinese young adults. However, less is known about their effects on emotional health and the mechanisms through which they function. This study analyzes the relationship between college students' smartphone social networking service use patterns, social gratification, social media self-control failure, and emotional health. Data was collected from 360 college students in China via application log tracking and a self-administered questionnaire. Structural equation modeling results showed that, after controlling for demographic variables, the use of video social networking site smartphone applications was associated with decreased social gratification, and ultimately, adverse emotional health. Using social networking site smartphone applications late at night exhibited worse emotional health via more social media self-control failure. The implications for designing and using social media applications are discussed.

A framework for design and usability testing of telerehabilitation system for adults with chronic diseases: A panoramic scoping review

Objective

This scoping review aimed to identify the design and usability testing of a telerehabilitation (TR) system, and its characteristics and functionalities that are best-suited for rehabilitating adults with chronic diseases.

Methods

Searches were conducted in PubMed, EBSCO, Web of Science, and Cochrane library for studies published between January 2017 and December 2022. We followed the Joanna Briggs Institute guidelines and the framework by Arksey and O'Malley. Screening was undertaken by two reviewers, and data extraction was undertaken by the first author. Then, the data were further reviewed and discussed thoroughly with the team members.

Results

A total of 31 results were identified, with the core criteria of developing and testing a telerehabilitation system, including a mobile app for cardiovascular diseases, cancer, diabetes, and chronic respiratory disorders. All developed systems resulted from multidisciplinary teams and employed mixed-methods research. We proposed the "input-process-output" framework that identified phases of both system design and usability testing. Through system design, we reported the use of user-centered design, iterative design, users' needs and characteristics, theory underpinning development, and the expert panel in 64%, 75%, 86%, 82%, and 71% of the studies, respectively. We recorded the application of moderated usability testing, unmoderated testing (1), and unmoderated testing (2) in 74%, 63%, and 15% of the studies, respectively. The identified design and testing activities produced a matured system, a high-fidelity prototype, and a released system in 81.5%, 15%, and 3.5%, respectively.

Conclusion

This review provides a framework for TR system design and testing for a wide range of chronic diseases that require prolonged management through remote monitoring using a mobile app. The identified "input-process-output" framework highlights the inputs, design, development, and improvement as components of the system design. It also identifies the "moderated-unmoderated" model for conducting usability testing. This review illustrates characteristics and functionalities of the TR systems and healthcare professional roles.

Appsolutely secure? Psychometric properties of the German version of an app information privacy concerns measure during COVID-19

Introduction

Privacy concerns are an important barrier to adoption and continued use of digital technologies, particularly in the health sector. With the introduction of mobile health applications (mHealth apps), the construct of app information privacy concerns has received increased attention. However, few validated measures exist to capture said concerns in population samples, although they can help to improve public health efforts.

Methods

Using a cross-sectional survey of German adults (mean age = 35.62; 63.5% female), this study examined psychometric properties of the app information privacy concerns scale (AIPC). Analyses comprised confirmatory factor analysis, factorial validity (exploratory factor analysis), internal consistency, convergent validity (i.e., correlations with privacy victimhood, and app privacy concerns), and discriminant validity (i.e., daily app use, adoption intentions, and attitudes toward COVID-19 contact tracing app use).

Results

The analysis did not support the proposed three-factor structure of the AIPC (i.e., anxiety, personal attitude, and requirements). Instead, a four-factor model was preferable that differentiated requirements regarding disclosure policies, and personal control. In addition, factors mirroring anxiety and personal attitude were extracted, but shared a significant overlap. However, these factors showed good reliability, convergent and discriminant validity.

Discussion

The findings underline the role of app information privacy concerns as a significant barrier to mHealth app use. In this context, anxiety and personal attitudes seemed particularly relevant, which has implications for health communication. Moreover, the observed differentiation of external (disclosure) and internal (control) requirements aligns with health behavior change models and thus is a promising area for future research.

Emerging Artificial Intelligence–Empowered mHealth: Scoping Review

Background

Artificial intelligence (AI) has revolutionized health care delivery in recent years. There is an increase in research for advanced AI techniques, such as deep learning, to build predictive models for the early detection of diseases. Such predictive models leverage mobile health (mHealth) data from wearable sensors and smartphones to discover novel ways for detecting and managing chronic diseases and mental health conditions.

Objective

Currently, little is known about the use of AI-powered mHealth (AIM) settings. Therefore, this scoping review aims to map current research on the emerging use of AIM for managing diseases and promoting health. Our objective is to synthesize research in AIM models that have increasingly been used for health care delivery in the last 2 years.

Methods

Using Arksey and O’Malley’s 5-point framework for conducting scoping reviews, we reviewed AIM literature from the past 2 years in the fields of biomedical technology, AI, and information systems. We searched 3 databases, PubsOnline at INFORMS, e-journal archive at MIS Quarterly, and Association for Computing Machinery (ACM) Digital Library using keywords such as “mobile healthcare,” “wearable medical sensors,” “smartphones”, and “AI.” We included AIM articles and excluded technical articles focused only on AI models. We also used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) technique for identifying articles that represent a comprehensive view of current research in the AIM domain.

Results

We screened 108 articles focusing on developing AIM models for ensuring better health care delivery, detecting diseases early, and diagnosing chronic health conditions, and 37 articles were eligible for inclusion, with 31 of the 37 articles being published last year (76%). Of the included articles, 9 studied AI models to detect serious mental health issues, such as depression and suicidal tendencies, and chronic health conditions, such as sleep apnea and diabetes. Several articles discussed the application of AIM models for remote patient monitoring and disease management. The considered primary health concerns belonged to 3 categories: mental health, physical health, and health promotion and wellness. Moreover, 14 of the 37 articles used AIM applications to research physical health, representing 38% of the total studies. Finally, 28 out of the 37 (76%) studies used proprietary data sets rather than public data sets. We found a lack of research in addressing chronic mental health issues and a lack of publicly available data sets for AIM research.

Conclusions

The application of AIM models for disease detection and management is a growing research domain. These models provide accurate predictions for enabling preventive care on a broader scale in the health care domain. Given the ever-increasing need for remote disease management during the pandemic, recent AI techniques, such as federated learning and explainable AI, can act as a catalyst for increasing the adoption of AIM and enabling secure data sharing across the health care industry.

Data Collection Mechanisms in Health and Wellness Apps: Review and Analysis

Background

There has been a steady rise in the availability of health wearables and built-in smartphone sensors that can be used to collect health data reliably and conveniently from end users. Given the feature overlaps and user tendency to use several apps, these are important factors impacting user experience. However, there is limited work on analyzing the data collection aspect of mobile health (mHealth) apps.

Objective

This study aims to analyze what data mHealth apps across different categories usually collect from end users and how these data are collected. This information is important to guide the development of a common data model from current widely adopted apps. This will also inform what built-in sensors and wearables, a comprehensive mHealth platform should support.

Methods

In our empirical investigation of mHealth apps, we identified app categories listed in a curated mHealth app library, which was then used to explore the Google Play Store for health and medical apps that were then filtered using our selection criteria. We downloaded these apps from a mirror site hosting Android apps and analyzed them using a script that we developed around the popular AndroGuard tool. We analyzed the use of Bluetooth peripherals and built-in sensors to understand how a given app collects health data.

Results

We retrieved 3251 apps meeting our criteria, and our analysis showed that 10.74% (349/3251) of these apps requested Bluetooth access. We found that 50.9% (259/509) of the Bluetooth service universally unique identifiers to be known in these apps, with the remainder being vendor specific. The most common health-related Bluetooth Low Energy services using known universally unique identifiers were Heart Rate, Glucose, and Body Composition. App permissions showed the most used device module or sensor to be the camera (669/3251, 20.57%), closely followed by location (598/3251, 18.39%), with the highest occurrence in the staying healthy app category.

Conclusions

We found that not many health apps used built-in sensors or peripherals for collecting health data. The small number of the apps using Bluetooth, with an even smaller number of apps using standard Bluetooth Low Energy services, indicates a wider use of proprietary algorithms and custom services, which restrict the device use. The use of standard profiles could open this ecosystem further and could provide end users more options for apps. The relatively small proportion of apps using built-in sensors along with a high reliance on manual data entry suggests the need for more research into using sensors for data collection in health and fitness apps, which may be more desirable and improve end user experience.

E-health interventions targeting STIs, sexual risk, substance use and mental health among men who have sex with men: four systematic reviews

Background

Human immunodeficiency virus/sexually transmitted infections, sexual risk, substance (alcohol and other legal and illegal drugs) use and mental ill health constitute a ‘syndemic’ of mutually reinforcing epidemics among men who have sex with men. Electronic health (e-health) interventions addressing these epidemics among men who have sex with men might have multiplicative effects. To our knowledge, no systematic review has examined the effectiveness of such interventions on these epidemics among men who have sex with men.

Objective

The objective was to synthesise evidence addressing the following: (1) What approaches and theories of change do existing e-health interventions employ to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk, alcohol/drug use or mental ill health among men who have sex with men? (2) What factors influence implementation? (3) What are the effects of such interventions on the aforementioned epidemics? (4) Are such interventions cost-effective?

Data sources

A total of 24 information sources were searched initially (October–November 2018) [the following sources were searched: ProQuest Applied Social Sciences Index and Abstracts; Campbell Library; EBSCO Cumulative Index to Nursing and Allied Health Literature Plus, Wiley Online Library The Cochrane Library; Centre for Reviews and Dissemination databases (the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database); the Health Technology Assessment database; Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) database of health promotion research (Bibliomap); ProQuest Dissertations & Theses Global; OvidSP EconLit; OvidSP EMBASE; OvidSP Global Health; OvidSP Health Management Information Consortium; ProQuest International Bibliography of the Social Sciences; Ovid MEDLINE ALL; OvidSP PsycINFO; Web of Science Science Citation Index Expanded; Elsevier Scopus; OvidSP Social Policy & Practice; Web of Science Social Sciences Citation Index Expanded; ProQuest Sociological Abstracts; ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform; EPPI-Centre Trials Register of Promoting Health Interventions; and the OpenGrey database], and an updated search of 19 of these was conducted in April 2020. Reference lists of included reports were searched and experts were contacted.

Review methods

Eligible reports presented theories of change and/or process, outcome and/or economic evaluations of e-health interventions offering ongoing support to men who have sex with men to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk behaviour, alcohol/drug use and/or common mental illnesses. References were screened by title/abstract, then by full text. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised using qualitative methods. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Original searches retrieved 27 eligible reports. Updated searches retrieved 10 eligible reports. Thirty-seven reports on 28 studies of 23 interventions were included: 33 on theories of change, 12 on process evaluations, 16 on outcome evaluations and one on an economic evaluation. Research question 1: five intervention types were identified – ‘online modular’, ‘computer games’ and ‘non-interactive’ time-limited/modular interventions, and open-ended interventions with ‘content organised by assessment’ and ‘general content’. Three broad types of intervention theories of change were identified, focusing on ‘cognitive/skills’, ‘self-monitoring’ and ‘cognitive therapy’. Research question 2: individual tailoring based on participant characteristics was particularly acceptable, and participants valued intervention content reflecting their experiences. Research question 3: little evidence was available of effects on human immunodeficiency virus or sexually transmitted infections. The analysis did not suggest that interventions were effective in reducing instances of human immunodeficiency virus or sexually transmitted infections. The overall meta-analysis for sexually transmitted infections reported a small non-significant increase in sexually transmitted infections in the intervention group, compared with the control group. Meta-analyses found a significant impact on sexual risk behaviour. The findings for drug use could not be meta-analysed because of study heterogeneity. Studies addressing this outcome did not present consistent evidence of effectiveness. Trials did not report effects on alcohol use or mental health. Research question 4: evidence on cost-effectiveness was limited.

Limitations

The quality of the eligible reports was variable and the economic synthesis was limited to one eligible study.

Conclusions

There is commonality in intervention theories of change and factors affecting receipt of e-health interventions. Evidence on effectiveness is limited.

Future work

Future trials should assess the impact of interventions on multiple syndemic factors, among them sexual risk, substance use and mental health; incorporate sufficient follow-up and sample sizes to detect the impact on human immunodeficiency virus/sexually transmitted infections; and incorporate rigorous process and economic evaluations.

Study registration

This study is registered as PROSPERO CRD42018110317.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

How Older Adults with Chronic Pain Manage Social Support Interactions with Mobile Media

Mobile media offer new ways for older adults to access and interact with their social support networks. While mobile media usage has been increasing among older adults, less is known about why older adults with chronic pain prefer to select members of their existing social network for quality social support interactions, what types of communication mechanisms they engage in when utilizing mobile media, and how they use their mobile media to manage their interactions and relationships. The analysis of 25 semi-structured interviews with older adults with chronic pain reveals that a sense of camaraderie and shared meaning of pain experiences underlie their preferences for communicating with similar others about chronic pain. On the other hand, having to take on a role reversal of comforting and receiving unsolicited advice are the main reasons for avoiding social support interactions with dissimilar others. Additionally, older adults strategically utilize specific features of mobile media such as SMS text messaging for short forms of validation and encouragement, staccato social support, and management of interaction coordination or avoidance. This study demonstrates how mobile technology can be adopted and appropriated to meet social, emotional, and interpersonal needs of older adults' lives. It also provides important insights into communicative dynamics of pain-related social support interactions and communication channel selection of older adults. The way mobile media are used to leverage social interactions and support networks can contribute to self-management, health-promoting behavior, and overall quality of life for older adults with chronic pain.

Participatory Design of a Mobile App to Safeguard Mental Resilience in the Context of Drug Use in Young Adults: Multi-Method Study

Background

Existing mental health apps are largely not aimed at generally healthy young people who may be experimenting with addictive substances and mind-altering experiences.

Objective

The aim of this study is to examine the interest and expectations of young people regarding a proposed smartphone app designed to help protect and promote mental health and resilience in the face of risks associated with substance use.

Methods

The study was based on agile system development and had 3 empirical substudies. Our feasibility study (study 1) included an anonymous questionnaire that examined the potential interest of young people in this type of app. It was answered by 339 Israelis aged 18-30 years. The second part of the feasibility study was a pilot study with 1.2% (4/339) of the people who answered the questionnaire and expressed interest in participating in a focus group. They tested and refined the elements planned for the focus groups. Study 2 was a participatory design study involving 7 focus groups of 5 to 7 participants each (young people aged 18-35 years, n=38). Persona development, open discussion, and a Technology Acceptance Model questionnaire were used to elicit user expectations and requirements for the app and to understand the perceived usefulness and usability of the proposed features. Study 3 comprised in-depth interviews with experts in the field of youth mental health and drug use to enlist their professional opinion regarding the value of such an app and recommendations about the features it should include.

Results

The mock-up for the proposed app had five key features: personalized assessment of risk for a drug-associated mental crisis, support for self-monitoring, useful information (eg, warning signs and first-aid guidelines), resilience-building exercises, and a support center. Participants rated highly the usefulness of all 5 main features and 96% (24/25) of the specific features we proposed within those main categories. The participants also suggested additional features as well as a new user persona we had not considered: the parents or family members of the young person. The focus groups rated highly the perceived usability of the app. Most of the experts saw value in all the main features and suggested specific knowledge sources for the app’s content. Finally, participants of both the feasibility study and the participatory design study expressed moderate to high interest in using the app for self-help and high interest in using the app to help friends.

Conclusions

The findings provide preliminary encouraging support for the 5 main features suggested by the research team and reinforce recommendations for mobile health apps found in the literature. The findings emphasize the insight that this kind of app should be designed primarily for use by individuals seeking to help others.

mHealth Interventions for Contraceptive Behavior Change in the United States: A Systematic Review

Ensuring people have access to their preferred method of contraception can be key for meeting their reproductive goals. A growing number of mHealth interventions show promise for improving access to contraception, but no literature review has identified the effects of mHealth interventions among both adolescents and adults in the United States. The purpose of this systematic review was to describe the format, theoretical basis, and impact of mHealth interventions for contraceptive behavior change (contraceptive initiation and continuation) among people of all ages in the US. A systematic review of the literature was conducted using six electronic databases guided by Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Data on study design, frequency, duration, mHealth modality, contraceptive method, behavior change theory, and behavioral outcome were extracted to facilitate comparison. Eighteen studies met eligibility criteria. The majority (11; 61%) used SMS (short message service). Twelve studies focused on contraceptive initiation, most (n = 8) of which also measured continued use over time. The remaining six interventions focused on continuation alone, generally through appointment reminders. Very little contraceptive behavior change was identified across studies. Current mHealth interventions may hold promise for some health areas but there is little evidence that they change contraceptive behavior. Future mHealth interventions should focus on assessing person-centered outcomes, including satisfaction, side effects, and reasons for discontinuation, to best support people to use their preferred contraceptive method.

eHealth and mHealth Development in Spain: Promise or Reality?

In the last decades, the use of Information and Communication Technologies (ICTs) has progressively spread to society and public administration. Health is one of the areas in which the use of ICTs has more intensively developed through what is now known as eHealth. That area has recently included mHealth. Spanish health system has stood out as one of the benchmarks of this technological revolution. The development of ICTs applied to health, especially since the outbreak of the pandemic caused by SARS Cov-2, has increased the range of health services delivered through smartphones and the development of subsequent specialized apps. Based on the data of a Survey on Use and Attitudes regarding eHealth in Spain, the aim of this research was to conduct a comparative analysis of the different eHealth and mHealth user profiles. The results show that the user profile of eHealth an mHealth services in Spain is not in a majority. Weaknesses are detected both in the knowledge and use of eHealth services among the general population and in the usability or development of their mobile version. Smartphones can be a democratizing vector, as for now, access to eHealth services is only available to wealthy people, widening inequality.

Physicians' Attitudes Toward Prescribable mHealth Apps and Implications for Adoption in Germany: Mixed Methods Study

Background

In October 2020, Germany became the first country, worldwide, to approve certain mobile health (mHealth) apps, referred to as DiGA (Digitale Gesundheitsanwendungen, in German, meaning digital health applications), for prescription with costs covered by standard statutory health insurance. Yet, this option has only been used to a limited extent so far.

Objective

The aim of this study was to investigate physicians’ and psychotherapists’ current attitudes toward mHealth apps, barriers to adoption, and potential remedies.

Methods

We conducted a two-stage sequential mixed methods study. In phase one, semistructured interviews were conducted with physicians and psychotherapists for questionnaire design. In phase two, an online survey was conducted among general practitioners, physicians, and psychotherapists.

Results

A total of 1308 survey responses by mostly outpatient-care general practitioners, physicians, and psychotherapists from across Germany who could prescribe DiGA were recorded, making this the largest study on mHealth prescriptions to date. A total of 62.1% (807/1299) of respondents supported the opportunity to prescribe DiGA. Improved adherence (997/1294, 77.0%), health literacy (842/1294, 65.1%), and disease management (783/1294, 60.5%) were most frequently seen as benefits of DiGA. However, only 30.3% (393/1299) of respondents planned to prescribe DiGA, varying greatly by medical specialty. Professionals are still facing substantial barriers, such as insufficient information (1135/1295, 87.6%), reimbursement for DiGA-related medical services (716/1299, 55.1%), medical evidence (712/1298, 54.9%), legal uncertainties (680/1299, 52.3%), and technological uncertainties (658/1299, 50.7%). To support professionals who are unsure of prescribing DiGA, extended information campaigns (1104/1297, 85.1%) as well as recommendations from medical associations (1041/1297, 80.3%) and medical colleagues (1024/1297, 79.0%) were seen as the most impactful remedies.

Conclusions

To realize the benefits from DiGA through increased adoption, additional information sharing about DiGA from trusted bodies, reimbursement for DiGA-related medical services, and further medical evidence are recommended.

How Human Resources Index, Relational Justice, and Perceived Productivity Change after Reorganization at a Hospital in Sweden That Uses a Structured Support Model for Systematic Work Environment Management

To facilitate systematic work environment management, which should be a natural part of business development, a structured support model was developed. The Stamina model has previously been used in Swedish municipalities, showing positive results. The aim was to study how the Human Resources Index (HRI), relational justice, short-term recovery and perceived productivity changed in a recently reorganised perioperative setting in a hospital in Sweden that uses a structured support model for systematic work environment management. A longitudinal design that took measurements at four time points was used in a sample of 500 employees in a perioperative hospital department. The results for the overall sample indicated a positive trend in the HRI (Mt1 = 48.5, SDt1 = 22.5; Mt3 = 56.7, SDt1 = 21.2; p < 0.001). Perceived health-related production loss (Mdt1 = 2, IQR = 3; Mdt3 = 0, IQR = 3; p < 0.001) and perceived work environment-related production loss (Mdt1 = 2, IQR = 3; Mdt3 = 0, IQR = 4; p < 0.001) showed major improvements. Short-term recovery showed a minor improvement (Mt1 = 2.61, SDt1 = 1.33; Mt3 = 2.65, SDt3 = 1.22; p = 0.872). In conclusion, the implementation of the Stamina model, of which the HRI constitutes an important part, seems to be a helpful tool to follow-up on work environment processes, and minimise production losses due to health and work environment-related issues.

Accessibility and Digital Mental Health: Considerations for More Accessible and Equitable Mental Health Apps

Digital mental health is often touted as a solution to issues of access to mental health care. However, there has been little research done to understand the accessibility of digital mental health, especially for those with disabilities. In this piece, we define accessibility as it relates to mental health apps, describe the current state of accessibility in the digital world broadly and in mental health apps more specifically, outline why accessibility matters in mental health apps, and identify future steps to better incorporate accessibility into research and development of mental health apps.

Effectiveness of a Dyadic Buddy App for Smoking Cessation: Randomized Controlled Trial

BACKGROUND

Tobacco smoking is one of the biggest public health threats. Smartphone apps offer new promising opportunities for supporting smoking cessation in real time. This randomized controlled trial investigated the effectiveness of an app that encourages individuals to quit smoking with the help of a social network member (buddy) in daily life.

OBJECTIVE

The objective of this study is to test the effectiveness of the SmokeFree buddy app compared with a control group with self-reported smoking abstinence and carbon monoxide (CO)-verified smoking abstinence as primary outcomes and self-reports of smoked cigarettes per day (CPD) as a secondary outcome.

METHODS

A total of 162 adults who smoked participated in this single-blind, two-arm, parallel-group, intensive longitudinal randomized controlled trial. Around a self-set quit date (ie, 7 days before the self-set quit date and 20 days after) and 6 months later, participants of the intervention and control groups reported on daily smoking abstinence and CPD in end-of-day diaries. Daily smoking abstinence was verified via daily exhaled CO assessments. This assessment was administered via an app displaying results of exhaled CO, thus addressing self-monitoring in both groups. In addition, participants in the intervention group used the SmokeFree buddy app, a multicomponent app that facilitates social support from a buddy of choice.

RESULTS

A significant reduction in CPD from baseline to the 6-month follow-up was observed among participants in both groups. Multilevel analyses revealed no significant intervention effect on self-reported and CO-verified daily smoking abstinence at the quit date and 3 weeks later. However, CPD was lower at the quit date and 3 weeks later in the intervention group than in the control group. No significant differences between groups were found for any outcome measures 6 months after the quit date. Overall, low app engagement and low perceived usefulness were observed.

CONCLUSIONS

Despite some encouraging short-term findings on the amount of smoking, the SmokeFree buddy app did not have beneficial effects on smoking abstinence over and above the self-monitoring control condition. Future studies should examine whether and what support processes can be effectively stimulated and how app use can be improved to better achieve this goal.

TRIAL REGISTRATION

ISRCTN Registry 11154315; https://www.isrctn.com/ISRCTN11154315.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-019-7723-z.

Proposing a mobile apps acceptance model for users in the health area: A systematic literature review and meta-analysis

Due to rapid advancements in the field of information and communication technologies, mobile health (mHealth) has become a significant topic in the delivery of healthcare. Despite the perceived advantages and the large number of mHealth initiatives, the success of mHealth ultimately relies on whether these initiatives are used; their benefits will be diminished should people not use them. Previous literature has found that the adoption of mHealth by users is not yet widespread, and little research has been conducted on this problem. Therefore, this study identifies the antecedents of the intention to use mHealth and proposes a general model that might prove beneficial in explaining the acceptance of mHealth. The authors performed a quantitative meta-analysis of 49 journal papers published over the past 10 years and systematically reviewed the evidence regarding the most commonly identified factors that may affect the acceptance of mHealth. The findings indicate that the proposed model includes the seven most commonly used relationships in the selected articles. More specifically, the model assumes that perceived usefulness positively affects perceived ease of use and user behavioral intention to use mHealth is commonly influenced by five factors: perceived usefulness, perceived ease of use, attitude toward behavior, subjective norms, and facilitating conditions. The results of this work provide important insights into the predictors of mHealth acceptance for future researchers and practitioners.

Popular Evidence-Based Commercial Mental Health Apps: Analysis of Engagement, Functionality, Aesthetics, and Information Quality

Background

There is a robust market for mobile health (mHealth) apps focused on self-guided interventions to address a high prevalence of mental health disorders and behavioral health needs in the general population. Disseminating mental health interventions via mHealth technologies may help overcome barriers in access to care and has broad consumer appeal. However, development and testing of mental health apps in formal research settings are limited and far outpaced by everyday consumer use. In addition to prioritizing efficacy and effectiveness testing, researchers should examine and test app design elements that impact the user experience, increase engagement, and lead to sustained use over time.

Objective

The aim of this study was to evaluate the objective and subjective quality of apps that are successful across both research and consumer sectors, and the relationships between objective app quality, subjective user ratings, and evidence-based behavior change techniques. This will help inform user-centered design considerations for mHealth researchers to maximize design elements and features associated with consumer appeal, engagement, and sustainability.

Methods

We conducted a user-centered design analysis of popular consumer apps with scientific backing utilizing the well-validated Mobile Application Rating Scale (MARS). Popular consumer apps with research support were identified via a systematic search of the App Store iOS (Apple Inc) and Google Play (Google LLC) and literature review. We evaluated the quality metrics of 19 mental health apps along 4 MARS subscales, namely, Engagement, Functionality, Aesthetics, and Information Quality. MARS total and subscale scores range from 1 to 5, with higher scores representing better quality. We then extracted user ratings from app download platforms and coded apps for evidence-based treatment components. We calculated Pearson correlation coefficients to identify associations between MARS scores, App Store iOS/Google Play consumer ratings, and number of evidence-based treatment components.

Results

The mean MARS score was 3.52 (SD 0.71), consumer rating was 4.22 (SD 0.54), and number of evidence-based treatment components was 2.32 (SD 1.42). Consumer ratings were significantly correlated with the MARS Functionality subscale (r=0.74, P<.001), Aesthetics subscale (r=0.70, P<.01), and total score (r=0.58, P=.01). Number of evidence-based intervention components was not associated with MARS scores (r=0.085, P=.73) or consumer ratings (r=–0.329, P=.16).

Conclusions

In our analysis of popular research-supported consumer apps, objective app quality and subjective consumer ratings were generally high. App functionality and aesthetics were highly consistent with consumer appeal, whereas evidence-based components were not. In addition to designing treatments that work, we recommend that researchers prioritize aspects of app design that impact the user experience for engagement and sustainability (eg, ease of use, navigation, visual appeal). This will help translate evidence-based interventions to the competitive consumer app market, thus bridging the gap between research development and real-world implementation.

Using mHealth Applications to Promote Self-Managed Health Behaviors Among Teens

THEORETICAL PRINCIPLES

As technology use increasingly expands, the opportunity to capitalize on it for healthcare education, monitoring, and assessment has grown rapidly, especially among adolescent patients. As apps are developed, consideration should be given to self-management theory concepts.

PHENOMENA ADDRESSED

The proliferation of mobile health (mHealth) applications allows adolescents to access healthcare information in new, innovative ways. Many health applications focus on health promotion, fitness, and nutrition and others help persons with chronic disease. This article offers a compelling case for incorporating mHealth into teen healthcare by reviewing current data on teens' technology use, showing how mHealth aligns with self-management theory concepts, and offering a case scenario on mHealth-enhanced self-management care.

RESEARCH LINKAGES

The ability to combine accurate and immediate healthcare information with continual social support could radically improve teen's self-management behaviors, especially when mHealth apps use connectivity, a feedback loop, and concepts known to enhance self-management behaviors.

A mhealth application for automated detection and diagnosis of strabismus

BACKGROUND AND OBJECTIVE

Amblyopia is a public health problem, and strabismus is its primary cause. Our objective is to evaluate the concordance of the diagnosis of strabismus between strabismus expert ophthalmologist and the mhealth application developed for this purpose.

METHODS

We evaluated the concordance of the diagnosis of strabismus between the expert ophthalmologist and the mhealth application by screening 224 children and adolescents in the 5-15 years age group, with snapshots of patients' eyes and their analysis thereof. We were using a multifunctional cell phone with Android and the ophthalmologist's clinical evaluation by analyzing the ocular deviations using simple cover and prism and alternate cover.

RESULTS

Fraction measurements were used with two cutoff points of 6 and 11 prismatic diopters (PD). Results were compared according to their concordances, with a fair Kappa equal to 0.43 (95%CI = [0.38; 0.48]), which was statistically significant (p < 0.0001) at the cutoff point of 6 PD and Kappa equal to 0.49 (95% CI = [0.35; 0.61]), which was statistically significant (p < 0.042) in the cutoff point of 11 PD.

CONCLUSIONS

The cutoff point of 6 PD was chosen for screening by this mhealth application since it caused the loss of only two patients with strabismus, whereas, in the case of 11 PD, the loss was five patients in the universe of 224. These results are promising for the use of this software as a screening method for patients with strabismus.

Can the Human Resources Index (HRI) Be Used as a Process Feedback Measurement in a Structured Support Model for Systematic Work Environment Management?

The aim of the study was to estimate the level of the human resources index (HRI) measure among Swedish municipal employees, and to investigate the association between human resources index (HRI) and relational justice, short-term recovery, work environment-related production loss, and health-related production loss. A cross-sectional design was used with one sample of municipal employees (n = 6402). The results showed a positive association (r = 0.31) between human resources index (HRI) and relational justice; a positive (r = 0.27) association between HRI and short-term recovery; a negative association between HRI and work environment-related production loss (r = −0.37); and a negative association between HRI and health-related production loss (r = −0.23). The findings implicate that HRI captures important aspects of the work environment such as productivity, relational justice, and short-term recovery. The HRI measure is part of a support model used in workplaces to systematically address work environment-related issues. Monitoring changes in the HRI measure, it is possible to determine whether the measures taken effect production loss, perceived leadership, and short-term recovery in a work group. The support model using HRI may thus be used to complement traditional work environment surveys conducted in Swedish organizations as obliged by legal provisions.

Goldilocks and the Three Bears: A Just-Right Hybrid Model to Synthesize the Growing Landscape of Publicly Available Health-Related Mobile Apps

Mobile health (mHealth) technologies have provided an innovative platform for the deployment of health care diagnostics, symptom monitoring, and prevention and intervention programs. Such health-related smartphone apps are universally accepted by patients and providers with over 50 million users worldwide. Despite the rise in popularity and accessibility among consumers, the evidence base in support of health-related apps has fallen well behind the rapid pace of industry development. To bridge this evidence gap, researchers are beginning to consider how to best apply evidence-based research standards to the systematic synthesis of the mHealth consumer market. In this viewpoint, we argue for the adoption of a "hybrid model" that combines a traditional systematic review with a systematic search of mobile app download platforms for health sciences researchers interested in synthesizing the state of the science of consumer apps. This approach, which we have successfully executed in a recent review, maximizes the benefits of traditional and novel approaches to address the essential question of whether popular consumer mHealth apps work.

Promoting Culturally Tailored mHealth: A Scoping Review of Mobile Health Interventions in Latinx Communities

This scoping review of mHealth research focuses on intervention studies that utilize mobile technologies to promote behavior change and improve health outcomes in U.S. Latinx communities. 342 mHealth articles were reviewed using PRIMSA protocols; most did not include a majority Latinx study population or did not report on an intervention. The final sample resulted in 23 articles published between 2012 and 2020. Reviewed interventions focused on conditions such as: diabetes, depression, substance abuse, obesity, hypertension, maternal health, and farmworker safety. About one-third of mHealth interventions included mobile applications, the rest were limited to texting programs. Text message reminders can help improve medication adherence and care access, especially when coupled with support from community health workers. Bi-directional text message interventions with feedback loops and personalized treatment options can build user agency. Additionally, multi-modal applications that combine texting with self-guided interactive content show promise for culturally tailored mHealth.

eHealth Interventions to Address Sexual Health, Substance Use, and Mental Health Among Men Who Have Sex With Men: Systematic Review and Synthesis of Process Evaluations

Background

Men who have sex with men (MSM) face disproportionate risks concerning HIV and other sexually transmitted infections, substance use, and mental health. These outcomes constitute an interacting syndemic among MSM; interventions addressing all 3 together could have multiplicative effects. eHealth interventions can be accessed privately, and evidence from general populations suggests these can effectively address all 3 health outcomes. However, it is unclear how useable, accessible, or acceptable eHealth interventions are for MSM and what factors affect this.

Objective

We undertook a systematic review of eHealth interventions addressing sexual risk, substance use, and common mental illnesses among MSM and synthesized evidence from process evaluations.

Methods

We searched 19 databases, 3 trials registers, OpenGrey, and Google, and supplemented this by reference checks and requests to experts. Eligible reports were those that discussed eHealth interventions offering ongoing support to MSM aiming to prevent sexual risk, substance use, anxiety or depression; and assessed how intervention delivery or receipt varied with characteristics of interventions, providers, participants, or context. Reviewers screened citations on titles, abstracts, and then full text. Reviewers assessed quality of eligible studies, and extracted data on intervention, study characteristics, and process evaluation findings. The analysis used thematic synthesis.

Results

A total of 12 reports, addressing 10 studies of 8 interventions, were eligible for process synthesis. Most addressed sexual risk alone or with other outcomes. Studies were assessed as medium and high reliability (reflecting the trustworthiness of overall findings) but tended to lack depth and breadth in terms of the process issues explored. Intervention acceptability was enhanced by ease of use; privacy protection; use of diverse media; opportunities for self-reflection and to gain knowledge and skills; and content that was clear, interactive, tailored, reflective of MSM’s experiences, and affirming of sexual-minority identity. Technical issues and interventions that were too long detracted from acceptability. Some evidence suggested that acceptability varied by race or ethnicity and educational level; findings on variation by socioeconomic status were mixed. No studies explored how intervention delivery or receipt varied by provider characteristics.

Conclusions

Findings suggest that eHealth interventions targeting sexual risk, substance use, and mental health are acceptable for MSM across sociodemographic groups. We identified the factors shaping MSM’s receipt of such interventions, highlighting the importance of tailored content reflecting MSM’s experiences and of language affirming sexual-minority identities. Intervention developers can draw on these findings to increase the usability and acceptability of integrated eHealth interventions to address the syndemic of sexual risk, substance use, and mental ill health among MSM. Evaluators of these interventions can draw on our findings to plan evaluations that explore the factors shaping usability and acceptability.

Theory Integration for Lifestyle Behavior Change in the Digital Age: An Adaptive Decision-Making Framework

Despite the growing popularity of digital health interventions, limitations of traditional behavior change theories and a lack of theory integration hinder theory-driven behavior change applications. In this paper, we aim to review theories relevant to lifestyle behavior change from the broader psychology literature and then integrate these theories into a new theoretical framework called adaptive decision-making to address two specific problems. First, our framework represents lifestyle behaviors at two levels-one of individual daily decisions (action level) and one of larger behavioral episodes (reflection level)-to more closely match the temporal characteristics of lifestyle behaviors and their associated digital data. Second, the framework connects decision-making theories and learning theories to explain how behaviors and cognitive constructs dynamically influence each other, making it a suitable scaffold for building computational models. We map common digital intervention techniques onto the behavioral and cognitive processes in the framework and discuss possible contributions of the framework to both theory development and digital intervention design.

Relationships Between Mobile eHealth Literacy, Diabetes Self-care, and Glycemic Outcomes in Taiwanese Patients With Type 2 Diabetes: Cross-sectional Study

Background

Understanding how people with diabetes seek online health information and use health applications is important to ensure these electronic tools are successfully supporting patient self-care. Furthermore, identifying the relationship between patient mobile eHealth literacy (mobile eHL) and diabetes outcomes can have far-reaching utility, for example, in the design of targeted interventions to address mobile eHL limitations. However, only limited studies have explored the impact of mobile eHL in a population with diabetes.

Objective

This study aims to present data about online information-seeking behavior and mobile health (mHealth) app usage, investigate the factors related to mobile eHL in Taiwanese patients with type 2 diabetes, and flesh out the relationship between eHealth literacy (eHL), mobile health literacy (mHL), and health outcomes.

Methods

Subjects were recruited from January 2017 to December 2017 in the outpatient departments of 3 hospitals in Taiwan. A total of 249 Taiwanese patients with diabetes voluntarily completed a cross-sectional survey assessing sociodemographic characteristics; diabetes status; knowledge and skills of computers, the internet, and mobile apps; mobile eHL; and patient outcomes (self-care behaviors, self-rated health, HbA_1c). Structural equation modeling analyses examined the model fit of mobile eHL scores and the interrelationships between latent constructs and observable variables.

Results

Of the 249 patients with diabetes, 67% (164/249) reported they had searched for online diabetes information. The participants with smartphones had owned them for an average of 6.5 years and used them for an average of 4.5 (SD 3.81) hours per day. Only 1.6% (4/249) of the patients used health apps. Some demographic factors affecting mobile eHL included age, education, and duration of type 2 diabetes. Mobile eHL was related to self-care behaviors as well as knowledge and skills of computers, the internet, and mobile technology, but only had a weak, indirect effect on self-rated health. The final model had adequate goodness-of-fit indexes: chi-square (83)=149.572, P<.001; comparative fit index (CFI)=0.925; root mean square of approximation (RMSEA)=0.057 (90% CI 004-006); chi-square/df=1.082. Mobile eHL had a weak, indirect effect on self-rated health through the variables of knowledge with skills.

Conclusions

Our study reveals that although people with diabetes who rated their health conditions as moderate were confident in using mobile eHealth and technology, few adopted these tools in their daily lives. The study found that mobile eHL had a direct effect on self-care behavior as well as knowledge and skills of computers, the internet, and mobile technology, and had an indirect effect on health outcomes (glycemic control and self-rated health status). Information about this population's experiences and the role mobile eHL plays in them can spur necessary mobile eHealth patient education.

Recruiting participants for an international mHealth study via Facebook Ads: Experiences from the Untire App RCT

INTRODUCTION

Social media recruitment via Facebook Ads seems to be a promising method for large-scale international trials examining the effectiveness of mHealth interventions. However, little is known about this method in terms of strategy, reach, and costs in the context of psycho-oncology. This paper presents the results of the recruitment strategy that was applied in the Untire app study and shows how many participants could be reached using advertisements (i.e., Ads) on Facebook, who participated, and what it cost.

METHOD

The Untire app study is a randomized controlled trial targeted at cancer patients and survivors across four English-speaking countries (i.e., Australia, Canada, the U.K., and the U.S.A.). Reach was assessed by the number of people who were shown the Ads, who clicked on the Ads, and completed study assessments. Demographic characteristics were gathered from Facebook Ads Manager and from online study assessments to describe who was reached. Costs were assessed by the budget spent and the cost per click for Ads, for reaching the study's landing page, and for completing study assessments. To conduct a powered RCT, we needed 164 12-weeks assessments in both the intervention and the control group.

RESULTS

From March till October 2018, we used 76 Ads, which were presented to 1.2 million people. 37.376 persons clicked on the study link in the Ads, resulting in 755 baseline completers. Most participants were female (92%), middle-aged (55.5 ± 9.79), and came from the U.K. (72%). The total Facebook advertisement costs from March till October 2018 were €17 k, resulting in an average cost of €0.45 per click on the Ads, €5.55 on average for a person reaching the study's landing page, and €14.89 on average per eligible participant. The costs for every baseline and 12-weeks completer were €22.42 and €47.69, respectively.

DISCUSSION

Reaching participants for international mHealth studies in psycho-oncology via Facebook Ads has potential but is costly. The key to reducing costs lies in constant optimization and testing of Ads and refinement of target audience characteristics.

Adverse Childhood Experiences and Building Resilience With the JoyPop App: Evaluation Study

BACKGROUND

The effects of adverse childhood experiences (ACEs) on mental health, self-regulatory capacities, and overall resilience are well-known. Given such effects, ACEs may play a role in how individuals adjust to challenges later in life. Of interest in this study is the transition to university, a time of heightened stress when adapting to circumstances is required and when those with ACEs may need additional in-the-moment support to exercise resilience. A smartphone app may provide a worthwhile and readily accessible medium for a resilience intervention, provided behavioral outcomes are adequately evaluated.

OBJECTIVE

This study evaluates the impact of an innovative, smartphone app-based resilience intervention. The JoyPop app was designed to promote resilience through the use of self-regulatory skills such as emotion regulation and executive functioning. Among a sample of first-year undergraduate students, we explored whether use of the app would be associated with positive changes in resilience and related outcomes, and whether these benefits were influenced by level of childhood adversity.

METHODS

Participants (N=156) were requested to use the JoyPop app for 4 weeks, at least twice daily. Changes in resilience, emotion regulation, executive functioning, and depression were assessed after 2 and 4 weeks of app usage using multilevel modeling.

RESULTS

The sample of 156 participants included 123 females and 33 males, with a mean age of 19.02 years (SD 2.90). On average participants used the app on 20.43 of the possible 28 days (SD 7.14). App usage was associated with improvements in emotion regulation (χ²₁=44.46; P<.001), such that it improved by 0.25 points on the 18-point scale for each additional day of app usage, and symptoms of depression (χ²₁=25.12; P<.001), such that depression symptoms were reduced by .08 points on the 9-point scale with each additional day of app usage. An interaction between ACEs and days of app usage existed for emotion regulation, such that participants with more adversity evidenced a faster rate of change in emotion regulation (P=.02).

CONCLUSIONS

Results highlight that daily incorporation of an app-based resilience intervention can help youth who have experienced adversity to improve emotion regulation skills and experience reductions in depression. The JoyPop app represents an important step forward in the integration of resilience intervention research with a technology-based medium that provides in-the-moment support.

Beating cancer-related fatigue with the Untire mobile app: Results from a waiting-list randomized controlled trial

OBJECTIVE

This waiting-list randomized controlled trial examined the effectiveness of a self-management mHealth app in improving fatigue and quality of life (QoL) in cancer patients and survivors.

METHODS

Persons with cancer-related fatigue (CRF) were recruited across four English speaking countries, via social media, and randomized into intervention (n = 519) and control (n = 280) groups. Whereas the intervention group received immediate access to the Untire app, the control group received access only after 12-weeks. Primary outcomes fatigue severity and interference, and secondary outcome QoL were assessed at baseline, 4, 8, and 12-weeks. We ran generalized linear mixed models for all outcomes to determine the effects of app access (yes/no), over 12-weeks, following the intention-to-treat principle.

RESULTS

Compared with the control group, the intervention group showed significantly larger improvements in fatigue severity (d = 0.40), fatigue interference (d = 0.35), and overall QoL on average (d = 0.32) (P's < .01), but not for overall QoL in the past week (P = .07). Sensitivity analyses indicated that participants with medium or high app use benefited most when compared with nonusers and control participants (P's ≤ .02). The intervention effect on fatigue interference was slightly stronger in younger participants (≤56 vs. >56). Effects did not depend on education and cancer status. Reliable change analyses indicated that significantly more people showed full recovery for fatigue in the intervention vs the control group (P's = .02).

CONCLUSIONS

The Untire app can be an effective mHealth solution for cancer patients and survivors with moderate to severe CRF.

Differential influences of social support on app use for diabetes self-management - a mixed methods approach

Background

Recent studies increasingly examine social support for diabetes self-management delivered via mHealth. In contrast to previous studies examining social support as an outcome of technology use, or technology as a means for delivering social support, this paper argues that social support has an impact on the use of diabetes mHealth apps. Specifically, we postulate differences between the impact of healthcare professional versus non-professional (family/friends) support on mobile app use for diabetes self-management.

Methods

This research employed a triangulation of methods including exploratory semi-structured face-to-face interviews (N = 21, Study 1) and an online survey (N = 65, Study 2) with adult type 1 and type 2 diabetes patients. Thematic analysis (Study 1) was used to explore the relevance of social support (by professionals versus non-professionals) for diabetes app use. Binary logistic regression (Study 2) was applied to compare healthcare decision-making, healthcare-patient communication, and the support by the personal patient network as predictors of diabetes app use, complemented by other predictors from self-management and technology adoption theory.

Results

The interviews (Study 1) demonstrated that (technology-supported) shared decision-making and supportive communication by healthcare professionals depended on their medical specialty. The personal patient network was perceived as either facilitating or hindering the use of mHealth for self-management. Binary logistic regression (Study 2) showed that the physician specialty significantly predicted the use of diabetes apps, with supervision by diabetes specialists increasing the likelihood of app use (as opposed to general practitioners). Additionally, specialist care positively related to a higher chance of shared decision-making and better physician-patient communication. The support by the personal patient network predicted diabetes app use in the opposite direction, with less family/friend support increasing the likelihood of app use.

Conclusion

The results emphasize the relevance of support by healthcare professionals and by the patient network for diabetes app use and disclose differences from the existing literature. In particular, the use of diabetes apps may increase in the absence of social support by family or friends (e.g., compensation for lack of support), and may decrease when such support is high (e.g., no perceived need to use technology).

Android and iPhone Mobile Apps for Psychosocial Wellness and Stress Management: Systematic Search in App Stores and Literature Review

BACKGROUND

In an oversaturated market of publicly available mobile apps for psychosocial self-care and stress management, health care providers, patients, and consumers interested in mental health-related apps may wonder which, if any, are efficacious. Readily available metrics for consumers include user popularity and media buzz rather than scientific evidence.

OBJECTIVE

This systematic review aimed to (1) examine the breadth of therapeutic contents and features of psychosocial wellness and stress management apps available to self-help seekers for public download and (2) determine which of these apps have original research support.

METHODS

First, we conducted a systematic review of publicly available apps on the iPhone App Store (Apple Inc) and Android Google Play (Google LLC) platforms using conventional self-help-seeking search terms related to wellness and stress. The results were limited to English-language apps available for free download. In total, 2 reviewers independently evaluated all apps and discussed the findings to reach 100% consensus regarding inclusion. Second, a literature review was conducted on the included apps to identify supporting studies with original data collection.

RESULTS

We screened 3287 apps and found 1009 psychosocial wellness and stress management apps. Content varied widely. The most common evidence-based strategy was mindfulness-meditation, followed by positive psychology and goal setting. Most apps were intended to be used as self-help interventions, with only 1.09% (11/1009) involving an electronic therapist and 1.88% (19/1009) designed as a supplement to in-person psychotherapy. Only 4.66% (47/1009) of apps targeted individuals with psychological disorders, and less than 1% of apps (6/1009, 0.59%) targeted individuals with other chronic illnesses. Approximately 2% (21/1009, 2.08%) were supported by original research publications, with a total of 25 efficacy studies and 10 feasibility studies. The Headspace mindfulness app had the most evidence, including 8 efficacy studies. Most other scientifically backed apps were supported by a single feasibility or efficacy study.

CONCLUSIONS

Only 2.08% (21/1009) of publicly available psychosocial wellness and stress management mobile apps discoverable to self-help seekers have published, peer-reviewed evidence of feasibility and/or efficacy. Clinicians and investigators may use these findings to help patients and families navigate the volume of emerging digital health interventions for stress management and wellness.

International mHealth Research: Old Tools and New Challenges

In this paper, we outline the policy implications of mobile health research conducted at the international level. We describe the manner in which such research may have an international dimension and argue that it is not likely to be excluded from conventionally applicable international regulatory tools. We suggest that closer policy attention is needed for this rapidly proliferating approach to health research.

Optimizing symptom control in children and adolescents with cancer

There is growing recognition of the degree to which symptoms negatively impact on children receiving cancer treatments. A recent study described that almost all inpatient pediatric oncology patients are experiencing at least one bothersome symptom and almost 60% are experiencing at least one severely bothersome symptom. Poor symptom control occurs because of challenges with communication of bothersome symptoms to clinicians, lack of clinical practice guidelines (CPGs) for most of these symptoms, and failure to administer preventative and therapeutic interventions known to be effective for symptom control. This article reviews approaches used to improve symptom control for children receiving cancer treatments. Areas addressed include systematic symptom screening and creation of CPGs for symptom management. Challenges with electronic health integration are also addressed. Several multi-symptom assessment scales have been developed but none have yet been used to directly influence patient management. The number of CPGs applicable to symptom control in pediatric oncology is increasing but remains small. Improving the creation of and adherence to CPGs for symptom management is an important priority. Finally, identifying ways that symptom management systems can be integrated into clinical work flows is essential; these will likely need to focus on electronic health records.