Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review

Innovative Approaches to Addressing Pediatric Mental Health: Digital Technologies in Pediatric Primary Care

Digital technologies can be used at multiple levels to support the mental health care of children including (1) health system/health care provider level; (2) patient-provider interface; (3) patient-facing consumer applications; and (4) new technology, including artificial intelligence. At each of these levels, these novel technologies may lead to care improvements but also may have risks. This review provides an overview of each of innovations across the digital landscape.

Mobile phone interventions to improve health outcomes among patients with chronic diseases: an umbrella review and evidence synthesis from 34 meta-analyses

This umbrella review of 34 meta-analyses, representing 235 randomised controlled trials done across 52 countries and 48 957 participants and ten chronic conditions, aimed to evaluate evidence on the efficacy of mobile phone interventions for populations with chronic diseases. We evaluated the strengths of evidence via the Fusar-Poli and Radua methodology. Compared with usual care, mobile apps had convincing effects on glycated haemoglobin reduction among adults with type 2 diabetes (d=0·44). Highly suggestive effects were found for both text messages and apps on various outcomes, including medication adherence (among patients with HIV in sub-Saharan Africa and people with cardiovascular disease), glucose management in type 2 diabetes, and blood pressure reduction in hypertension. Many effects (42%) were non-significant. Various gaps were identified, such as a scarcity of reporting on moderators and publication bias by meta-analyses, little research in low-income and lower-middle-income countries, and little reporting on adverse events.

Quality Assessment of Digital Health Apps: Umbrella Review

BACKGROUND

With an increasing number of digital health apps available in app stores, it is important to assess these technologies reliably regarding their quality. This is done to mitigate the risks associated with their use. There are many different guidelines, methods, and metrics available to assess digital health apps with regard to their quality.

OBJECTIVE

This study aimed to give a holistic summary of the current methods and "condition agnostic" frameworks that are broadly applicable for the quality assessment of all digital health apps.

METHODS

A systematic search of literature was conducted on 4 databases: Scopus, PubMed, ACM Digital Library, and IEEE Xplore. We followed the PICOS (Population, Patient, or Problem; Intervention; Comparison; Outcomes; and Study Design) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodologies when conducting this umbrella review. The search was conducted on January 26, 2024, for review articles published between 2018 and 2023. We identified 4781 candidate papers for inclusion; after title and abstract screening, 39 remained. After full-text analysis, we included 15 review articles in the full review.

RESULTS

Of the 15 review articles, scoping reviews were the most common (n=6, 40%), followed by systematic reviews (n=4, 27%), narrative reviews (n=4, 27%), and a rapid review (n=1, 7%). A total of 4 (27%) review articles proposed assessment criteria for digital health apps. "Data privacy and/or security" was the most mentioned criterion (n=13, 87%) and "Cost" was the least mentioned criterion (n=1, 7%) for the assessment of digital health apps. The Mobile App Rating Scale was the most frequently used framework for quality assessment of digital health apps.

CONCLUSIONS

There is a lack of unity or consolidation across identified frameworks, as most do not meet all the identified criteria from the reviewed articles. Safety concerns associated with the use of digital health apps may be mitigated with the use of quality frameworks.

Barriers and enablers to salt intake reduction in Australian adults with high blood pressure

High dietary salt intake is a known risk factor for hypertension. However, Australians continue to consume excessive amounts of salt. The purpose of this study was to identify barriers, enablers and strategies to reduce salt in a sample of Australian adults with hypertension. This was a qualitative study. Participants were asked a set of open-ended questions during focus groups conducted between October 2020 and April 2021. Sessions were recorded and transcribed. Using an inductive approach, the transcript data from the focus groups were thematically analysed. This involved checking accuracy, becoming familiar with the data, coding responses based on questions, identifying themes through common patterns and validating themes by grouping similar questions that represented the data and study aim effectively. Thirty-one adults (55 % females) with high blood pressure participated in the focus group discussions. Participants demonstrated good knowledge of high blood pressure risk factors but lacked an understanding of recommended salt intake levels and sources of hidden salt. Challenges in reducing salt intake included the limited availability of low-salt commercial foods. Participants suggested improved food labelling and the use of technology-based interventions to promote healthier choices. Findings highlight the need for behavioural interventions, policy reforms and collaborations between the government, food industries and health organisations to address high salt intake in the population.

Public mobile chronic obstructive pulmonary disease applications for self-management: Patients and healthcare professionals' perspectives

Poorly controlled chronic obstructive pulmonary disease (COPD) can negatively impact quality of life but mobile applications (apps) are popular digital tools that may mitigate these support needs. However, it is unclear if public mobile COPD apps are acceptable to healthcare professionals and patients, people living with COPD. Objectives: The primary objective is to determine people with COPD and healthcare professionals' perspectives on the appropriateness of public mobile COPD apps for supporting individuals' needs. The secondary objectives were to identify the ideal features and styles of mobile COPD apps for COPD self-management; and to identify the facilitators, barriers and needs for future COPD app research and development. Methods: Public mobile COPD apps were rated by questionnaires administered before and after focus group meetings. Ratings were reported as medians with interquartile ranges and median scores were categorized into three levels of appropriateness: 1-3 for inappropriate; 4-6 for uncertain; and 7-9 for appropriate. Results: A total of 6 people with COPD (mean age 68.2 ± 4.8years) and 22 healthcare professionals (mean age 45 ± 8.3years) completed this study. People with COPD identified one and healthcare professionals identified three public mobile COPD apps to be appropriate. They had different preferences for features and engagement styles but similar preferences for facilitators and barriers to use. Stakeholders mutually rated one public mobile COPD app as appropriate for self-management and emphasized the need for apps to be supplementary and customizable, rather than replacements for clinical management.

GPs' attitudes towards and experiences of using the Dermabuddy health app for the management of patients with dermatological conditions: a descriptive cross-sectional study

BACKGROUND

Dermatological presentations are common in primary care. The digital health space is growing in investment, revenue, and in usership numbers. Doctors utilise mobile health apps for referencing, communicating, and for clinical decision making. Dermabuddy is a secure mobile health app by which information and expertise around skin problems can be shared among a group of medical professionals with the aim of finding the best treatment and management plan.

AIM

To assess the utility of the Dermabuddy health app for GPs and associated trainees in the Republic of Ireland.

DESIGN & SETTING

This is a descriptive cross-sectional study, which involved a survey link distributed by email to GPs with Irish Medical Council membership.

METHOD

GPs were surveyed on their experiences of using the dermatology mobile application, Dermabuddy.

RESULTS

In total, 203 members took this questionnaire (13.5% response rate). Ninety-six per cent who responded to the statement, 'The app was easy to use', agreed it was 'easy' or 'very easy'. Eighty-seven per cent of those who responded to the statement, 'I would use this app again', agreed they 'definitely would'. Fifty-eight per cent of those who responded to the statement, 'The app is useful for my healthcare practice', gave it a five-star rating. The content of 36 comments included advice for improvement and positive feedback.

CONCLUSION

The Dermabuddy app was well received by participants in this study. Across all sections of the questionnaire looking at aspects of the app, including ease of use, interface and satisfaction, and usefulness, there was a positive response. Mobile health apps, such as Dermabuddy, may provide alternative solutions to meet the rising challenge of managing patients with dermatological conditions in primary care.

Mobile solution and chronic diseases: development and implementation of a mobile application and digital platform for collecting, analyzing data, monitoring and managing health care

BACKGROUND

Technological advances based on mobile health (mHealth), the field of digital health (eHealth) aimed at managing health services and care and their concomitant transformations, have become increasingly important in the 21st century. In this context, care for individuals diagnosed with Chronic Non-Communicable Diseases (CNCDs) deserves to be highlighted. The aim of this study is to present the creation, development and implementation of the Telehealth Center of the Federal University of Viçosa (NUTELES - UFV), for the monitoring and management of health care for individuals with Arterial Hypertension (AH) and/or Diabetes Mellitus (DM).

METHODS

This study, carried out in 2022 and 2023, involved 374 patients diagnosed with AH and/or DM in the health micro-region of Viçosa/MG, Brazil, comprising nine municipalities. The research aims to describe the creation, development and implementation of a software (NutelesApp) for the collection, storage, management and analysis of epidemiological research in public health, focusing specifically, on the monitoring and management of health care for individuals with AH and/or DM monitored by Primary Health Care (PHC). The parameters collected and analyzed were obtained through a questionnaire applied to patients, consisting of 70 questions, subdivided into 12 classes of questions. The epidemiological survey data was collected using mobile devices and analyzed using computer techniques based on statistical analysis. Once the field teams had completed their work, the files were transferred to servers for general analysis processing, using estimates of means, prevalence and respective standard errors, calculated using the Statistical Package for Social Science (SPSS) program, which takes into account the planning variables and includes the basic weights resulting from the sampling process. This study was approved by the Human Research Ethics Committee and registered, prior to recruitment, by the Brazilian Registry of Clinical Trials (ReBEC), ID: RBR-45hqzmf (Last approval date: 11/30/2022).

RESULTS

The information obtained through data collection with subsequent exploratory analysis of epidemiological data using the NutelesApp software suggests that mobile applications intended for the purpose of monitoring and managing healthcare for people with AH and/or DM should address the variables necessary to support a process of understanding the health conditions and/or disease of the individual as a whole and provide short- and long-term learning. Regarding the results of the survey using the software, the variables of 374 people were analyzed. Majority are female (73.2%) and white (43.5%). Most patients are elderly (average 64 years), with blood pressure levels within the normal range for this population, BMI indicates overweight, AC increased risk for cardiovascular events and CC within the recommendation value. All biochemical parameters analyzed were above normal limits.

CONCLUSIONS

The description of the creation and development of the software includes practical examples of its implementation, the results collected and its applicability in real scenarios, presenting determining criteria that can provide assertive and timely interventions for monitoring and managing the health and/or disease parameters of patients with HA and/or DM. In addition, the beneficial consequences of using this application will extend to health units and their respective management, improving the services provided by PHC and enhancing strategies and actions for health promotion and disease prevention.

Evaluation of Digital Mental Health Technologies in the United States: Systematic Literature Review and Framework Synthesis

BACKGROUND

Digital mental health technologies (DMHTs) have the potential to enhance mental health care delivery. However, there is little information on how DMHTs are evaluated and what factors influence their use.

OBJECTIVE

A systematic literature review was conducted to understand how DMHTs are valued in the United States from user, payer, and employer perspectives.

METHODS

Articles published after 2017 were identified from MEDLINE, Embase, PsycINFO, Cochrane Library, the Health Technology Assessment Database, and digital and mental health congresses. Each article was evaluated by 2 independent reviewers to identify US studies reporting on factors considered in the evaluation of DMHTs targeting mental health, Alzheimer disease, epilepsy, autism spectrum disorder, or attention-deficit/hyperactivity disorder. Study quality was assessed using the Critical Appraisal Skills Program Qualitative and Cohort Studies Checklists. Studies were coded and indexed using the American Psychiatric Association's Mental Health App Evaluation Framework to extract and synthesize relevant information, and novel themes were added iteratively as identified.

RESULTS

Of the 4353 articles screened, data from 26 unique studies from patient, caregiver, and health care provider perspectives were included. Engagement style was the most reported theme (23/26, 88%), with users valuing DMHT usability, particularly alignment with therapeutic goals through features including anxiety management tools. Key barriers to DMHT use included limited internet access, poor technical literacy, and privacy concerns. Novel findings included the discreetness of DMHTs to avoid stigma.

CONCLUSIONS

Usability, cost, accessibility, technical considerations, and alignment with therapeutic goals are important to users, although DMHT valuation varies across individuals. DMHT apps should be developed and selected with specific user needs in mind.

Understanding user engagement in mobile health applications from a privacy management perspective

Mobile health applications (mHealth apps) have surged in popularity for their role in promoting knowledge exchange and providing emotional support among health consumers. However, this enhanced social connectivity via these apps has led to an escalation in privacy breaches, potentially hindering user engagement. Drawing upon the communication privacy management theory, this study proposes a moderated mediation model to link social privacy concerns to user engagement in mHealth apps. An online survey involving 1149 mHealth app users was conducted in China to empirically validate the proposed model. Results indicated that social privacy concerns were negatively related to user engagement in mHealth apps, and perceived privacy of the app partially mediated this relationship. Moreover, perceived control positively moderated the indirect relationship between social privacy concerns and user engagement via perceived privacy. Specifically, the negative impact of social privacy concerns on perceived privacy was mitigated for users who reported higher levels of perceived control, indicating that when users feel more in control of their personal data, they are less affected by concerns over social privacy. Theoretically, this study has the potential to help scholars understand user engagement in mHealth apps from a privacy management perspective. Practically, the results of this study could assist mobile app providers and health professionals in devising evidence-based strategies to enhance social engagement and promote effective and sustainable use of mHealth apps among health consumers.

Impact of mobile Internet use on health-seeking behaviors: evidence from China

Introduction

Although health-seeking behaviors are crucial to China's healthcare delivery system, the influence of mobile Internet use in this context remains under-explored. This study aimed to comprehensively explore the influence of mobile Internet use on health-seeking behaviors, and meticulously examined the heterogeneity in health outcomes associated with the intersection between mobile Internet use and health-seeking behaviors.

Methods

We used nationally representative data derived from the China Family Panel Studies. Given that individuals typically make the decision to use mobile Internet autonomously, an instrumental variable regression methodology was adopted to mitigate potential selection biases.

Results

Our findings revealed that mobile Internet use significantly promoted self-medication and adversely affected the use of primary care facilities among Chinese adults. Furthermore, our findings highlighted the heterogeneous effects of mobile Internet use across diverse health demographic groups.

Conclusion

These findings underscore the importance of strategic planning and utilizing mobile Internet resources to steer individuals toward more appropriate healthcare-seeking behaviors.

Clinical Validation of Digital Healthcare Solutions: State of the Art, Challenges and Opportunities

Digital health technologies (DHTs) at the intersection of health, medical informatics, and business aim to enhance patient care through personalised digital approaches. Ensuring the efficacy and reliability of these innovations demands rigorous clinical validation. A PubMed literature review (January 2006 to July 2023) identified 1250 papers, highlighting growing academic interest. A focused narrative review (January 2018 to July 2023) delved into challenges, highlighting issues such as diverse regulatory landscapes, adoption issues in complex healthcare systems, and a plethora of evaluation frameworks lacking pragmatic guidance. Existing frameworks often omit crucial criteria, neglect empirical evidence, and clinical effectiveness is rarely included as a criterion for DHT quality. The paper underscores the urgency of addressing challenges in accreditation, adoption, business models, and integration to safeguard the quality, efficacy, and safety of DHTs. A pivotal illustration of collaborative efforts to address these challenges is exemplified by the Digital Health Validation Center, dedicated to generating clinical evidence of innovative healthcare technologies and facilitating seamless technology transfer. In conclusion, it is necessary to harmonise evaluation approaches and frameworks, improve regulatory clarity, and commit to collaboration to integrate rigorous clinical validation and empirical evidence throughout the DHT life cycle.

Prediction of anemia in real-time using a smartphone camera processing conjunctival images

Anemia is defined as a low hemoglobin (Hb) concentration and is highly prevalent worldwide. We report on the performance of a smartphone application (app) that records images in RAW format of the palpebral conjunctivae and estimates Hb concentration by relying upon computation of the tissue surface high hue ratio. Images of bilateral conjunctivae were obtained prospectively from a convenience sample of 435 Emergency Department patients using a dedicated smartphone. A previous computer-based and validated derivation data set associating estimated conjunctival Hb (HBc) and the actual laboratory-determined Hb (HBl) was used in deriving Hb estimations using a self-contained mobile app. Accuracy of HBc was 75.4% (95% CI 71.3, 79.4%) for all categories of anemia, and Bland-Altman plot analysis showed a bias of 0.10 and limits of agreement (LOA) of (-4.73, 4.93 g/dL). Analysis of HBc estimation accuracy around different anemia thresholds showed that AUC was maximized at transfusion thresholds of 7 and 9 g/dL which showed AUC values of 0.92 and 0.90 respectively. We found that the app is sufficiently accurate for detecting severe anemia and shows promise as a population-sourced screening platform or as a non-invasive point-of-care anemia classifier.

The BLV App Arcade: a new curated repository and evaluation rubric for mobile applications supporting blindness and low vision

PURPOSE

Visual impairment-related disabilities have become increasingly pervasive. Current reports estimate a total of 36 million persons with blindness and 217 million persons with moderate to severe visual impairment worldwide. Assistive technologies (AT), including text-to-speech software, navigational/spatial guides, and object recognition tools have the capacity to improve the lives of people with blindness and low vision. However, access to such AT is constrained by high costs and implementation barriers. More recently, expansive growth in mobile computing has enabled many technologies to be translated into mobile applications. As a result, a marketplace of accessibility apps has become available, yet no framework exists to facilitate navigation of this voluminous space.

MATERIALS AND METHODS

We developed the BLV (Blind and Low Vision) App Arcade: a fun, engaging, and searchable curated repository of app AT broken down into 11 categories spanning a wide variety of themes from entertainment to navigation. Additionally, a standardized evaluation metric was formalized to assess each app in five key dimensions: reputability, privacy, data sharing, effectiveness, and ease of use/accessibility. In this paper, we describe the methodological approaches, considerations, and metrics used to find, store and score mobile applications.

CONCLUSION

The development of a comprehensive and standardized database of apps with a scoring rubric has the potential to increase access to reputable tools for the visually impaired community, especially for those in low- and middle-income demographics, who may have access to mobile devices but otherwise have limited access to more expensive technologies or services.

Evaluating the Diagnostic Performance of Symptom Checkers: Clinical Vignette Study

BACKGROUND

Medical self-diagnostic tools (or symptom checkers) are becoming an integral part of digital health and our daily lives, whereby patients are increasingly using them to identify the underlying causes of their symptoms. As such, it is essential to rigorously investigate and comprehensively report the diagnostic performance of symptom checkers using standard clinical and scientific approaches.

OBJECTIVE

This study aims to evaluate and report the accuracies of a few known and new symptom checkers using a standard and transparent methodology, which allows the scientific community to cross-validate and reproduce the reported results, a step much needed in health informatics.

METHODS

We propose a 4-stage experimentation methodology that capitalizes on the standard clinical vignette approach to evaluate 6 symptom checkers. To this end, we developed and peer-reviewed 400 vignettes, each approved by at least 5 out of 7 independent and experienced primary care physicians. To establish a frame of reference and interpret the results of symptom checkers accordingly, we further compared the best-performing symptom checker against 3 primary care physicians with an average experience of 16.6 (SD 9.42) years. To measure accuracy, we used 7 standard metrics, including M1 as a measure of a symptom checker's or a physician's ability to return a vignette's main diagnosis at the top of their differential list, F1-score as a trade-off measure between recall and precision, and Normalized Discounted Cumulative Gain (NDCG) as a measure of a differential list's ranking quality, among others.

RESULTS

The diagnostic accuracies of the 6 tested symptom checkers vary significantly. For instance, the differences in the M1, F1-score, and NDCG results between the best-performing and worst-performing symptom checkers or ranges were 65.3%, 39.2%, and 74.2%, respectively. The same was observed among the participating human physicians, whereby the M1, F1-score, and NDCG ranges were 22.8%, 15.3%, and 21.3%, respectively. When compared against each other, physicians outperformed the best-performing symptom checker by an average of 1.2% using F1-score, whereas the best-performing symptom checker outperformed physicians by averages of 10.2% and 25.1% using M1 and NDCG, respectively.

CONCLUSIONS

The performance variation between symptom checkers is substantial, suggesting that symptom checkers cannot be treated as a single entity. On a different note, the best-performing symptom checker was an artificial intelligence (AI)-based one, shedding light on the promise of AI in improving the diagnostic capabilities of symptom checkers, especially as AI keeps advancing exponentially.

Problems and Barriers Related to the Use of mHealth Apps From the Perspective of Patients: Focus Group and Interview Study

BACKGROUND

Since fall 2020, mobile health (mHealth) apps have become an integral part of the German health care system. The belief that mHealth apps have the potential to make the health care system more efficient, close gaps in care, and improve the economic outcomes related to health is unwavering and already partially confirmed. Nevertheless, problems and barriers in the context of mHealth apps usually remain unconsidered.

OBJECTIVE

The focus groups and interviews conducted in this study aim to shed light on problems and barriers in the context of mHealth apps from the perspective of patients.

METHODS

Guided focus groups and individual interviews were conducted with patients with a disease for which an approved mHealth app was available at the time of the interviews. Participants were recruited via self-help groups. The interviews were recorded, transcribed, and subjected to a qualitative content analysis. The content analysis was based on 10 problem categories ("validity," "usability," "technology," "use and adherence," "data privacy and security," "patient-physician relationship," "knowledge and skills," "individuality," "implementation," and "costs") identified in a previously conducted scoping review. Participants were asked to fill out an additional questionnaire about their sociodemographic data and about their use of technology.

RESULTS

A total of 38 patients were interviewed in 5 focus groups (3 onsite and 2 web-based) and 5 individual web-based interviews. The additional questionnaire was completed by 32 of the participants. Patients presented with a variety of different diseases, such as arthrosis, tinnitus, depression, or lung cancer. Overall, 16% (5/32) of the participants had already been prescribed an app. During the interviews, all 10 problem categories were discussed and considered important by patients. A myriad of problem manifestations could be identified for each category. This study shows that there are relevant problems and barriers in the context of mHealth apps from the perspective of patients, which warrant further attention.

CONCLUSIONS

There are essentially 3 different areas of problems in the context of mHealth apps that could be addressed to improve care: quality of the respective mHealth app, its integration into health care, and the expandable digital literacy of patients.

Human Healthcare and Its Pharmacy Component from a Safety Point of View

Healthcare plays a crucial role in public and national safety as a significant part of state activity and a component of national safety, whose mission is to organize and ensure affordable medical care for the population. The four stages of the genesis of healthcare safety development with the corresponding safety models of formation were defined: technical, human factor or security management, systemic security management, and cognitive complexity. It was established that at all stages, little attention is paid to the issues of the formation of the pharmaceutical sector's safety. Taking into account the development of safety models that arise during the four stages of the genesis of safety science, we have proposed a model of the evolution of pharmaceutical safety formation. At the same time, future research is proposed to focus on new holistic concepts of safety, such as "Safety II", evaluation and validation methods, especially in the pharmaceutical sector, where the development of this topic remained in the second stage of the evolution of science, the search for pharmaceutical errors related to drugs.

The digital divide in rural and regional communities: a survey on the use of digital health technology and implications for supporting technology use

OBJECTIVE

A digital divide exists for people from rural and regional areas where they are less likely and confident to engage in digital health technologies. The aim of this study was to evaluate the digital health literacy and engagement of people from rural and regional communities, with a focus on identifying barriers and facilitators to using technology.

RESULTS

Forty adults living in rural/regional areas completed a survey consisting of the eHealth Literacy Scale (eHEALS) with additional items surveying participants' experience with a range of digital health technologies. All participants had used at least one digital health technology. Most (80%) participants had an eHEALS score of 26 or above indicating confidence in online health information. Commonly reported barriers to digital health technology use centred on product complexity and reliability, awareness of resources, lack of trust, and cost. Effective digital health technology use is becoming increasingly important, there may be a need to prioritise and support people with lower levels of digital health literacy. We present opportunities to support community members in using and accessing digital health technology.

Don't judge a book or health app by its cover: User ratings and downloads are not linked to quality

OBJECTIVE

To analyse the relationship between health app quality with user ratings and the number of downloads of corresponding health apps.

MATERIALS AND METHODS

Utilising a dataset of 881 Android-based health apps, assessed via the 300-point objective Organisation for the Review of Care and Health Applications (ORCHA) assessment tool, we explored whether subjective user-level indicators of quality (user ratings and downloads) correlate with objective quality scores in the domains of user experience, data privacy and professional/clinical assurance. For this purpose, we applied spearman correlation and multiple linear regression models.

RESULTS

For user experience, professional/clinical assurance and data privacy scores, all models had very low adjusted R squared values (< .02). Suggesting that there is no meaningful link between subjective user ratings or the number of health app downloads and objective quality measures. Spearman correlations suggested that prior downloads only had a very weak positive correlation with user experience scores (Spearman = .084, p = .012) and data privacy scores (Spearman = .088, p = .009). There was a very weak negative correlation between downloads and professional/clinical assurance score (Spearman = -.081, p = .016). Additionally, user ratings demonstrated a very weak correlation with no statistically significant correlations observed between user ratings and the scores (all p > 0.05). For ORCHA scores multiple linear regression had adjusted R-squared = -.002.

CONCLUSION

This study highlights that widely available proxies which users may perceive to signify the quality of health apps, namely user ratings and downloads, are inaccurate predictors for estimating quality. This indicates the need for wider use of quality assurance methodologies which can accurately determine the quality, safety, and compliance of health apps. Findings suggest more should be done to enable users to recognise high-quality health apps, including digital health literacy training and the provision of nationally endorsed "libraries".

Evaluation of Patient-Facing Mobile Apps to Support Physiotherapy Care: Systematic Review

BACKGROUND

Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation.

OBJECTIVE

The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential.

METHODS

A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app's potential to change behavior.

RESULTS

In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15).

CONCLUSIONS

Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29047.

Filling the gaps in the evaluation and selection of mobile health technologies in respiratory medicine

INTRODUCTION

Mobile health (mHealth) technology in respiratory medicine is a fast-growing and promising digital technology that is popular among patients and healthcare providers (HCPs). They provide reminders and step-by-step instructions for the correct inhalation technique, monitor patients' adherence to treatment, and facilitate communication between patients and HCPs.

AREAS COVERED

While numerous mHealth apps have been developed over the years, most applications do not have supporting evidence. Selecting the best mHealth app in respiratory medicine is challenging due to limited studies carrying out mHealth app selection. Although mHealth technologies play an important part in the future of respiratory medicine, there is no single guide on the evaluation and selection of mHealth technologies for patients with pulmonary diseases. This paper aims to provide an overview of mHealth technologies, particularly emphasizing digital inhalers and standalone applications used in asthma. Additionally, it offers insights into the evaluation, selection, and pertinent considerations surrounding mHealth applications in respiratory medicine.

EXPERT OPINION

Evaluating mHealth apps will take time, resources, and collaboration between stakeholders such as governmental regulatory bodies, subject-matter experts, and industry representatives. Filling the gaps in the evaluation and selection of the mHealth app will improve clinical decision-making, personalized treatments, self-management and disease monitoring in respiratory medicine.

The landscape of decentralized clinical trials (DCTs): focusing on the FDA and EMA guidance

Decentralized clinical trials (DCTs) consist of off-site trial-related procedures referred to as decentralized elements. We aimed to provide an overview of the landscape of DCTs by comparing regulatory guidance reports and analyzing decentralized elements from clinical trial registries. Two guidance reports on DCTs published by the U.S. Food and Drug Administration and the European Medicines Agencies were summarized and analyzed. Both guidance publications commonly emphasized an assessment of the appropriateness of decentralized elements along 2 axes: patient safety and data integrity. DCT cases were identified from ClinicalTrials.gov by searching with 6 keywords: decentralized, remote, mobile, digital, virtual, and hybrid. Cases where the keyword was used in a non-DCT context, such as digital flexor tendon, were excluded by means of natural language processing. A total of 4,874 trials were identified as DCT cases, with annual increases, especially after 2020. The most common keywords were 'mobile' and 'digital' (36.2% and 24.8%, respectively). Interventions in the DCT cases were analyzed by means of a network analysis. Behavioral and technological tokens were frequently combined, such as 'rehabilitation' and 'app.' Drugs were used in only 1.8% of the DCT cases. Of these, most drugs had been approved previously (96.8%) and were in oral formulation (67.2%). Most of the DCT cases identified in this study involved simple interventions and low-risk drugs. These characteristics were in accordance with the common recommendations in the DCT guidance publications.

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.

What would it take to improve the uptake and utilisation of mHealth applications among older Australians? A qualitative study

Objective Health-related apps on mobile devices (mHealth apps) have become an effective self-management tool and treatment support for patients. There is limited research, however, on how older people (50 and over) perceive the opportunity of using mHealth apps. Our aim was to investigate the perceptions of older people in Australia regarding the opportunity of using prescribed or doctor-recommended mHealth apps and provide insights which can enhance their uptake of mHealth. Methods This was a qualitative study using semi-structured interviews involving 21 participants aged 51-82 years. Qualitative thematic analysis was used to categorise the factors that influence the adoption of mHealth apps by older adults. Results We show that beyond the prominent influencing factors from technology adoption research (such as performance and effort expectancy, social influence and facilitating conditions), health-specific factors such as a trusting doctor-patient relationship and strong health self-efficacy positively influence the intended adoption of mHealth apps among older adults. In addition, the IT security and accurate interpretation of participants' input in an mHealth app can present barriers to mHealth app adoption. Conclusion Our analyses provide additional insights complementing existing technology adoption research. Their successful adoption and utilisation require further empirical evidence on its effectiveness along with attention to the voices of those who are meant to use them. To address potential barriers, improve the quality and security of mHealth apps, and thus achieve greater patient safety, the involvement of consumers, regulators and health professionals is necessary.

SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment

Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.

Seeking help for mental health during the COVID-19 pandemic: A longitudinal analysis of adults' experiences with digital technologies and services

The COVID-19 pandemic brought about dramatic changes in how patients access healthcare from its outset. Lockdown restrictions and remote working led to a proliferation of digital technologies and services, which also impacted mental health provisions. Against the backdrop of new and changing support services, along with an unprecedented emphasis on mental health, relatively little is known about how adults sought out and received support for their mental health during this period. With a sample of 27,574 adults assessed longitudinally online over 12 months of the pandemic in the UK, we analysed reports of help-seeking for mental health, as well as sources of treatment or support and the perceived helpfulness of treatments received. We observed that the proportions of participants who reported seeking help remained relatively consistent throughout the 12-month period (ranging from 12.6% to 17.0%). Online talking therapies were among the most frequently sought sources (15.3%), whereas online self-guided treatments were among the least frequently sought sources (5%). Telephone lines, both NHS and non-governmental, had marked treatment 'gaps'. These treatment gaps, where individuals sought treatment but did not receive it, were especially evident for men and older adults. Our findings underscore online talking therapies as being a widely-sought and helpful source of mental health support. This is important given the current global need for accessible treatment options.

Quality of Digital Health Interventions Across Different Health Care Domains: Secondary Data Analysis Study

BACKGROUND

There are more than 350,000 digital health interventions (DHIs) in the app stores. To ensure that they are effective and safe to use, they should be assessed for compliance with best practice standards.

OBJECTIVE

The objective of this paper was to examine and compare the compliance of DHIs with best practice standards and adherence to user experience (UX), professional and clinical assurance (PCA), and data privacy (DP).

METHODS

We collected assessment data from 1574 DHIs using the Organisation for the Review of Care and Health Apps Baseline Review (OBR) assessment tool. As part of the assessment, each DHI received a score out of 100 for each of the abovementioned areas (ie, UX, PCA, and DP). These 3 OBR scores are combined to make up the overall ORCHA score (a proxy for quality). Inferential statistics, probability distributions, Kruskal-Wallis, Wilcoxon rank sum test, Cliff delta, and Dunn tests were used to conduct the data analysis.

RESULTS

We found that 57.3% (902/1574) of the DHIs had an Organisation for the Review of Care and Health Apps (ORCHA) score below the threshold of 65. The overall median OBR score (ORCHA score) for all DHIs was 61.5 (IQR 51.0-73.0) out of 100. A total of 46.2% (12/26) of DHI's health care domains had a median equal to or above the ORCHA threshold score of 65. For the 3 assessment areas (UX, DP, and PCA), DHIs scored the highest for the UX assessment 75.2 (IQR 70.0-79.6), followed by DP 65.1 (IQR 55.0-73.4) and PCA 49.6 (IQR 31.9-76.1). UX scores had the least variance (SD 13.9), while PCA scores had the most (SD 24.8). Respiratory and urology DHIs were consistently highly ranked in the National Institute for Health and Care Excellence Evidence Standards Framework tiers B and C based on their ORCHA score.

CONCLUSIONS

There is a high level of variability in the ORCHA scores of DHIs across different health care domains. This suggests that there is an urgent need to improve compliance with best practices in some health care areas. Possible explanations for the observed differences might include varied market maturity and commercial interests within the different health care domains. More investment to support the development of higher-quality DHIs in areas such as ophthalmology, allergy, women's health, sexual health, and dental care may be needed.

Association Between the Characteristics of mHealth Apps and User Input During Development and Testing: Secondary Analysis of App Assessment Data

BACKGROUND

User involvement is increasingly acknowledged as a central part of health care innovation. However, meaningful user involvement during the development and testing of mobile health apps is often not fully realized.

OBJECTIVE

This study aims to examine in which areas user input is most prevalent and whether there is an association between user inclusion and compliance with best practices for mobile health apps.

METHODS

A secondary analysis was conducted on an assessment data set of 1595 health apps. The data set contained information on whether the apps had been developed or tested with user input and whether they followed best practices across several domains. Background information was also available regarding the apps' country of origin, targeted condition areas, subjective user ratings, download numbers, and risk (as per the National Institute for Health and Care Excellence Evidence Standards Framework [ESF]). Descriptive statistics, Mann-Whitney U tests, and Pearson chi-square analyses were applied to the data.

RESULTS

User involvement was reported by 8.71% (139/1595) of apps for only the development phase, by 33.67% (537/1595) of apps for only the testing phase, by 21.88% (349/1595) of apps for both phases, and by 35.74% (570/1595) of apps for neither phase. The highest percentage of health apps with reported user input during development was observed in Denmark (19/24, 79%); in the condition areas of diabetes (38/79, 48%), cardiology (15/32, 47%), pain management (20/43, 47%), and oncology (25/54, 46%); and for high app risk (ESF tier 3a; 105/263, 39.9%). The highest percentage of health apps with reported user input during testing was observed in Belgium (10/11, 91%), Sweden (29/34, 85%), and France (13/16, 81%); in the condition areas of neurodiversity (42/52, 81%), respiratory health (58/76, 76%), cardiology (23/32, 72%), and diabetes (56/79, 71%); and for high app risk (ESF tier 3a; 176/263, 66.9%). Notably, apps that reported seeking user input during testing demonstrated significantly more downloads than those that did not (P=.008), and user inclusion was associated with better compliance with best practices in clinical assurance, data privacy, risk management, and user experience.

CONCLUSIONS

The countries and condition areas in which the highest percentage of health apps with user involvement were observed tended to be those with higher digital maturity in health care and more funding availability, respectively. This suggests that there may be a trade-off between developers' willingness or ability to involve users and the need to meet challenges arising from infrastructure limitations and financial constraints. Moreover, the finding of a positive association between user inclusion and compliance with best practices indicates that, where no other guidance is available, users may benefit from prioritizing health apps developed with user input as the latter may be a proxy for broader app quality.

The Internet, Apps, and the Anesthesiologist

Modern anesthesia continues to be impacted in new and unforeseen ways by digital technology. Combining portability and versatility, mobile applications or "apps" provide a multitude of ways to enhance anesthetic and peri-operative care. Research suggests that the uptake of apps into anesthetic practice is becoming increasingly routine, especially amongst younger anesthetists brought up in the digital age. Despite this enthusiasm, there remains no consensus on how apps are safely and efficiently integrated into anesthetic practice. This review summarizes the most popular forms of app usage in anesthesia currently and explores the challenges and opportunities inherent in implementing app use in anesthesia, with an emphasis on a practical approach for the modern anesthetist.

Chatbot-supported psychoeducation in adult attention-deficit hyperactivity disorder: randomised controlled trial

BACKGROUND

Although psychoeducation is generally recommended for the treatment of adult attention-deficit hyperactivity disorder (ADHD), participation in clinical psychoeducation groups is impeded by waiting times and the constrained number of patients who can simultaneously attend a group. Digital psychoeducation attempts are promising, but the rapidly expanding number of apps lack evidence and are mostly limited to only a few implemented interactive elements.

AIMS

To determine the potential of digital, self-guided psychoeducation for adult ADHD, a newly developed interactive chatbot was compared with a previously validated, conventional psychoeducation app.

METHOD

Forty adults with ADHD were randomised, of whom 17 participants in each group completed self-guided psychoeducation based on either a chatbot or conventional psychoeducation app between October 2020 and July 2021. ADHD core symptoms were assessed before and after the 3-week interventions, using both the blinded observer-rated Integrated Diagnosis of ADHD in Adulthood interview and the self-rated ADHD Self-Assessment Scale (ADHS-SB).

RESULTS

Observer- and patient-rated ADHD symptoms were significantly reduced from pre- to post-intervention (observer-rated: mean difference -6.18, 95% CI -8.06 to -4.29; patient-rated: mean difference -2.82, 95% CI -4.98 to -0.67). However, there were no group × intervention interaction effects that would indicate a stronger therapeutic benefit of one of the interventions. Likewise, administered psychoeducational knowledge quizzes did not show differences between the groups. No adverse events were reported.

CONCLUSIONS

Self-guided psychoeducation based on a chatbot or a conventional app appears similarly effective and safe for improving ADHD core symptoms. Future research should compare additional control interventions and examine patient-related outcomes and usability preferences in detail.

Apps in healthcare and medical research; European legislation and practical tips every healthcare provider should know

BACKGROUND

The use of apps in healthcare and medical research is increasing. Apps in healthcare may be beneficial to patients and healthcare professionals, but their use comes with potential risks. How to use apps in clinical care is not standard part of medical training, resulting in a lack of knowledge. As healthcare professionals and their employers can be held accountable for the wrongful use of medical apps, this situation is undesirable. This article addresses the most important European legislation regarding medical apps from the perspective of healthcare providers.

METHODS

This review provides an overview of current and changing regulations, focusing on apps used in healthcare and medical research. Three topics are discussed: 1) the relevant European legislation and its enforcement, 2) the responsibilities and liability of the medical professional when using these apps, and 3) an overview of the most practical considerations medical professionals should know when using or building a medical app.

RESULTS

When using and developing medical apps, data privacy must be guaranteed according to the GDPR guidelines. Several international standards make it easier to comply with the GDPR, such as ISO/IEC 27001 and 27002. Medical Devices Regulation was implemented on May 26, 2021, and as a result, medical apps will more often qualify as medical devices. The important guidelines for manufacturers to comply with Medical Devices Regulation are ISO 13485, ISO 17021, ISO 14971 and ISO/TS 82304-2.

CONCLUSION

The use of medical apps in healthcare and medical research can be beneficial to patients, medical professionals, and society as a whole. This article provides background information on legislation and a comprehensive checklist for anyone wanting to start using or building medical apps.

Nutrition and Diet Apps: Brazilian Panorama before and during the COVID-19 Pandemic

In the last decade, we have seen a substantial increase in the development and use of mobile technology to improve diet and healthy eating behaviors.

OBJECTIVE

To describe the characteristics of nutrition and diet apps before and after the COVID-19 pandemic available in Brazil.

METHODS

Nutrition and diet apps were identified using the official Apple and Google stores. The search occurred in January 2020 and May 2022 in Brazil. We extracted the nutritional content and standard indicators (e.g., being developed before or after 2020, number of languages, target population, investment, prices, seller, number of reviews and downloads, consumer rating).

RESULTS

280 apps were launched before and 411 during the COVID-19 period. Most apps were available in at least ten languages (96.6%), with no indication of age (95.6%) or partial or full cost (59%). As for the contents, 18.9% addressed personal diet suggestions; 73.4%, nutritional education; 48.8%, revenues; 35.9%, physical activity with a nutritional guide; 2.3%, nutritional recommendation for eating out; 23.9%, grocery shopping with a scan code; 32.4%, food diary; 18.9%, water intake; and 4.6%, nutrition/diseases. The data show an evolution that may have been boosted by the pandemic and that reveals a trend towards the development of apps with educational content.

CONCLUSION

During the pandemic, there was a positive qualitative and quantitative movement in e-health regarding the promotion of education.

AIM (Angular Indication Measurement)- Visual Acuity: An adaptive, self-administered, and generalizable vision assessment method used to measure visual acuity

This proof-of-concept study introduces Angular Indication Measurement and applies it to VA (AIM-VA). First, we compared the ability of AIM-VA and ETDRS to detect defocus and astigmatic blur in 22 normally-sighted adults. Spherical and cylindrical lenses (±0.00D, +0.25D, +0.50D, +0.75D, +1.00D, +2.00D and +0.50D, +1.00D, +2.00D each at 0°, 90°, 135°, respectively) in the dominant eye induced blur. Second, we compared repeatability over two tests of AIM-VA and ETDRS. A 2-way-ANOVA showed a main effect for defocus-blur and test with no interaction. A 3-way-ANOVA for the astigmatism experiment revealed main effects for test type, blur, and direction and with no interactions. Planned multiple comparisons showed AIM had greater astigmatic-induced VA loss than ETDRS. Bland-Altman plots showed small bias and no systematic learning effect for either test type and improved repeatability with >2 adaptive steps for AIM-VA. AIM-VA's ability to detect defocus was comparable with that of an ETDRS letter chart and showed greater sensitivity to astigmatic blur, and AIM-VA's repeatability is comparable with ETDRS when using 2 or more adaptive steps. AIM's self-administered orientation judgment approach is generalizable to interrogate other visual functions, e.g., contrast, color, motion, stereo-vision.

The effectiveness of mobile application for monitoring diabetes mellitus and hypertension in the adult and elderly population: systematic review and meta-analysis

CONTEXT

Arterial Hypertension (AH) and Diabetes Mellitus (DM) are diseases that are getting worse all over the world. Linked to this advance, is the growing digital health market with numerous mobile health applications, which aim to help patients and professionals in the proper management of chronic diseases. The aim of this study was to analyze, through a systematic review and meta-analysis, the effectiveness of using mobile health applications in monitoring AH and/or DM in the adult and elderly population.

METHODS

The systematic review and meta-analysis was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Metanalyses guidelines and involved searching five databases - Medline/PubMed, Embase, CINAHL, Virtual Library in Health and Cochrane Library. The review included randomized and cohort clinical trials testing the effects of the intervention on changing biochemical parameters and clinical efficacy in people treated for AH and/or DM. The quality of the selected studies was assessed based on the evaluation criteria of the Joanna Briggs Institute tool. The random effects meta-analysis method was used to explain effect distribution between studies, by Stata® software (version 11.0) and publication bias was examined by visual inspection of graphs and Egger test.

RESULTS

We included 26 studies in the systematic review and 17 in the meta-analysis. These studies were published between 2014 to 2022 in 14 countries. Were reported improvement in knowledge and self-management of AH and DM, social motivation with treatment and behavioral change, reduction in glycated hemoglobin values, fasting glucose and blood pressure, improvement in adherence to drug treatment, among others. The result of the meta-analysis showed that there is evidence that the use of mobile applications can help reduce glycated hemoglobin by 0.39% compared to the usual care group.

CONCLUSIONS

Monitoring and self-monitoring of behaviors and health care related to AH and DM in adults and the elderly through mobile applications, has clinically significant effectiveness in reducing glycated hemoglobin levels. Future studies should provide more evidence and recommendations for best practices and development of digital health interventions.

TRIAL REGISTRATION

PROSPERO. International Prospective Registry of Systematic Reviews. CRD42022361928.

Identification of the Most Suitable Mobile Apps to Support Dietary Approaches to Stop Hypertension (DASH) Diet Self-Management: Systematic Search of App Stores and Content Analysis

Smartphone apps might provide an opportunity to support the Dietary Approaches to Stop Hypertension (DASH) diet, a healthy diet designed to help lower blood pressure. This study evaluated DASH diet self-management apps based on their quality, likely effectiveness, and data privacy/security to identify the most suitable app(s). A systematic search and content analysis were conducted of all DASH diet apps available in Google Play and the Apple App Store in the UK in November 2022. Apps were included if they provided DASH diet tracking. A previous systematic literature review found some commercial apps not found in the app store search, and these were also included in this review. Three reviewers used the App Quality Evaluation Tool (AQEL) to assess each app's quality across seven domains: knowledge acquisition, skill development, behaviour change, purpose, functionality, and appropriateness for adults with hypertension. Domains with a score of 8 or higher were considered high-quality. Two reviewers assessed the apps' data privacy and security and then coded Behaviour change techniques (BCTs) linked to the Theoretical Domain Framework (TDF) underpinning the likely effectiveness of the apps. Seven DASH diet apps were assessed, showing the limited availability of apps supporting DASH diet self-management. The AQEL assessment showed that three apps scored higher than eight in most of the AQEL domains. Nineteen BCTs were used across the apps, linked to nine TDF action mechanisms that may support DASH diet self-management behaviours. Four apps met standards for privacy and security. All seven apps with self-monitoring functionality had sufficient theoretical basis to demonstrate likely effectiveness. However, most had significant quality and data security shortcomings. Only two apps, NOOM and DASH To TEN, were found to have both adequate quality and security and were thus deemed suitable to support DASH diet self-management.

Patient-targeted mobile applications in healthcare

There has been an increase in the number of healthcare-related applications targeted at patients for use on mobile phones. With an increasing proportion of the population using such applications, it is important to understand the associated limitations, safety concerns and challenges of legalisation. This article explores the impact of these applications on frontline care and patient wellbeing, evaluating the literature surrounding the benefits and challenges of patient-targeted mobile applications in health care and analysing the limitations of existing research. The proclaimed benefits of such applications are not always evidence based. Furthermore, many healthcare applications are created by laypeople and not validated by healthcare authorities, creating a potential to cause patient harm. Further research is needed to identify long-term effects on both healthcare systems and individuals' psychosocial wellbeing. However, research in this field often lacks a universal perspective and may be influenced by underlying financial motives to promote use of the applications.

Orthodontic apps: An assessment of content accuracy and validity

OBJECTIVE

To assess the content accuracy of orthodontic treatment information in patient-focused apps.

DESIGN

A cross-sectional review study.

SETTING

Orthodontic apps available on the UK Android and Apple App Stores.

METHODS

Apps identified in a previous research study and those identified via a questionnaire of specialist orthodontists were assessed for accuracy of content utilising an evidence-based checklist. The checklist covered five main orthodontically relevant themes and 32 codes with respective items.

RESULTS

The accuracy of information content for 16 patient-focused apps was assessed. Eight apps provided information related to orthodontic treatment and handling emergencies. Five apps were reminder apps and a small number (n = 3) contained games and timers for toothbrushing and aligners. With regard to the accuracy of information content, only two apps contained information across all five themes of the evidence-based checklist. Only one app received a score of 'fair - excellent' under the oral hygiene theme; interestingly, this app was the most commonly used patient-focused app. Eight apps containing orthodontic treatment information scored poorly as they had inaccurate information on handling emergency situations. None of the apps were deemed excellent with regard to accuracy of information content.

CONCLUSION

The orthodontic mobile apps assessed in this study mostly contained information of poor accuracy. Therefore, there is a need for high-quality apps with credible information supported by evidence to be developed.

The Craving-Manager smartphone app designed to diagnose substance use/addictive disorders, and manage craving and individual predictors of relapse: a study protocol for a multicenter randomized controlled trial

Background

The rate of individuals with addiction who are currently treated are low, and this can be explained by barriers such as stigma, desire to cope alone, and difficulty to access treatment. These barriers could be overcome by mobile technologies. EMI (Ecological Momentary Intervention) is a treatment procedure characterized by the delivery of interventions (messages on smartphones) to people in their daily lives. EMI presents opportunities for treatments to be available to people during times and in situations when they are most needed. Craving is a strong predictor of relapse and a key target for addiction treatment. Studies using Ecological Momentary Assessment (EMA) method have revealed that, in daily life, person-specific cues could precipitate craving, that in turn, is associated with a higher probability to report substance use and relapse in the following hours. Assessment and management of these specific situations in daily life could help to decrease addictive use and avoid relapse. The Craving-Manager smartphone app has been designed to diagnose addictive disorders, and assess and manage craving as well as individual predictors of use/relapse. It delivers specific and individualized interventions (counseling messages) composed of evidence-based addiction treatments approaches (cognitive behavioral therapy and mindfulness). The Craving-Manager app can be used for any addiction (substance or behavior). The objective of this protocol is to evaluate the efficacy of the Craving-Manager app in decreasing use (of primary substance(s)/addictive behavior(s)) over 4 weeks, among individuals on a waiting list for outpatient addiction treatment.

Methods/design

This multicenter double-blind randomized controlled trial (RCT) will compare two parallel groups: experimental group (full interventional version of the app, 4 weeks, EMA + EMI), versus control group (restricted version of the app, 4 weeks, only EMA). Two hundred and seventy-four participants will be recruited in 6 addiction treatment centers in France.

Discussion

This RCT will provide indication on how the Craving-Manager app will reduce addictive use (e.g., better craving management, better stimulus control) in both substance and behavioral addictions. If its efficacy is confirmed, the app could offer the possibility of an easy to use and personalized intervention accessible to the greatest number of individuals with addiction.

Clinical Trial Registration

ClinicalTrials.gov: NCT04732676.

Dr. Smartphone, can you support my trauma? An informatics analysis study of App Store apps for trauma- and stressor-related disorders

Background

Psychological trauma is prevalent in developed countries, with prevalence rates and treatment needs exceeding health system capacity. As telemedicine and out-of-patient care are promoted, there has been an expansion of digital apps to compliment therapeutic stages in psychological trauma. To date there are no reviews that have compared these apps and their clinical utility. This study aims to identify the availability of trauma- and stressor-related mhealth apps, assess their functionality, and review their therapeutic abilities.

Methodology

The authors conducted a systematic search using an iPhone 13 Pro in the Australian IOS App Store to extract trauma- and stressor-related apps that resulted from the search criteria. A cross-adaptation of the Mobile App Rating Scale (MARS) and the Comprehensive App Evaluation Model (CAEM) were used as a framework to produce the mTrauma App Evaluation Conceptual Model and Informatics Framework. App content descriptors were analysed based on their general characteristics, usability, therapeutic focus, clinical utility, data integration. Following an applicability in concordance with psychological trauma-informed delivery.

Results

A total of 234 apps resulting from the search strategy were screened, with 81 apps that met the inclusion criteria. The majority of apps were marketed to 4+ to 17+ years of age, categorised as 'health and fitness', with the highest target markets observed for adolescents, children, parents, clinicians, and clients. A total of 43 apps (53.1%) contained a trauma-informed specified section, and 37 (45.7%) incorporated a section useful to support trauma-related symptoms. A significant number of apps there was an absence of therapeutic utility (in 32 apps (39.5%)). Most apps were supporting post-traumatic stress disorder-informed, cognitive behavioural therapy and eye movement desensitisation and reprocessing. Provision of psychoeducation, courses, guided sessions, trainings, self-reflection/journaling, symptom management and progress tracking were highly present.

Conclusions

Trauma-informed mobile apps are available in the App Store, expanding in its target market reach and usability, with an increase of creative psychotherapies being introduced alongside conventional modalities. However, based on the app descriptors, the scarcity of evidenced-based testimonials and therapeutic applicability remains questionable for clinical validity. Although mhealth tools are marketed as trauma-related, current available apps employ a multifunctional approach to general psychological symptomatology, through to associated comorbid conditions and emphasizes on passive activity. For higher uptake on user engagement, clinical application and validity, trauma-apps require curated specification to fulfil its role as complimentary psychological treatment.

Guidelines to Establish an Equitable Mobile Health Ecosystem

Mobile health (mHealth)-that is, use of mobile devices, such as mobile phones, monitoring devices, personal digital assistants, and other wireless devices, in medical care-is a promising approach to the provision of support services. mHealth may aid in facilitating monitoring of mental health conditions, offering peer support, providing psychoeducation (i.e., information about mental health conditions), and delivering evidence-based practices. However, some groups may fail to benefit from mHealth despite a high need for mental health services, including people from racially and ethnically disadvantaged groups, rural residents, individuals who are socioeconomically disadvantaged, and people with disabilities. A well-designed mHealth ecosystem that considers multiple elements of design, development, and implementation can afford disadvantaged populations the opportunity to address inequities and facilitate access to and uptake of mHealth. This article proposes inclusion of the following principles and standards in the development of an mHealth ecosystem of equity: use a human-centered design, reduce bias in machine-learning analytical techniques, promote inclusivity via mHealth design features, facilitate informed decision making in technology selection, embrace adaptive technology, promote digital literacy through mHealth by teaching patients how to use the technology, and facilitate access to mHealth to improve health outcomes.

A Systematic Assessment of the Quality of Smartphone Applications for Gastroesophageal Reflux Disease

Background and Aims

Smartphone applications aimed at patients with gastroesophageal reflux disease (GERD) have been downloaded more than 100,000 times, yet no systematic assessment of their quality has been completed. This study aimed to objectively assess the quality of GERD smartphone applications for patient education and disease management.

Methods

The Apple App Store and Google Play Store were systematically searched for relevant applications. Two independent reviewers performed the application screening and eligibility assessment. Included applications were graded using the validated Mobile Application Rating Scale, which encompasses 4 domains (engagement, functionality, aesthetics, and information) as well as an overall application quality score. The associations between overall application quality, user ratings and download numbers were evaluated.

Results

Of the 4816 unique applications identified, 46 met inclusion criteria (patient education = 37, disease management = 9). Mean overall application quality score was 3.02 ± 0.40 out of 5 ("acceptable"), with 61% (28/46) rated as "poor" (score 2.0-2.9). Applications scored highest for aesthetics (3.24 ± 0.48) and functionality (3.88 ± 0.37) and lowest for information (2.58 ± 0.64) and engagement (2.39 ± 0.65). Disease management applications were of significantly higher quality than education-focused applications (3.59 ± 0.38 vs 2.88 ± 0.26, P < .001). There was no correlation between graded quality and either user ratings or the number of downloads.

Conclusion

While numerous smartphone applications exist to support patients with GERD, their quality is variable. Patient education applications are of particularly low quality. Our findings can help to inform the selection of applications by patients and guide clinicians' recommendations. This study also highlights the need for higher-quality, evidence-informed applications aimed at GERD patient education.

Greek validation of the user version of the Mobile Application Rating Scale (uMARS)

OBJECTIVE

The original user version of the Mobile Application Rating Scale (uMARS) is an English-language questionnaire that was designed to allow non-expert app users to assess the quality of health apps. We aimed to translate into the Greek language and validate the uMARS.

METHODS

This was a qualitative prospective study. The World Health Organization translation process was followed and a readily available and free-of-charge app was used for the validation process. Internal consistency and reliability were tested twice within one month by 91 Greek medical students.

RESULTS

The total uMARS score showed excellent internal consistency (Cronbach's alpha = 0.86). The internal consistencies of its subscales were also very high (engagement alpha = 0.71; functionality alpha = 0.71; aesthetics alpha = 0.67; information alpha = 0.63), with the notable exception of the satisfaction alpha, which was 0.61. The uMARS total score demonstrated almost perfect agreement levels in most of the subscales according to the r_WG index from baseline to 1 month.

CONCLUSIONS

The Greek uMARS is a reliable and valid tool for assessing the quality of mobile apps.

Development and Evaluation of Health Recommender Systems: Systematic Scoping Review and Evidence Mapping

BACKGROUND

Health recommender systems (HRSs) are information retrieval systems that provide users with relevant items according to the users' needs, which can motivate and engage users to change their behavior.

OBJECTIVE

This study aimed to identify the development and evaluation of HRSs and create an evidence map.

METHODS

A total of 6 databases were searched to identify HRSs reported in studies from inception up to June 30, 2022, followed by forward citation and grey literature searches. Titles, abstracts, and full texts were screened independently by 2 reviewers, with discrepancies resolved by a third reviewer, when necessary. Data extraction was performed by one reviewer and checked by a second reviewer. This review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) statement.

RESULTS

A total of 51 studies were included for data extraction. Recommender systems were used across different health domains, such as general health promotion, lifestyle, and generic health service. A total of 23 studies had reported the use of a combination of recommender techniques, classified as hybrid recommender systems, which are the most commonly used recommender techniques in HRSs. In the HRS design stage, only 10 of 51 (19.6%) recommender systems considered personal preferences of end users in the design or development of the system; a total of 29 studies reported the user interface of HRSs, and most HRSs worked on users' mobile interfaces, usually a mobile app. Two categories of HRS evaluations were used, and evaluations of HRSs varied greatly; 62.7% (32/51) of the studies used the offline evaluations using computational methods (no user), and 33.3% (17/51) of the studies included end users in their HRS evaluation.

CONCLUSIONS

Through this scoping review, nonmedical professionals and policy makers can visualize and better understand HRSs for future studies. The health care professionals and the end users should be encouraged to participate in the future design and development of HRSs to optimize their utility and successful implementation. Detailed evaluations of HRSs in a user-centered approach are needed in future studies.

Exploring the Needs and Expectations of Expectant and New Parents for an mHealth Application to Support the First 1000 Days of Life: Steps toward a Co-Design Approach

To improve maternal and child health, it is essential to adhere to health-promoting and preventive measures. However, reliable information as well as effective tools are not easy to identify in this field. Our cross-sectional study investigated the needs and expectations of expectant and new mothers and fathers as potential primary users of a hypothetical application supporting the first 1000 days of life. Between May and August 2022, we recruited expectant and new parents by administering an 83-item 5-point Likert scale questionnaire related to the content, functionalities, and technical features of the hypothetical app. We stratified responses using sociodemographic characteristics and then performed ward hierarchical clustering. The 94 women and 69 men involved in our study generally agreed with the proposed content, but expressed low interest in certain app functionalities or features, including those related to the interaction mechanism and interactivity. Women were generally more demanding than men. Our findings, resulting from the engagement of end-users, may be useful for designers and technology providers to implement mHealth solutions that, in addition to conveying reliable information, are tailored to the needs and preferences of end-users in the first 1000 days of life.

Pregnancy Apps for Self-Monitoring: Scoping Review of the Most Popular Global Apps Available in Australia

Digital health tools, such as apps, have the potential to promote healthy behaviours, especially self-monitoring, which can facilitate pregnancy management and reduce the risk of associated pregnancy health conditions. While pregnancy apps are popular amongst pregnant women, there is limited information about the overall quality of their content or self-monitoring tools and the number of behaviour change techniques (BCTs) that they include. The aim of this study was thus to assess the quality of pregnancy apps for self-monitoring, and their usage of BCTs. We identified pregnancy apps by web scraping the most popular global apps for self-monitoring in the Apple App Store and Google Play Store available in Australia. The app quality was evaluated using the scorecard approach and the inclusion of BCTs was evaluated using the ABACUS tool. We identified 31 pregnancy apps that met our eligibility criteria. We found that pregnancy apps tended to score the highest in the domains of 'cost and time', 'usability', and 'technical', and lowest on 'clinical' and 'end-user requirements'. Additionally, the majority of apps contained minimal BCTs. Based on our findings, we propose a digital health scorecard visualisation that would break down app quality criteria and present them in a more accessible way to clinicians and pregnant users. We conclude that these findings highlight the shortcomings of available commercial pregnancy apps and the utility of a digital health scorecard visualisation that would empower users to make more informed decisions about which apps are the most appropriate for their needs.

User types, psycho-social effects and societal trends related to the use of consumer health technologies

Objective

The term consumer health technologies we use in this paper refers to fitness and health apps, wearables and other self-tracking devices that collect health-related data. Our paper aims to bridge the gap between the growing literature base of sociological research and ethical reflection on the (non-intended) effects of consumer health technology use on the psycho-social level, such as stress, responsibilization or a loss of intuitive sense for signs of health or illness. Special consideration should be given to vulnerable individuals, as the positive and negative effects of consumer health technology use may be unequally distributed. This perspective may help to guide policymaking and the responsible development of consumer health technologies.

Methods

Using a narrative review approach, we refer to empirical and theoretical studies dealing with user types and effects related to the use of consumer health technologies. We provide an overview of consumer health technology user typologies and evidence of the unintended psycho-social effects of consumer health technology use. On this basis, we propose a user typology that may serve as a future tool for ethical reflection on negative side effects.

Results

Evidence of the potential negative side effects of consumer health technology use, as presented in the literature, is inconclusive due to the high diversity of consumer health technology users and the way they use consumer health technologies. Our proposed user typology aims to more comprehensively document the diversity of users by incorporating the way in which users identify with and use their self-tracked data, attitudes towards the new technology and social interactions via consumer health technologies, and the purpose and self-determinedness of consumer health technology use.

Conclusions

More systematic and quantitative empirical research on the effects of consumer health technology use in diverse settings and with diverse user types is necessary to inform public health policy. In addition to evidence-based certification of medical consumer health technologies, more practical and flexible ways to protect users from side effects may have to be developed and adopted, especially regarding the increasing number of non-medical consumer health technologies.

Features and characteristics of publicly available mHealth apps for self-management in chronic obstructive pulmonary disease

Mobile health applications (mHealth apps) may be able to support people living with chronic obstructive pulmonary disease (COPD) to develop the appropriate skills and routines for adequate self-management. Given the wide variety of publicly available mHealth apps, it is important to be aware of their characteristics to optimize their use and mitigate potential harms.

Objective

To report the characteristics and features of publicly available apps for COPD self-management.

Methods

MHealth apps designed for patients' COPD self-management were searched in the Google Play and Apple app stores. Two reviewers trialed and assessed the eligible apps using the MHealth Index and Navigation Database framework to describe the characteristics, qualities, and features of mHealth apps across five domains.

Results

From the Google Play and Apple stores, thirteen apps were identified and eligible for further evaluation. All thirteen apps were available for Android devices, but only seven were available for Apple devices. Most apps were developed by for-profit organizations (8/13), non-profit organizations (2/13), and unknown developers (3/13). Many apps had privacy policies (9/13), but only three apps described their security systems and two mentioned compliance with local health information and data usage laws. Education was the common app feature; additional features were medication reminders, symptom tracking, journaling, and action planning. None provided clinical evidence to support their use.

Conclusions

Publicly available COPD apps vary in their designs, features, and overall quality. These apps lack evidence to support their clinical use and cannot be recommended at this time.

Navigating Medical Device Certification: A Qualitative Exploration of Barriers and Enablers Amongst Innovators, Notified Bodies and Other Stakeholders

BACKGROUND

Medical device certification has undergone significant changes in recent years. However, exploration of stakeholder experiences remains relatively limited, particularly in the context of software as a medical device. This study sought to explore stakeholder experiences of medical device certification across both the UK and EU.

METHODS

Semi-structured interviews (n = 22) analysed using inductive-thematic analysis, synthesised using activity theory.

RESULTS

Innovators, consultants and notified bodies share more similarities than differences when discussing barriers and enablers to achieving medical device certification. Systemic tensions between existing rules, tools, community understanding and division of labour currently undermine the intended aim of certification processes. Existing rules are considered complex, with small and medium-sized enterprises considered disproportionality affected, resulting in several unintended outcomes including the perceived 'killing' of innovation. Existing certification processes are described as unfit for purpose, unethical and unsustainable.

CONCLUSION

Stakeholder experiences suggest that the intention of establishing a robust and sustainable regulatory framework capable of ensuring a high level of safety whilst also supporting innovation is not yet being realised. Failure to enact desired changes may further jeopardise future innovations, outcomes and care quality.

A Chilean survey of perinatal women and health care professionals' views towards perinatal apps

BACKGROUND

Women around the globe are increasingly engaging with pregnancy and parenting apps, almost becoming a routine part of the maternity experience. However, little is known about what perinatal women and health care professionals feel about those apps in Latin American countries, where the digital transformation has been slower but where digital technologies could also bridge gaps in access to quality health care.

METHODS

This study aimed to assess views towards pregnancy and parenting apps in perinatal women and perinatal health care professionals in Chile through an online survey. In perinatal women, we explored app use, what they value in the apps they use, and what an "ideal app" would be for them. In health professionals, we explored opinions about women using perinatal apps and what they think a perfect app for their clients would be.

RESULTS

The survey was completed by 451 perinatal women and 54 perinatal health care professionals. Results show that perinatal women in Chile frequently use perinatal apps, and they and health care professionals show a positive attitude towards them. The most valued attributes are information and monitoring of body changes during pregnancy, information and monitoring of the baby's development (in the uterus and after birth), information and tips on how to stay healthy, and having the possibility to interact with other women.

CONCLUSIONS

Perinatal apps are accepted by perinatal women and health care professionals in Chile. Some needs for an "ideal app" emerged. Participants mentioned the need to address mental health, including the mental health of their partner, and the need for support during the transition to parenthood.

Safety considerations for assessing the quality of apps used during pregnancy: A scoping review

Objective

Pregnant women are increasingly turning to apps targeting knowledge and behaviour change for supporting healthy lifestyles and managing medical conditions. Yet, there is growing concern over the credibility and safety of content within mobile health (mHealth) apps. This scoping review aimed to systematically and thematically consolidate safety considerations described in reviews evaluating pregnancy-specific apps.

Methods

PubMed, Ovid MEDLINE® and EPub, CINAHL, Web of Science, Cochrane Libraries, and SCOPUS were systematically searched to identify reviews that assessed apps targeting pregnant women. Data related to safety were extracted and thematically analysed to establish a set of relevant safety considerations.

Results

Sixteen reviews met the inclusion criteria. The included reviews assessed an average of 27 apps each and targeted pregnancy topics, such as nutrition and physical activity. Five major and 20 minor themes were identified, including information, transparency, credibility, privacy and security, and app tailoring. Information, transparency, and credibility relate to the evidence base of information within the app, privacy and security of apps relate to the protection of personal information and data, and app tailoring relates to the consideration of contextual factors, such as local guidelines and digital health literacy.

Conclusions

Results present possible safety considerations when evaluating pregnancy-specific apps and emphasise a clear need for consumer guidance on how to make informed decisions around engagement and use of mHealth apps during pregnancy.

Evidence synthesis, digital scribes, and translational challenges for artificial intelligence in healthcare

Healthcare has well-known challenges with safety, quality, and effectiveness, and many see artificial intelligence (AI) as essential to any solution. Emerging applications include the automated synthesis of best-practice research evidence including systematic reviews, which would ultimately see all clinical trial data published in a computational form for immediate synthesis. Digital scribes embed themselves in the process of care to detect, record, and summarize events and conversations for the electronic record. However, three persistent translational challenges must be addressed before AI is widely deployed. First, little effort is spent replicating AI trials, exposing patients to risks of methodological error and biases. Next, there is little reporting of patient harms from trials. Finally, AI built using machine learning may perform less effectively in different clinical settings.