Evolution and current status of mhealth research: a systematic review

How to Improve People's Intentions Regarding COVID-19 Vaccination in China: A Randomized Controlled Trial

BACKGROUND

The global COVID-19 pandemic has impaired the health and living conditions of millions of people. For governments to formulate policies promoting vaccination behavior, it is important to understand individuals' intentions to vaccinate. This study explores the effectiveness of a brief online intervention based on the Health Action Process Approach (HAPA) in improving individuals' COVID-19 vaccination intention, as well as considering the reasons for their unwillingness to get vaccinated.

METHOD

A total of 1,258 participants were assessed using a questionnaire to determine their phase of vaccination intention (pre-intention, intention, and action). Subsequently, focused on the underlying factors in the pre-intention phase (i.e., task self-efficacy, outcome expectation, and risk perception), a 7-day randomized controlled HAPA intervention (n intervention = 57, n control = 49) was conducted online for individuals who were not willing to get vaccinated. The measurement points included pre- (T1), post- (T2), and 30-day follow-up (T3).

RESULTS

The intervention may effectively improve participants' COVID-19 vaccination intentions; however, it had no impact on their planning and actions involved in taking the vaccine.

CONCLUSIONS

This study provides relevant reference data for government stakeholders to use in developing public awareness campaigns and policies to encourage COVID-19 vaccination.

[Effectiveness of a tablet telerehabilitation application in patients with distal radius fracture]

INTRODUCTION

To assess whether, in patients with distal radius fracture feedback-guided exercises performed on a tablet touchscreen reduce healthcare usage and improve clinical recovery, more than the conventional home exercise program prescribed on paper.

MATERIAL AND METHODS

A multicentre, parallel, two-group, pragmatic, controlled trial with assessor blinding and intention-to-treat analysis. Forty-six patients with distal radius fracture were recruited in Andalusian Public Health System. Participants in the experimental and control groups received the same in-patient physiotherapy sessions. Experimental group received a home exercise program using the ReHand tablet application and control group received an evidence-based home exercise program on paper. The primary outcome was the number of physiotherapy sessions tallied from hospitals data management system. Secondary outcomes included: the face-to-face rehabilitation consultations with a physiatrist, and clinical outcomes such as functional ability, grip strength, dexterity, pain intensity and range of motion.

RESULTS

The experimental group required fewer physiotherapy sessions (MD: -16.94; 95%CI: -32.5 to -1.38) and rehabilitation consultations (MD: -1.7; 95%CI: -3.39 to -0.02) compared to the control group.

CONCLUSIONS

In patients with distal radius fracture, prescribing feedback-guided exercises performed on a tablet touchscreen provided by ReHand reduced number of physiotherapy sessions and rehabilitation consultations.

Improving nutritional status of children using artificial intelligence-based mobile application postsurgery: randomised controlled trial

Background

Malnutrition is a common problem in children postsurgery especially in low-middle-income countries. Health-based mobile apps play an important role for better nutritional status.

Methods

This is a two-arm randomised controlled trial, which was conducted at a tertiary care hospital, Rawalpindi. The study duration was 6 months from February 2021 to July 2021. The sample size with power of 80% and significance level of 5% was calculated to be 88. The intervention group was given a diet-related mobile app, and the usual care group was handed a pamphlet with diet instructions on discharge.

Findings

The mean weight of all participants was 15 (SD 5.7) kg at the time of discharge. However, at the end of the 8th week, the mean weight of the participants in the usual care group was 16.5 (SD 7.2) kg and that of the intervention group was 17.1 (SD 5) kg. The average calorie consumed by the usual care group was 972 (SD 252) kcal and 1000.75 (SD 210) kcal by the intervention group after 8 weeks of discharge. The average protein consumed by the usual care group was 34.3 (SD 12.5) g and 39 (SD 6.4) g by the intervention group after 8 weeks of discharge.

Interpretation

This study showed strength for the future of scalable modern technology for self-nutrition monitoring. There was a slight increase in the weight and nutritional intake of both groups.

Trial registration number

NCT04782635.

Effectiveness of a Telerehabilitation Evidence-Based Tablet App for Rehabilitation in Traumatic Bone and Soft Tissue Injuries of the Hand, Wrist, and Fingers

OBJECTIVE

To assess whether feedback-guided exercises performed on a tablet touchscreen improve clinical recovery and reduce health care usage more than the conventional home exercise program prescribed on paper in patients with bone and soft tissue injuries of the wrist, hand, and/or fingers treated by public health services.

DESIGN

A multicenter assessor-blinded, parallel, 2-group controlled trial.

SETTING

Trauma and rehabilitation services of 4 hospitals.

PARTICIPANTS

Six hundred sixty-three patients with limited functional ability due to bone and soft tissue injuries of the wrist, hand, and/or fingers (N=663).

INTERVENTIONS

The experimental group received a home exercise program using a tablet-based application with feedback, monitoring, and progression; the control group received an evidence-based home exercise program on paper.

MAIN OUTCOME MEASURES

The primary outcome was functional ability through Patient Rated Wrist Evaluation for wrist conditions and the short version of Disabilities of the Arm, Shoulder and Hand for all other hand pathologies. Secondary outcomes included dexterity, pain intensity, grip strength, and health care usage (number of patients referred to rehabilitation service and number of clinical appointments).

RESULTS

The experimental group showed a significant improvement on the Patient Rated Wrist Evaluation (P=.001) and the short version of Disabilities of the Arm, Shoulder and Hand (P=.001) with medium effect sizes (η²=0.066-0.067) when compared with the control group. Regarding health care usage, the experimental group presented a reduction of 41% in the rate of referrals to face-to-face rehabilitation service consultations, a reduction of rehabilitation consultations (mean difference=-1.64; 95% confidence interval, -2.64 to -0.65) and physiotherapy sessions (mean difference=-8.52, 95% confidence interval, -16.92 to -0.65) compared to the control group.

CONCLUSIONS

In patients with bone and soft tissue injuries of the wrist, hand, and/or fingers, prescribing feedback-guided exercises performed on a tablet touchscreen was more effective for improving patients' functional ability and reduced the number of patients referred to rehabilitation consultation and number of clinical appointments.

Ethical, legal, and social aspects of symptom checker applications: a scoping review

Symptom Checker Applications (SCA) are mobile applications often designed for the end-user to assist with symptom assessment and self-triage. SCA are meant to provide the user with easily accessible information about their own health conditions. However, SCA raise questions regarding ethical, legal, and social aspects (ELSA), for example, regarding fair access to this new technology. The aim of this scoping review is to identify the ELSA of SCA in the scientific literature. A scoping review was conducted to identify the ELSA of SCA. Ten databases (e.g., Web of Science and PubMed) were used. Studies on SCA that address ELSA, written in English or German, were included in the review. The ELSA of SCA were extracted and synthesized using qualitative content analysis. A total of 25,061 references were identified, of which 39 were included in the analysis. The identified aspects were allotted to three main categories: (1) Technology; (2) Individual Level; and (3) Healthcare system. The results show that there are controversial debates in the literature on the ethical and social challenges of SCA usage. Furthermore, the debates are characterised by a lack of a specific legal perspective and empirical data. The review provides an overview on the spectrum of ELSA regarding SCA. It offers guidance to stakeholders in the healthcare system, for example, patients, healthcare professionals, and insurance providers and could be used in future empirical research to investigate the perspectives of those affected, such as users.

Empowerment through Mobile Apps: A Mixed Methods Case Study of an Application for Pregnant Women

This article analyses the manner in which mobile health applications contribute to the empowerment of patients. The theoretical background included m-health, user empowerment and value co-creation. Quantitative and qualitative methods were used to investigate the representative case study of the Kangaroo application, a free app designed by a health-tech start-up and a reference Brazilian hospital which seeks to make Brazilian women empowered for a healthy pregnancy. The data collection effort comprised application log analysis of 6 months of records of almost one-hundred thousand users, a mobile-based survey with approximately 400 women, and 16 in-depth interviews. The results demonstrated that the app’s social features impacted more than personal features. This research’s results suggested that the perception of patient empowerment is not greater for the active users of the application, so the patient is not related to ‘doing’, but rather to ‘being able to do’. The participation of specialised professionals, who moderate and interact with the app community, is valued by the users and mentioned as a differential among other health information sources available on the Web. This study was approved by the Brazilian Research Ethics Committee.

Physical Activity Surveillance in Children and Adolescents using Smartphone Technology: Systematic Review (Preprint)

BACKGROUND

Self-reported physical activity (PA) questionnaires have traditionally been used for PA surveillance in children and adolescents, especially in free-living conditions. Objective measures are more accurate at measuring PA, but high cost often creates a barrier for their use in low- and middle-income settings. The advent of smartphone technology has greatly influenced mobile health and has offered new opportunities in health research, including PA surveillance.

OBJECTIVE

This review aimed to systematically explore the use of smartphone technology for PA surveillance in children and adolescents, specifically focusing on the use of smartphone apps.

METHODS

A literature search was conducted using 5 databases (PubMed, Scopus, CINAHL, MEDLINE, and Web of Science) and Google Scholar to identify articles relevant to the topic that were published from 2008 to 2023. Articles were included if they included children and adolescents within the age range of 5 to 18 years; used smartphone technology as PA surveillance; had PA behavioral outcomes such as energy expenditure, step count, and PA levels; were written in English; and were published between 2008 and 2023.

RESULTS

We identified and analyzed 8 studies (5 cross-sectional studies and 3 cohort studies). All participants were aged 12-18 years, and all studies were conducted in high-income countries only. Participants were recruited from schools, primary care facilities, and voluntarily. Five studies used mobile apps specifically and purposely developed for the study, whereas 3 studies used mobile apps downloadable from the Apple App Store and Android Play Store. PA surveillance using these apps was conducted from 24 hours to 4 weeks.

CONCLUSIONS

Evidence of PA surveillance using smartphone technology in children and adolescents was insufficient, which demonstrated the knowledge gap. Additional research is needed to further study the feasibility and validity of smartphone apps for PA surveillance among children and adolescents, especially in low- and middle-income countries.

Development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention for adults with alcohol misuse who are experiencing homelessness

BACKGROUND

Adults experiencing homelessness have much higher rates of alcohol misuse than housed individuals. This study describes the development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention (JITAI) to reduce alcohol use among adults experiencing homelessness.

METHODS

We conducted a pilot trial (N = 41; mean age [SD] = 45.2 [11.5]; 19.5% women) of the Smart-T Alcohol JITAI where participants completed brief ecological momentary assessments (EMAs) each day, received personalized treatment messages following each EMA, and accessed on-demand intervention content for 4 weeks. The prediction algorithm and treatment messages were developed based on an independent but similar sample as part of the trial. We examined three drinking outcomes: daily drinking (yes/no), drinks per day, and heavy episodic drinking, controlling for scores on the Alcohol Use Disorders Identification Test (AUDIT) at baseline, age, and sex using quadratic growth curve models.

RESULTS

Over the 4-week period, participants showed a decline in all alcohol use outcomes. Participants also reported high levels of satisfaction with the JITAI.

CONCLUSIONS

Use of the Smart-T Alcohol JITAI was well received and provided encouraging evidence that it may reduce any drinking, drinks per day, and heavy episodic drinking among adults experiencing homelessness.

Mobile health platform based on user-centered design to promote exercise for patients with peripheral artery disease

Background

Peripheral artery disease (PAD) is a cardiovascular disease that can be improved by risk factor modification. Mobile health (mHealth) intervention is an effective method of healthcare delivery to promote behavior changes. An mHealth platform can encourage consistent involvement of participants and healthcare providers for health promotion. This study aimed to develop an mHealth platform consisting of a smartphone application (app) synchronized with a wearable activity tracker and a web-based portal to support exercise intervention in patients with PAD.

Methods

This study was conducted based on an iterative development process, including analysis, design, and implementation. In the analysis phase, a literature review and needs assessment through semi-structured interviews (n = 15) and a questionnaire-based survey (n = 138) were performed. The initial prototype design and contents were developed based on the users’ requirements. In the implementation phase, multidisciplinary experts (n = 4) evaluated the heuristics, following which the mHealth platform was revised. User evaluation of the usability was performed by nurses (n = 4) and patients with PAD (n = 3).

Results

Through the development process, the functional requirements of the platform were represented through visual display, reminder, education, self-monitoring, goal setting, goal attainment, feedback, and recording. In-app videos of exercise and PAD management were produced to provide information and in-app automatic text messages were developed for user motivation. The final version of the platform was rated 67.86 out of 100, which indicated “good” usability.

Conclusions

The mHealth platform was designed and developed for patients with PAD and their healthcare providers. This platform can be used to educate and promote individualized exercise among patients with PAD.

SMART-LAMP: A Smartphone-Operated Handheld Device for Real-Time Colorimetric Point-of-Care Diagnosis of Infectious Diseases via Loop-Mediated Isothermal Amplification

Nucleic acid amplification diagnostics offer outstanding features of sensitivity and specificity. However, they still lack speed and robustness, require extensive infrastructure, and are neither affordable nor user-friendly. Thus, they have not been extensively applied in point-of-care diagnostics, particularly in low-resource settings. In this work, we have combined the loop-mediated isothermal amplification (LAMP) technology with a handheld portable device (SMART-LAMP) developed to perform real-time isothermal nucleic acid amplification reactions, based on simple colorimetric measurements, all of which are Bluetooth-controlled by a dedicated smartphone app. We have validated its diagnostic utility regarding different infectious diseases, including Schistosomiasis, Strongyloidiasis, and COVID-19, and analyzed clinical samples from suspected COVID-19 patients. Finally, we have proved that the combination of long-term stabilized LAMP master mixes, stored and transported at room temperature with our developed SMART-LAMP device, provides an improvement towards true point-of-care diagnosis of infectious diseases in settings with limited infrastructure. Our proposal could be easily adapted to the diagnosis of other infectious diseases.

A Stakeholder-Centered mHealth Implementation Inquiry Within the Digital Health Innovation Ecosystem in South Africa: MomConnect as a Demonstration Case

Background

The internet is a useful web-based multimedia platform for accessing and disseminating information unconstrained by time, distance, and place. To the health care sector’s benefit, the advent and proliferation of mobile devices have provided an opportunity for interventions that combine asynchronous technology-aided health services to improve the lives of the less privileged and marginalized people and their communities, particularly in developing societies.

Objective

This study aimed to report on the perspectives of the different stakeholders involved in the study and to review an existing government mobile health (mHealth) program. It forms part of a study to design a re-engineered strategy based on the best demonstrated practices (considerations and methods) and learned experiences from the perspectives of multiple stakeholders within the digital health innovation ecosystem in South Africa.

Methods

This study used an ethnographic approach involving document review, stakeholder mapping, semistructured individual interviews, focus group discussions, and participant observations to explore, describe, and analyze the perspectives of its heterogeneous participant categories representing purposively sampled but different constituencies.

Results

Overall, 80 participants were involved in the study, in addition to the 6 meetings the researcher attended with members of a government-appointed task team. In addition, 46 archived records and reports were consulted and reviewed as part of gathering data relating to the government’s MomConnect project. Among the consulted stakeholders, there was general consensus that the existing government-sponsored MomConnect program should be implemented beyond mere piloting, to as best as possible capacity within the available resources and time. It was further intimated that the scalability and sustainability of mHealth services as part of an innovative digital health ecosystem was hamstrung by challenges that included stakeholder mismanagement, impact assessment inadequacies, management of data, lack of effective leadership and political support, inappropriate technology choices, eHealth and mHealth funding, integration of mHealth to existing health programs in tandem with Goal 3 of the Sustainable Development Goals, integration of lessons learned from other mHealth initiatives to avoid resource wastage and duplication of efforts, proactive evaluation of both mHealth and eHealth strategies, and change management and developing human resources for eHealth.

Conclusions

This study has only laid a foundation for the re-engineering of mHealth services within the digital health innovation ecosystem. This study articulated the need for stakeholder collaboration, such as continuous engagement among academics, technologists, and mHealth fieldwork professionals. Such compelling collaboration is accentuated more by the South African realities of the best practices in the fieldwork, which may not necessarily be documented in peer-reviewed or systematic research documents from which South African professionals, research experts, and practitioners could learn. Further research is needed for the retrospective analysis of mHealth initiatives and forecasting of the sustainability of current and future mHealth initiatives in South Africa.

[Mobile technologies in healthcare: reflections on development, application, legal aspects, and ethicsTecnologías sanitarias móviles: reflexiones sobre desarrollo, aplicación, legislación y ética]

The association between fast-growing mobile technologies and increasingly more mobile devices has allowed the introduction of virtual environments into daily activities. That includes the health care domain, where concepts such telemedicine, telehealth, eHealth, and mHealth have emerged. In addition to presenting these new concepts, this article aims to discuss the advancements and challenges of mobile health technologies stemming from considerations regarding development, application, legal aspects, and ethics. Because of their innovative nature, mobile health technologies entail the engagement of many actors in the journey to reach end users, covering conception, technical development, sanitary regulations, and design of clinical guidelines, having raised a great deal or interest in terms of monitoring and care across a variety of clinical conditions. However, assessment of the effectiveness and safety of mobile health technologies does not seem to involve the same methodological rigor imposed for clinical trials of drugs and other health products; still, the enthusiasm produced by this innovation counters some of the regulatory and ethics concerns relating to data protection, privacy, access to mobile devices, and technological or social inequality. Despite possible limitations, mobile technologies, as well as other telehealth resources, have produced promising results. Digital healthcare has great potential for expansion and represents an opportunity for the review of traditional practices with selection of mobile technologies for incorporation into the health care system whenever evidence-based benefits are verified.

INFORMATION RESOURCES AMONG FLEMISH PREGNANT WOMEN: A CROSS-SECTIONAL STUDY (Preprint)

Background

There has been an exponential growth in the availability of apps, resulting in increased use of pregnancy apps. However, information on resources and use of apps among pregnant women is relatively limited.

Objective

The aim of this study is to map the current information resources and the use of pregnancy apps among pregnant women in Flanders.

Methods

A cross-sectional study was conducted, using a semistructured survey (April-June 2019) consisting of four different domains: (1) demographics; (2) use of devices; (3) sources of information; and (4) use of pregnancy apps. Women were recruited by social media, flyers, and paper questionnaires at prenatal consultations. Statistical analysis was mainly focused on descriptive statistics. Differences in continuous and categorical variables were tested using independent Student t tests and chi-square tests. Correlations were investigated between maternal characteristics and the women’s responses.

Results

In total, 311 women completed the entire questionnaire. Obstetricians were the primary source of information (268/311, 86.2%) for pregnant women, followed by websites/internet (267/311, 85.9%) and apps (233/311, 74.9%). The information that was most searched for was information about the development of the baby (275/311, 88.5%), discomfort/complaints (251/311, 80.7%) and health during pregnancy (248/311, 79.7%), administrative/practical issues (233/311, 74.9%), and breastfeeding (176/311, 56.6%). About half of the women (172/311, 55.3%) downloaded a pregnancy app, and primarily searched app stores (133/311, 43.0%). Pregnant women who are single asked their mothers (22/30, 73.3%) or other family members (13/30, 43.3%) for significantly more information than did married women (mother [in law]: 82/160, 51.3%, P=.02; family members: 35/160, 21.9%, P=.01). Pregnant women with lower education were significantly more likely to have a PC or laptop than those with higher education (72/73, 98.6% vs 203/237, 85.5%; P=.008), and to consult other family members for pregnancy information (30/73, 41.1% vs 55/237, 23.1%; P<.001), but were less likely to consult a gynecologist (70/73, 95.9% vs 198/237, 83.5%; P=.001). They also followed more prenatal sessions (59/73, 80.8% vs 77/237, 32.5%; P=.04) and were more likely to search for information regarding discomfort/complaints during pregnancy (65/73, 89% vs 188/237, 79.5%; P=.02). Compared to multigravida, primigravida were more likely to solicit advice about their pregnancy from other women in their social networks (family members: primigravida 44/109, 40.4% vs multigravida 40/199, 20.1%; P<.001; other pregnant women: primigravida 58/109, 53.2% vs multigravida 80/199, 40.2%; P<.03).

Conclusions

Health care professionals need to be aware that apps are important and are a growing source of information for pregnant women. Concerns rise about the quality and safety of those apps, as only a limited number of apps are subjected to an external quality check. Therefore, it is important that health care providers refer to high-quality digital resources and take the opportunity to discuss digital information with pregnant women.

Mobile-Health based physical activities co-production policies towards cardiovascular diseases prevention: findings from a mixed-method systematic review

BACKGROUND

Cardiovascular disease (CVD) is the first cause of death globally, with huge costs worldwide. Most cases of CVD could be prevented by addressing behavioural risk factors. Among these factors, there is physical and amateur sports activity (PASA), which has a linear negative correlation with the risk of CVD. Nevertheless, attempts to encourage PASA, as exercise prescription programmes, achieved little impact at the community-wide level. A new frontier to promote PASA is represented by mobile health tools, such as exergaming, mobile device apps, health wearables, GPS/GIS and virtual reality. Nevertheless, there has not yet been any evident turnabout in patient active involvement towards CVD prevention, and inactivity rates are even increasing. This study aims at framing the state of the art of the literature about the use of m-health in supporting PASA, as a user-centric innovation strategy, to promote co-production health policies aiming at CVD prevention.

METHODS

A mixed-method systematic literature review was conducted in the fields of health and healthcare management to highlight the intersections between PASA promotion and m-health tools in fostering co-produced services focused on CVD prevention. The literature has been extracted by the PRISMA logic application. The resulting sample has been first statistically described by a bibliometric approach and then further investigated with a conceptual analysis of the most relevant contributions, which have been qualitatively analysed.

RESULTS

We identified 2,295 studies, on which we ran the bibliometric analysis. After narrowing the research around the co-production field, we found 10 papers relevant for the concept analysis of contents. The interest about the theme has increased in the last two decades, with a high prevalence of contributions from higher income countries and those with higher CVD incidence. The field of research is highly multi-disciplinary; most of documents belong to the medical field, with only a few interconnections with the technology and health policy spheres. Although the involvement of patients is recognized as fundamental for CVD prevention through PASA, co-design schemes are still lacking at the public management level.

CONCLUSIONS

While the link between the subjects of motor activity, medicine and technology is clear, the involvement of citizens in the service delivery process is still underinvestigated, especially the issue concerning how "value co-creation" could effectively be applied by public agencies. In synthesis, the analysis of the role of co-production as a system coordination method, which is so important in designing and implementing preventive care, is still lacking.

Usability of a telehealth solution based on TV interaction for the elderly: the VITASENIOR-MT case study

Remote monitoring of biometric data in the elderly population is an important asset for improving the quality of life and level of independence of elderly people living alone. However, the design and implementation of health technological solutions often disregard the elderly physiological and psychological abilities, leading to low adoption of these technologies. We evaluate the usability of a remote patient monitoring solution, VITASENIOR-MT, which is based on the interaction with a television set. Twenty senior participants (over 64 years) and a control group of 20 participants underwent systematic tests with the health platform and assessed its usability through several questionnaires. Elderly participants scored high on the usability of the platform, very close to the evaluation of the control group. Sensory, motor and cognitive limitations were the issues that most contributed to the difference in usability assessment between the elderly group and the control group. The solution showed high usability and acceptance regardless of age, digital literacy, education and impairments (sensory, motor and cognitive), which shows its effective viability for use and implementation as a consumer product in the senior market.

eHealth and mHealth Development in Spain: Promise or Reality?

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

Defining Telehealth for Research, Implementation, and Equity (Preprint)

When the COVID-19 pandemic spurred a disruption in health care delivery, the role of telehealth shifted from an option to a near necessity to maintain access when in-person care was deemed too risky. Each state and many organizations developed temporary telehealth policies for the COVID-19 emergency, each policy with its own definitions, coverage, government cases, and regulations. As pandemic-era policies are now being replaced with more permanent guidelines, we are presented with an opportunity to reevaluate how telehealth is integrated into routine health care delivery. We believe that the timing and nature of the sequential steps for redefining telehealth are critical and that it is important to develop a clear and agreed-on definition of telehealth and its components at this time. We further suggest a necessary preliminary step is to support clear communication and interoperability throughout the development of this definition. Precise and standardized definitions could create an unambiguous environment for clinical care for both patients and providers while enabling researchers to have more precise control over their investigations of telehealth. A consensus when defining telehealth and its derivatives at this critical stage could create a consistent expectation of care for all patients and those who set the standards of care, as it has for other clinical scenarios with clear guidelines.

[Untact Visit Service Development Based on an Application Reflecting the Circumstances during COVID-19: Focusing on Utilization in the Pediatric Intensive Care Units]

PURPOSE

This study aimed to develop an untact visit service based on an application that can be utilized in the pediatric intensive care unit (PICU) during COVID-19.

METHODS

This study adopted the double diamond process of service design comprising the discovery, defining, and development stages.

RESULTS

We developed an untact visit service based on an application that considered the child's status, schedule, photo, and video messages, and so on. Moreover, we derived a service flow regarding the required roles and the type of flow shown between each stakeholder.

CONCLUSION

Considering the ongoing pandemic, the untact visit service is designed to increase rapport and participation of parents, share the child's information in real-time, and provide one-stop service without increasing healthcare providers' work. It will be a useful visit service that can be applied and evaluated in various hospital settings and the PICU.

Risk factor management of atrial fibrillation using mHealth: The Atrial Fibrillation – Helping Address Care with Remote Technology (AF-HEART) Pilot Study

Background

Personalized treatment of atrial fibrillation (AF) risk factors using mHealth and telehealth may improve patient outcomes.

Objective

The purpose of this study was to assess the feasibility of the Atrial Fibrillation Helping Address Care with Remote Technology (AF-HEART) intervention on the following patient outcomes: (1) heart rhythm tracking; (2) weight, alcohol, blood pressure (BP), and sleep apnea reduction; (3) AF symptom reduction; and (4) quality-of-life (QOL) improvement.

Methods

A total of 20 patients with AF undergoing antiarrhythmic therapy, cardioversion, and/or catheter ablation were enrolled and followed for 6 months. The AF-HEART intervention included remote heart rhythm, weight, and BP tracking; televisits with a dietician focusing on AF risk factors; and referrals for sleep apnea and hypertension treatment.

Results

Patients transmitted a median of 181 rhythm recordings during the 6-month follow-up period. Patients lost an average of 3.5 kilograms at 6 months (P = .005). Patients had improved SF-12 scores (P = .01), AFSS score (P = .01), EQ-5D score (P = .006), and AFEQT Global Score (P = .03). There was significant correlation between weight loss and decrease in symptom severity (r = -0.45, P = .05), and between % weight loss and decrease in symptom severity (r = -0.49, P = .03).

Conclusion

This study described the feasibility of the AF-HEART intervention for (1) consistent remote tracking of heart rhythm, weight, and BP; (2) achievement of weight loss; (3) reduction of symptoms; and (4) improvement in QOL. Expansion to a larger randomized study is planned.

Smartphone-Based Interventions for Physical Activity Promotion: Scoping Review of the Evidence Over the Last 10 Years

Background

Several reviews of mobile health (mHealth) physical activity (PA) interventions suggest their beneficial effects on behavior change in adolescents and adults. Owing to the ubiquitous presence of smartphones, their use in mHealth PA interventions seems obvious; nevertheless, there are gaps in the literature on the evaluation reporting processes and best practices of such interventions.

Objective

The primary objective of this review is to analyze the development and evaluation trajectory of smartphone-based mHealth PA interventions and to review systematic theory- and evidence-based practices and methods that are implemented along this trajectory. The secondary objective is to identify the range of evidence (both quantitative and qualitative) available on smartphone-based mHealth PA interventions to provide a comprehensive tabular and narrative review of the available literature in terms of its nature, features, and volume.

Methods

We conducted a scoping review of qualitative and quantitative studies examining smartphone-based PA interventions published between 2008 and 2018. In line with scoping review guidelines, studies were not rejected based on their research design or quality. This review, therefore, includes experimental and descriptive studies, as well as reviews addressing smartphone-based mHealth interventions aimed at promoting PA in all age groups (with a subanalysis conducted for adolescents). Two groups of studies were additionally included: reviews or content analyses of PA trackers and meta-analyses exploring behavior change techniques and their efficacy.

Results

Included articles (N=148) were categorized into 10 groups: commercial smartphone app content analyses, smartphone-based intervention review studies, activity tracker content analyses, activity tracker review studies, meta-analyses of PA intervention studies, smartphone-based intervention studies, qualitative formative studies, app development descriptive studies, qualitative follow-up studies, and other related articles. Only 24 articles targeted children or adolescents (age range: 5-19 years). There is no agreed evaluation framework or taxonomy to code or report smartphone-based PA interventions. Researchers did not state the coding method, used various evaluation frameworks, or used different versions of behavior change technique taxonomies. In addition, there is no consensus on the best behavior change theory or model that should be used in smartphone-based interventions for PA promotion. Commonly reported systematic practices and methods have been successfully identified. They include PA recommendations, trial designs (randomized controlled trials, experimental trials, and rapid design trials), mixed methods data collection (surveys, questionnaires, interviews, and focus group discussions), scales to assess app quality, and industry-recognized reporting guidelines.

Conclusions

Smartphone-based mHealth interventions aimed at promoting PA showed promising results for behavior change. Although there is a plethora of published studies on the adult target group, the number of studies and consequently the evidence base for adolescents is limited. Overall, the efficacy of smartphone-based mHealth PA interventions can be considerably improved through a more systematic approach of developing, reporting, and coding of the interventions.

Usage of eHealth/mHealth Services among Young Czech Adults and the Impact of COVID-19: An Explorative Survey

Various mHealth/eHealth services play an increasingly important role in healthcare systems and personal lifestyle management. Yet, the relative popularity of these services among the young population of the Czech Republic was not known. Therefore, we carried out an on-line survey with a convenience sample (n = 299) of young adults aged 18–29 and living in the Czech Republic. To this end, we adapted the survey instrument which was previously used in a similar study conducted in a different cultural context (Hong Kong). In our study, we found out that health tutorial activities (i.e., acquiring information on diet, exercise, fitness) were the most common among our respondents (M = 2.81, SD = 1.14). These were followed by health information seeking activities (i.e., acquiring information on medical problems) (M = 2.63, SD = 0.89) and medical services (i.e., the eHealth/mHealth services that provide infrastructural support, such as ePrescription and doctor appointment organizers) (M = 2.18, SD = 0.97). Based on the grouping according to gender and existing health condition, pairwise comparisons showed statistically significant differences. We also briefly analyzed the influence of the COVID-19 pandemic on the examined activities. Based on their relative popularity, we suggest leveraging the potential of health tutorial activities to improve public health.

Acceptability of a Mobile Phone Support Tool (Call for Life Uganda) for Promoting Adherence to Antiretroviral Therapy Among Young Adults in a Randomized Controlled Trial: Exploratory Qualitative Study

Background

Adherence to treatment is critical for successful treatment outcomes. Although factors influencing antiretroviral therapy (ART) adherence vary, young adults are less likely to adhere owing to psychosocial issues such as stigma, ART-related side effects, and a lack of access to treatment. The Call for Life Uganda (CFLU) mobile health (mHealth) tool is a mobile phone–based technology that provides text messages or interactive voice response functionalities through a web interface and offers 4 modules of support.

Objective

This study aims to describe the acceptability and feasibility of a mobile phone support tool to promote adherence to ART among young adults in a randomized controlled trial.

Methods

An exploratory qualitative design with a phenomenological approach at 2 study sites was used. A total of 17 purposively selected young adults with HIV infection who had used the mHealth tool CFLU from 2 clinics were included. In total, 11 in-depth interviews and 1 focus group discussion were conducted to examine the following topics: experience with the CFLU tool (benefits and challenges), components of the tool, the efficiency of the system (level of comfort, ease, or difficulty in using the system), how CFLU resolved adherence challenges, and suggestions to improve CFLU. Participants belonged to 4 categories of interest: young adults on ART for the prevention of mother-to-child transmission, young adults switching to or on the second-line ART, positive partners in an HIV-discordant relationship, and young adults initiating the first-line ART. All young adults had 12 months of daily experience using the tool. Data were analyzed using NVivo version 11 software (QSR International Limited) based on a thematic approach.

Results

The CFLU mHealth tool was perceived as an acceptable intervention; young adults reported improvement in medication adherence, strengthened clinician-patient relationships, and increased health knowledge from health tips. Appointment reminders and symptom reporting were singled out as beneficial and helped to address the problems of forgetfulness and stigma-related issues. HIV-related stigma was reported by a few young people. Participants requested extra support for scaling up CFLU to make it more youth friendly. Improving the tool to reduce technical issues, including network outages and a period of software failure, was suggested. They suggested that in addition to digital solutions, other support, including the promotion of peer support meetings and the establishment of a designated space and staff members for youth, was also important.

Conclusions

This mHealth tool was an acceptable and feasible strategy for improving ART adherence and retention among young adults in resource-limited settings.

Trial Registration

ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080

Examining Protection Motivation and Network Externality Perspective Regarding the Continued Intention to Use M-Health Apps

M-health apps have developed rapidly and are widely accepted, but users' continued intention to use m-health apps has not been fully explored. This study was designed to obtain a better understanding of users' continued intention to use m-health apps. We developed a theoretical model by incorporating the protection motivation theory and network externalities and conducted an empirical study of a 368-respondent sample. The results showed that: (1) perceived vulnerability has a direct impact on users' self-efficacy and response efficacy; (2) self-efficacy and response efficacy have a direct impact on users' attitudes and continued intention; (3) network externalities affect users' attitudes and continued intention, among which direct network externalities have an indirect impact on users' continued intention through attitude; and (4) the impacts of self-efficacy, response efficacy, and indirect network externalities on continued intention are partially meditated by attitudes.

Smartphone Usage Among Doctors in the Clinical Setting in Two Culturally Distinct Countries: Cross-sectional Comparative Study

BACKGROUND

Smartphones and mobile applications have seen a surge in popularity in recent years, a pattern that has also been reflected in the health care system. Despite increased reliance among clinicians however, limited research has been conducted on the uptake and impact of smartphone usage in medical practice, especially outside the Western world.

OBJECTIVE

This study aimed to identify the usage of smartphones and medical apps by doctors in the clinical setting in 2 culturally distinct countries: King Hamad University Hospital (KHUH), Bahrain and Queen Mary Hospital (QMH), Hong Kong.

METHODS

A cross-sectional, comparative study was conducted where doctors in both hospitals were asked to take part in a 15-item online survey. The questions were categorized into the following groups: demographics of the study population, ownership and main use of smartphones, number and names of medical apps currently owned, rating usage of smartphones for medical purposes, time spent on a smartphone related to clinical use, clinical reliance on smartphones, and views on further integration of smartphones. The results were then tabulated and analyzed using SPSS Statistics 25 for Mac (IBM Corp Inc, Armonk, NY).

RESULTS

A total of 200 doctors were surveyed, with a total of 99.0% (99/100) of the doctors owning a smartphone in both KHUH and QMH; 58% (57/99) and 55% (54/99) of the doctors from KHUH and QMH, respectively, identified communication as their main use of smartphones in the clinical setting (P=.004). Doctors from KHUH were likely to spend more time on medical apps than doctors from QMH (P=.002). According to the overall results of both hospitals, 48% (32/67) of the junior doctors claimed high reliance on smartphones, whereas only 32.3% (41/127) of the senior doctors said the same (P=.03). Of doctors in KHUH and QMH, 78.0% (78/100) and 69.0% (69/100), respectively, either strongly agreed or agreed that smartphones need to be integrated into the clinical setting. In terms of preferences for future apps, 48% (48/100) and 56% (56/100) of the doctors in KHUH and QMH, respectively, agreed that more medical applications need to be created in order to support smartphone use in the clinical setting.

CONCLUSIONS

These results suggest a substantial acceptance of smartphones by doctors in the clinical setting. It also elicits the need to establish policies to officially integrate smartphone technology into health care in accordance with ethical guidelines. More emphasis should be placed on creating medical applications that aid health care professionals in attaining their information from accurate sources and also regulate a system to monitor the usage of mobile devices within hospitals to prevent a breach of patient privacy and confidentiality.

Biological characteristics and biomarkers of novel SARS-CoV-2 facilitated rapid development and implementation of diagnostic tools and surveillance measures

Existing coronavirus named as a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has speeded its spread across the globe immediately after emergence in China, Wuhan region, at the end of the year 2019. Different techniques, including genome sequencing, structural feature classification by electron microscopy, and chest imaging using computed tomography, are primarily used to diagnose and screen SARS-CoV-2 suspected individuals. Determination of the viral structure, surface proteins, and genome sequence has provided a design blueprint for the diagnostic investigations of novel SARS-CoV-2 virus and rapidly emerging diagnostic technologies, vaccine trials, and cell-entry-inhibiting drugs. Here, we describe recent understandings on the spike glycoprotein (S protein), receptor-binding domain (RBD), and angiotensin-converting enzyme 2 (ACE2) and their receptor complex. This report also aims to review recently established diagnostic technologies and developments in surveillance measures for SARS-CoV-2 as well as the characteristics and performance of emerging techniques. Smartphone apps for contact tracing can help nations to conduct surveillance measures before a vaccine and effective medicines become available. We also describe promising point-of-care (POC) diagnostic technologies that are under consideration by researchers for advancement beyond the proof-of-concept stage. Developing novel diagnostic techniques needs to be facilitated to establish automatic systems, without any personal involvement or arrangement to curb an existing SARS-CoV-2 epidemic crisis, and could also be appropriate for avoiding the emergence of a future epidemic crisis.

Understanding the evaluation of mHealth app features based on a cross-country Kano analysis

While mobile health (mHealth) apps play an increasingly important role in digitalized health care, little is known regarding the effects of specific mHealth app features on user satisfaction across different healthcare system contexts. Using personal health record (PHR) apps as an example, this study identifies how potential users in Germany and Denmark evaluate a set of 26 app features, and whether evaluation differences can be explained by the differences in four pertinent user characteristics, namely privacy concerns, mHealth literacy, mHealth self-efficacy, and adult playfulness. Based on survey data from both countries, we employed the Kano method to evaluate PHR features and applied a quartile-based sample-split approach to understand the underlying relationships between user characteristics and their perceptions of features. Our results not only reveal significant differences in 14 of the features between Germans and Danes, they also demonstrate which of the user characteristics best explain each of these differences. Our two key contributions are, first, to explain the evaluation of specific PHR app features on user satisfaction in two different healthcare contexts and, second, to demonstrate how to extend the Kano method in terms of explaining subgroup differences through user characteristic antecedents. The implications for app providers and policymakers are discussed.

Evaluation of Acoustic Analyses of Voice in Nonoptimized Conditions

Objectives This study aimed to evaluate the fidelity and accuracy of a smartphone microphone and recording environment on acoustic measurements of voice. Method A prospective cohort proof-of-concept study. Two sets of prerecorded samples (a) sustained vowels (/a/) and (b) Rainbow Passage sentence were played for recording via the internal iPhone microphone and the Blue Yeti USB microphone in two recording environments: a sound-treated booth and quiet office setting. Recordings were presented using a calibrated mannequin speaker with a fixed signal intensity (69 dBA), at a fixed distance (15 in.). Each set of recordings (iPhone-audio booth, Blue Yeti-audio booth, iPhone-office, and Blue Yeti-office), was time-windowed to ensure the same signal was evaluated for each condition. Acoustic measures of voice including fundamental frequency (f_o), jitter, shimmer, harmonic-to-noise ratio (HNR), and cepstral peak prominence (CPP), were generated using a widely used analysis program (Praat Version 6.0.50). The data gathered were compared using a repeated measures analysis of variance. Two separate data sets were used. The set of vowel samples included both pathologic (n = 10) and normal (n = 10), male (n = 5) and female (n = 15) speakers. The set of sentence stimuli ranged in perceived voice quality from normal to severely disordered with an equal number of male (n = 12) and female (n = 12) speakers evaluated. Results The vowel analyses indicated that the jitter, shimmer, HNR, and CPP were significantly different based on microphone choice and shimmer, HNR, and CPP were significantly different based on the recording environment. Analysis of sentences revealed a statistically significant impact of recording environment and microphone type on HNR and CPP. While statistically significant, the differences across the experimental conditions for a subset of the acoustic measures (viz., jitter and CPP) have shown differences that fell within their respective normative ranges. Conclusions Both microphone and recording setting resulted in significant differences across several acoustic measurements. However, a subset of the acoustic measures that were statistically significant across the recording conditions showed small overall differences that are unlikely to have clinical significance in interpretation. For these acoustic measures, the present data suggest that, although a sound-treated setting is ideal for voice sample collection, a smartphone microphone can capture acceptable recordings for acoustic signal analysis.

Virus detection using nanoparticles and deep neural network-enabled smartphone system

Emerging and reemerging infections present an ever-increasing challenge to global health. Here, we report a nanoparticle-enabled smartphone (NES) system for rapid and sensitive virus detection. The virus is captured on a microchip and labeled with specifically designed platinum nanoprobes to induce gas bubble formation in the presence of hydrogen peroxide. The formed bubbles are controlled to make distinct visual patterns, allowing simple and sensitive virus detection using a convolutional neural network (CNN)-enabled smartphone system and without using any optical hardware smartphone attachment. We evaluated the developed CNN-NES for testing viruses such as hepatitis B virus (HBV), HCV, and Zika virus (ZIKV). The CNN-NES was tested with 134 ZIKV- and HBV-spiked and ZIKV- and HCV-infected patient plasma/serum samples. The sensitivity of the system in qualitatively detecting viral-infected samples with a clinically relevant virus concentration threshold of 250 copies/ml was 98.97% with a confidence interval of 94.39 to 99.97%.

Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis

BACKGROUND

Telemonitoring studies in chronic heart failure are characterized by mixed mortality and hospitalization outcomes, which have deterred the uptake of telemonitoring in clinical practice. These mixed outcomes may reflect the diverse range of patient management strategies incorporated in telemonitoring. To address this, we compared the effects of different telemonitoring strategies on clinical outcomes.

OBJECTIVE

The aim of this systematic review and subgroup meta-analysis was to identify noninvasive telemonitoring strategies attributing to improvements in all-cause mortality or hospitalization outcomes for patients with chronic heart failure.

METHODS

We reviewed and analyzed telemonitoring strategies from randomized controlled trials (RCTs) comparing telemonitoring intervention with usual care. For each strategy, we examined whether RCTs that applied the strategy in the telemonitoring intervention (subgroup 1) resulted in a significantly lower risk ratio (RR) of all-cause mortality or incidence rate ratio (IRR) of all-cause hospitalization compared with RCTs that did not apply this strategy (subgroup 2).

RESULTS

We included 26 RCTs (N=11,450) incorporating 18 different telemonitoring strategies. RCTs that provided medication support were found to be associated with a significantly lower IRR value than RCTs that did not provide this type of support (P=.01; subgroup 1 IRR=0.83, 95% CI 0.72-0.95 vs subgroup 2 IRR=1.02, 95% CI 0.93-1.12). RCTs that applied mobile health were associated with a significantly lower IRR (P=.03; IRR=0.79, 95% CI 0.64-0.96 vs IRR=1.00, 95% CI 0.94-1.06) and RR (P=.01; RR=0.67, 95% CI 0.53-0.85 vs RR=0.95, 95% CI 0.84-1.07).

CONCLUSIONS

Telemonitoring strategies involving medication support and mobile health were associated with improvements in all-cause mortality or hospitalization outcomes. These strategies should be prioritized in telemonitoring interventions for the management of patients with chronic heart failure.

mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review

Background

Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement.

Objective

The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions.

Methods

An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis.

Results

A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals.

Conclusions

mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population.

mHealth: providing a mindfulness app for women with chronic pelvic pain in gynaecology outpatient clinics: qualitative data analysis of user experience and lessons learnt

OBJECTIVES

To determine whether a pre-existing smartphone app to teach mindfulness meditation is acceptable to women with chronic pelvic pain (CPP) and can be integrated into clinical practice within the National Health Service (NHS) CPP pathways, and to inform the design of a potential randomised clinical trial.

DESIGN

A prestudy patient and public involvement (PPI) group to collect feedback on the acceptability of the existing app and study design was followed by a three-arm randomised feasibility trial. In addition, we undertook interviews and focus groups with patients and staff to explore app usability and acceptability. We also obtained participant comments on the research process, such as acceptability of the study questionnaires.

SETTING

Two gynaecology clinics within Barts Health NHS, London, UK.

PARTICIPANTS

Patients with CPP lasting ≥6 months with access to smartphone or personal computer and understanding of basic English.

INTERVENTION

The intervention was mindfulness meditation content plus additional pain module delivered by a smartphone app. Active controls received muscle relaxation content from the same app. Passive (waiting list) controls received usual care.

MAIN OUTCOME MEASURES

Themes on user feedback, app usability and integration, and reasons for using/not using the app.

RESULTS

The use of the app was low in both active groups. Patients in the prestudy PPI group, all volunteers, were enthusiastic about the app (convenience, content, portability, flexibility, ease of use). Women contributing to the interview or focus group data (n=14), from a 'real world' clinic (some not regular app users), were less positive, citing as barriers lack of opportunities/motivation to use the app and lack of familiarity and capabilities with technology. Staff (n=7) were concerned about the potential need for extra support for them and for the patients, and considered the app needed organisational backing and peer acceptance.

CONCLUSION

The opinions of prestudy PPI volunteers meeting in their private time may not represent those of patients recruited at a routine clinic appointment. It may be more successful to codesign/codevelop an app with typical users than to adapt existing apps for use in real-world clinical populations.

TRIAL REGISTRATION NUMBER

ISRCTN10925965.

Unpacking mHealth interventions: A systematic review of behavior change techniques used in randomized controlled trials assessing mHealth effectiveness

Objective

Mobile health interventions have surged in popularity but their implementation varies widely and evidence of effectiveness is mixed. We sought to advance understanding of the diversity of behavior change techniques in mHealth interventions, especially those that leverage advanced mobile technologies.

Methods

We conducted a systematic review of articles published between 2007 and 2017 in high-impact journals in medicine, medical informatics, and health psychology to identify randomized controlled trials in which the effectiveness of an mobile health intervention was tested. Search terms included a mix of general (e.g. mobile health), hardware (e.g. Android, iPhone), and format (e.g. SMS, application) terms.

Results

In a systematic review of 21 studies, we found the techniques of personalization, feedback and monitoring, and associations were most commonly used in mobile health interventions, but there remains considerable opportunity to leverage more sophisticated aspects of ubiquitous computing. We found that prompts and cues were the most common behavior change techniques used in effective trials, but there was notable overlap in behavior change techniques used in ineffective trials.

Conclusions

Our results identify techniques that are commonly used in mobile health interventions and highlight pathways to advance the science of mobile health.

Assessment of Mobile Health Apps Using Built-In Smartphone Sensors for Diagnosis and Treatment: Systematic Survey of Apps Listed in International Curated Health App Libraries

Background

More than a million health and well-being apps are available from the Apple and Google app stores. Some apps use built-in mobile phone sensors to generate health data. Clinicians and patients can find information regarding safe and effective mobile health (mHealth) apps in third party–curated mHealth app libraries.

Objective

These independent Web-based repositories guide app selection from trusted lists, but do they offer apps using ubiquitous, low-cost smartphone sensors to improve health? This study aimed to identify the types of built-in mobile phone sensors used in apps listed on curated health app libraries, the range of health conditions these apps address, and the cross-platform availability of the apps.

Methods

This systematic survey reviewed three such repositories (National Health Service Apps Library, AppScript, and MyHealthApps), assessing the availability of apps using built-in mobile phone sensors for the diagnosis or treatment of health conditions.

Results

A total of 18 such apps were identified and included in this survey, representing 1.1% (8/699) to 3% (2/76) of all apps offered by the respective libraries examined. About one-third (7/18, 39%) of the identified apps offered cross-platform Apple and Android versions, with a further 50% (9/18) only dedicated to Apple and 11% (2/18) to Android. About one-fourth (4/18, 22%) of the identified apps offered dedicated diagnostic functions, with a majority featuring therapeutic (9/18, 50%) or combined functionality (5/18, 28%). Cameras, touch screens, and microphones were the most frequently used built-in sensors. Health concerns addressed by these apps included respiratory, dermatological, neurological, and anxiety conditions.

Conclusions

Diligent mHealth app library curation, medical device regulation constraints, and cross-platform differences in mobile phone sensor architectures may all contribute to the observed limited availability of mHealth apps using built-in phone sensors in curated mHealth app libraries. However, more efforts are needed to increase the number of such apps on curated lists, as they offer easily accessible low-cost options to assist people in managing clinical conditions.

Analysis of Physiological and Activity Data Specific to Locations Obtained through Geographical Clustering

This paper presents methods for the investigation and visualization of spatial, physical and physiological data acquired by wearable sensors. Several clustering methods and descriptive statistics are combined. Based on graph theory, an individual network was constructed depending on daily physiological and activity data. By using such networks, clusters and day-to-day differences can be utilized to present physiological status and activity. One possible application is the usage of these subject-specific location and activity based influences in diagnostic and therapy such as of cardiac diseases.

Why We Eat What We Eat: Assessing Dispositional and In-the-Moment Eating Motives by Using Ecological Momentary Assessment

Background

Why do we eat? Our motives for eating are diverse, ranging from hunger and liking to social norms and affect regulation. Although eating motives can vary from eating event to eating event, which implies substantial moment-to-moment differences, current ways of measuring eating motives rely on single timepoint questionnaires that assess eating motives as situation-stable dispositions (traits). However, mobile technologies including smartphones allow eating events and motives to be captured in real time and real life, thus capturing experienced eating motives in-the-moment (states).

Objective

This study aimed to examine differences between why people think they eat (trait motives) and why they eat in the moment of consumption (state motives) by comparing a dispositional (trait) and an in-the-moment (state) assessment of eating motives.

Methods

A total of 15 basic eating motives included in The Eating Motivation Survey (ie, liking, habit, need and hunger, health, convenience, pleasure, traditional eating, natural concerns, sociability, price, visual appeal, weight control, affect regulation, social norms, and social image) were assessed in 35 participants using 2 methodological approaches: (1) a single timepoint dispositional assessment and (2) a smartphone-based ecological momentary assessment (EMA) across 8 days (N=888 meals) capturing eating motives in the moment of eating. Similarities between dispositional and in-the-moment eating motive profiles were assessed according to 4 different indices of profile similarity, that is, overall fit, shape, scatter, and elevation. Moreover, a visualized person × motive data matrix was created to visualize and analyze between- and within-person differences in trait and state eating motives.

Results

Similarity analyses yielded a good overall fit between the trait and state eating motive profiles across participants, indicated by a double-entry intraclass correlation of 0.52 (P<.001). However, although trait and state motives revealed a comparable rank order (r=0.65; P<.001), trait motives overestimated 12 of 15 state motives (P<.001; d=1.97). Specifically, the participants assumed that 6 motives (need and hunger, price, habit, sociability, traditional eating, and natural concerns) are more essential for eating than they actually were in the moment (d>0.8). Furthermore, the visualized person × motive data matrix revealed substantial interindividual differences in intraindividual motive profiles.

Conclusions

For a comprehensive understanding of why we eat what we eat, dispositional assessments need to be extended by in-the-moment assessments of eating motives. Smartphone-based EMAs reveal considerable intra- and interindividual differences in eating motives, which are not captured by single timepoint dispositional assessments. Targeting these differences between why people think they eat what they eat and why they actually eat in the moment may hold great promise for tailored mobile health interventions facilitating behavior changes.

Can mobile health apps replace GPs? A scoping review of comparisons between mobile apps and GP tasks

Background

Mobile health applications (mHealth apps) are increasingly being used to perform tasks that are conventionally performed by general practitioners (GPs), such as those involved in promoting health, preventing disease, diagnosis, treatment, monitoring, and support for health services. This raises an important question: can mobile apps replace GPs? This study aimed to systematically search for and identify mobile apps that can perform GP tasks.

Methods

A scoping review was carried out. The Google Play Store and Apple App Store were searched for mobile apps, using search terms derived from the UK Royal College of General Practitioners (RCGP) guideline on GPs’ core capabilities and competencies. A manual search was also performed to identify additional apps.

Results

The final analysis included 17 apps from the Google Play Store and Apple App Store, and 21 apps identified by the manual search. mHealth apps were found to have the potential to replace GPs for tasks such as recording medical history and making diagnoses; performing some physical examinations; supporting clinical decision making and management; assisting in urgent, long-term, and disease-specific care; and health promotion. In contrast, mHealth apps were unable to perform medical procedures, appropriately utilise other professionals, and coordinate a team-based approach.

Conclusions

This scoping review highlights the functions of mHealth apps that can potentially replace GP tasks. Future research should focus on assessing the performance and quality of mHealth apps in comparison with that of real doctors.

The Potential of mHealth Applications in Improving Resistant Hypertension Self-Assessment, Treatment and Control

PURPOSE OF REVIEW

To review the evidence supporting the use of mobile health (mHealth) apps to improve resistant hypertension self-assessment, treatment and control.

RECENT FINDINGS

mHealth apps have been used to directly measure blood pressure (BP) levels, either using the oscillometric method with automated inflatable cuffs or using pulse wave signals detected by smartphone technology without the need for cuffs. These app-based BP monitors tend to over or underestimate BP levels when compared to a gold standard aneroid sphygmomanometer. However, the differences in BP measurements are within the acceptable range of 5 mmHg pre-defined by the European Society of Hypertension International Protocol Revision 2010. mHealth apps are also used as tools to support physicians in improving hypertension treatment. App-based clinical decision support systems are innovative solutions, in which patient information is entered in the app and management algorithms provide recommendations for hypertension treatment. The use of these apps has been shown to be feasible and easily integrated into the workflow of healthcare professionals, and, therefore particularly useful in resource-limited settings. In addition, apps can be used to improve hypertension control by facilitating regular BP monitoring, communication between patients and health professionals, and patient education; as well as by reinforcing behaviours through reminders, including medication-taking and appointment reminders. Several studies provided evidence supporting the use of apps for hypertension control. Although some of the results are promising, there is still limited evidence on the benefits of using such mHealth tools, as these studies are relatively small and with a short-term duration. Recent research has shown that mHealth apps can be beneficial in terms of improving hypertension self-assessment, treatment and control, being especially useful to help differentiate and manage true and pseudo-resistant hypertension. However, future research, including large-scale randomised clinical trials with user-centred design, is crucial to further evaluate the potential scalability and effectiveness of such mHealth apps in the resistant hypertension context.

The effectiveness of app-based mobile interventions on nutrition behaviours and nutrition-related health outcomes: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to assess the effectiveness of app-based mobile interventions for improving nutrition behaviours and nutrition-related health outcomes, including obesity indices (eg, body mass index [BMI]) and clinical parameters (eg, blood lipids). Seven databases were searched for studies published between 2006 and 2017. Forty-one of 10 132 identified records were included, comprising 6348 participants and 373 outcomes with sample sizes ranging from 10 to 833, including 27 randomized controlled trials (RCTs). A beneficial effect of app-based mobile interventions was identified for improving nutrition behaviours (g = 0.19; CI, 0.06-0.32, P = .004) and nutrition-related health outcomes (g = 0.23; CI, 0.11-0.36, P < .001), including positive effects on obesity indices (g = 0.30; CI, 0.15-0.45, P < .001), blood pressure (g = 0.21; CI, 0.01-0.42, P = .043), and blood lipids (g = 0.15; CI, 0.03-0.28, P = .018). Most interventions were composed of four behaviour change technique (BCT) clusters, namely, "goals/planning," "feedback/monitoring," "shaping knowledge," and "social support." Moderating effects including study design, type of app (commercial/research app), sample characteristics (clinical/non-clinical sample), and intervention characteristics were not statistically significant. The inclusion of additional treatment components besides the app or the number or type of BCTs implemented did not moderate the observed effectiveness, which underscores the potential of app-based mobile interventions for implementing effective and feasible interventions operating at scale for fighting the obesity epidemic in a broad spectrum of the population.

Development of an eHealth Readiness Assessment Framework for Botswana and Other Developing Countries: Interview Study

BACKGROUND

Electronic health (eHealth) readiness has been defined as the preparedness of health care institutions or communities for the anticipated change brought about by programs related to information and communication technology use. To ascertain the degree of such preparedness, an eHealth readiness assessment (eHRA) is needed. Literature on the existing eHRA frameworks and tools shows high inconsistency in content, definitions, and recommendations, and none have been found to be entirely suitable for assessing eHealth readiness in the context of developing countries. To develop an informed eHRA framework and tools with applicability to Botswana and similar developing countries, insight was sought from a broad spectrum of eHealth key informants in Botswana to identify and inform relevant issues, including those not specifically addressed in available eHRA tools.

OBJECTIVE

The aim of this study was to evaluate key informant (local expert) opinions on aspects that need to be considered when developing an eHRA framework suitable for use in developing countries.

METHODS

Interviews with 18 purposively selected key informants were recorded and transcribed. Thematic analysis of transcripts involved the use of an iterative approach and NVivo 11 software. The major themes, as well as subthemes, emerging from the thematic analysis were then discussed and agreed upon by the authors through consensus.

RESULTS

Analysis of interviews identified four eHealth readiness themes (governance, stakeholder issues, resources, and access), with 33 subthemes and 9 sub-subthemes. A major finding was that these results did not directly correspond in content or order to those previously identified in the literature. The results highlighted the need to perform exploratory research before developing an eHRA to ensure that those topics of relevance and importance to the local setting are first identified and then explored in any subsequent eHRA using a locally relevant framework and stakeholder-specific tools. In addition, seven sectors in Botswana were found to play a role in ensuring successful implementation of eHealth projects and might be targets for assessment.

CONCLUSIONS

Insight obtained from this study will be used to inform the development of an evidence-based eHealth readiness assessment framework suitable for use in developing countries such as Botswana.

Potential benefits of integrating ecological momentary assessment data into mHealth care systems

The advancement of wearable/ambulatory technologies has brought a huge change to data collection frameworks in recent decades. Mobile health (mHealth) care platforms, which utilize ambulatory devices to collect naturalistic and often intensively sampled data, produce innovative information of potential clinical relevance. For example, such data can inform clinical study design, recruitment approach, data analysis, and delivery of both "traditional" and novel (e.g., mHealth) interventions. We provide a conceptual overview of how data measured continuously or repeatedly via mobile devices (e.g., smartphone and body sensors) in daily life could be fruitfully used within a mHealth care system. We highlight the potential benefits of integrating ecological momentary assessment (EMA) into mHealth platforms for collecting, processing, and modeling data, and delivering and evaluating novel interventions in everyday life. Although the data obtained from EMA and related approaches may hold great potential benefits for mHealth care system, there are also implementation challenges; we briefly discuss the challenges to integrating EMA into mHealth care system.

User Preferences and Persona Design for an mHealth Intervention to Support Adherence to Cardiovascular Disease Medication in Singapore: A Multi-Method Study

BACKGROUND

The use of mobile health (mHealth) has gained popularity globally, including for its use in a variety of health interventions, particularly through short message service (SMS) text messaging. However, there are challenges to the use of mHealth, particularly among older users who have a large heterogeneity in usability and accessibility barriers when using technology.

OBJECTIVE

In order to better understand and conceptualize the diversity of users and give insight into their particular needs, we turned to persona creation. Personas are user archetypes created through data generated from multi-method inquiry with actual target users. Personas are an appropriate yet largely underutilized component of current mHealth research.

METHODS

Leveraging data from a multi-method study conducted in Singapore with an ethnically diverse population including Chinese, Malay, and Indian participants, we used a proforma to analyze data from the qualitative component (ie, 20 in-depth interviews) and quantitative component (ie, 100 interviewer-guided surveys). We then identified key characteristics, including technology use and preferences as well as adherence factors, to synthesize five personas reflective of persons over the age of 40 years in Singapore with atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors, such as hypertension.

RESULTS

We present five personas typologized as (1) The Quiet Analog, (2) The Busy Grandparent, (3) The Socializer, (4) The Newly Diagnosed, and (5) The Hard-to-Reach. We report on four key characteristics: health care access, medication adherence, mobile phone technology usage (ie, ownership, access, and utilization), and interest in mHealth. Finally, we provide insights into how these personas may be used in the design and implementation of an mHealth intervention. Our work demonstrates how multi-method data can create biopsychosocial personas that can be used to explore and address the diversity in behaviors, preferences, and needs in user groups.

CONCLUSIONS

With wider adoption of mHealth, it is important that we consider user-centered design techniques and design thinking in order to create meaningful, patient-centered interventions for adherence to medications. Future research in this area should include greater exploration of how these five personas can be used to better understand how and when is best to deliver mHealth interventions in Singapore and beyond.

Encouraging On-Time Completion of Leprosy Patients Treatment: Implementing E-Leprosy Framework to Primary Health Care in Indonesia

Low adherence to leprosy treatment is the main challenge in Indonesia. This is a quasi-experimental observational study in a real setting of a leprosy control program in Indonesia. The study is aimed at evaluating an e-leprosy framework in increasing the rate of on-time attendance at primary health care and on-time completion of treatment of leprosy patients. This study has implemented an e-leprosy framework for primary health care at Pekalongan District. The intervention was conducted for 19 months to observe a 1-episode long-term treatment of leprosy patients. The study collected data of 391 registered patients from June 2012 to March 2016. Based on the inclusion and exclusion criteria, this study selected 188 patients. The SMS (short message service) reminders proved to be effective in increasing on-time completion and on-time attendance rates by 21% and 14.6%, respectively. There is a trend for late collections of the drugs at the 3rd, 8th, and 11th multidrug therapy drug collections.

Taking connected mobile-health diagnostics of infectious diseases to the field

Mobile health, or 'mHealth', is the application of mobile devices, their components and related technologies to healthcare. It is already improving patients' access to treatment and advice. Now, in combination with internet-connected diagnostic devices, it offers novel ways to diagnose, track and control infectious diseases and to improve the efficiency of the health system. Here we examine the promise of these technologies and discuss the challenges in realizing their potential to increase patients' access to testing, aid in their treatment and improve the capability of public health authorities to monitor outbreaks, implement response strategies and assess the impact of interventions across the world.

Procedures to Select Digital Sensing Technologies for Passive Data Collection With Children and Their Caregivers: Qualitative Cultural Assessment in South Africa and Nepal

BACKGROUND

Populations in low-resource settings with high childhood morbidity and mortality increasingly are being selected as beneficiaries for interventions using passive sensing data collection through digital technologies. However, these populations often have limited familiarity with the processes and implications of passive data collection. Therefore, methods are needed to identify cultural norms and family preferences influencing the uptake of new technologies.

OBJECTIVE

Before introducing a new device or a passive data collection approach, it is important to determine what will be culturally acceptable and feasible. The objective of this study was to develop a systematic approach to determine acceptability and perceived utility of potential passive data collection technologies to inform selection and piloting of a device. To achieve this, we developed the Qualitative Cultural Assessment of Passive Data collection Technology (QualCAPDT). This approach is built upon structured elicitation tasks used in cultural anthropology.

METHODS

We piloted QualCAPDT using focus group discussions (FGDs), video demonstrations of simulated technology use, attribute rating with anchoring vignettes, and card ranking procedures. The procedure was used to select passive sensing technologies to evaluate child development and caregiver mental health in KwaZulu-Natal, South Africa, and Kathmandu, Nepal. Videos were produced in South Africa and Nepal to demonstrate the technologies and their potential local application. Structured elicitation tasks were administered in FGDs after showing the videos. Using QualCAPDT, we evaluated the following 5 technologies: home-based video recording, mobile device capture of audio, a wearable time-lapse camera attached to the child, proximity detection through a wearable passive Bluetooth beacon attached to the child, and an indoor environmental sensor measuring air quality.

RESULTS

In South Africa, 38 community health workers, health organization leaders, and caregivers participated in interviews and FGDs with structured elicitation tasks. We refined the procedure after South Africa to make the process more accessible for low-literacy populations in Nepal. In addition, the refined procedure reduced misconceptions about the tools being evaluated. In Nepal, 69 community health workers and caregivers participated in a refined QualCAPDT. In both countries, the child's wearable time-lapse camera achieved many of the target attributes. Participants in Nepal also highly ranked a home-based environmental sensor and a proximity beacon worn by the child.

CONCLUSIONS

The QualCAPDT procedure can be used to identify community norms and preferences to facilitate the selection of potential passive data collection strategies and devices. QualCAPDT is an important first step before selecting devices and piloting passive data collection in a community. It is especially important for work with caregivers and young children for whom cultural beliefs and shared family environments strongly determine behavior and potential uptake of new technology.

DNA engineered micromotors powered by metal nanoparticles for motion based cellphone diagnostics

HIV-1 infection is a major health threat in both developed and developing countries. The integration of mobile health approaches and bioengineered catalytic motors can allow the development of sensitive and portable technologies for HIV-1 management. Here, we report a platform that integrates cellphone-based optical sensing, loop-mediated isothermal DNA amplification and micromotor motion for molecular detection of HIV-1. The presence of HIV-1 RNA in a sample results in the formation of large-sized amplicons that reduce the motion of motors. The change in the motors motion can be accurately measured using a cellphone system as the biomarker for target nucleic acid detection. The presented platform allows the qualitative detection of HIV-1 (n = 54) with 99.1% specificity and 94.6% sensitivity at a clinically relevant threshold value of 1000 virus particles/ml. The cellphone system has the potential to enable the development of rapid and low-cost diagnostics for viruses and other infectious diseases.

Innovation process of mHealth: An overview of FDA-approved mobile medical applications

Mobile health or mHealth is expected to provide a way to revolutionize patient care through a wide range of usages. In reality, regulatory authorities have also begun approving mobile medical applications as medical devices. However, the key factors that drive innovations in mHealth, in particular, the dynamics of technological development and market creation, are unclear. To address these issues, the present study explores the key factors that drive the growth of the mHealth industry and potential innovation pathways that need to be incorporated into corporate development strategies of organizations. We analyzed the mHealth products approved by FDA to date (N = 189) in accordance with the novelty of market and/or products and found that new product development in the existing medical market formed the majority (N = 171) whereas diversification or new market development took up only a minor portion (N = 16 or 2, respectively). We also found that the present mHealth industry is being shaped by new entrants or start-ups with expertise in the field of information and communication technology, particularly in collaboration with incumbents in the pharmaceutical and medical devices industry in the cases of radical innovation.

What do emergency medicine and burns specialists from resource constrained settings expect from mHealth-based diagnostic support? A qualitative study examining the case of acute burn care

BACKGROUND

Traumatic injury is a serious global health burden, particularly in low- and middle-income countries where medical care often lacks resources and expertise. In these contexts, diagnostic telemedicine could prove a cost effective tool, yet it remains largely underused here, and knowledge on its potential impact is limited. Particularly scarce is the view of the expert user physicians, and how they themselves relate to this technology.

METHODS

This qualitative study investigated tele-experts' (n = 15) views on the potential for image based teleconsultation to be integrated in trauma and emergency care services. A semi-structured interview guide was used to gather data concerning an mHealth app for burns diagnostics in the acute care setting, in the Western Cape, South Africa. Questions examined challenges and opportunities in user acceptance and outcomes, in specific case management and in the wider healthcare system. Resulting data were subject to qualitative content analysis.

RESULTS

Experts perceived remote diagnostic support through mHealth as linking directly to several key ideas in medicine, including barriers to care, medical culture and hierarchy, and medical ethics within a society. Ideas running through the data pertained to the widening and narrowing of inherent gaps in the healthcare system, and the formalisation of processes, practices and relationships, effected by the introduction of an app. Wide consensus was stated on positive outcomes such as increased education opportunities, improved professional relationships and a better ability to advise and diagnose, all further facilitated through greater ease of access. The belief was that these could achieve a narrowing of systemic divides within healthcare, although it was acknowledged that the possibility to induce the opposite effect also arose. Differing opinions were voiced relating to the involvement of allied health professionals and feedback.

CONCLUSION

Experts see several aspects to an mHealth app for remote diagnostic support which could enhance provision of trauma and emergency care in a resource poor setting, relating to reduced delays, streamlined care and improved outcomes. Attention is also drawn, however, to specifics of the environment which would demand further and careful consideration for success - time pressure, intensity and the wide range of subspecialties to be considered.

Herbopolis - A mobile serious game to educate players on herbal medicines

BACKGROUND

Use of herbal medicines is common. There is a need for education in this area. Mobile games are useful educational tools for motivating learning. A mobile game on herbal medicines can potentially enhance players' herb-related knowledge. Our objective was to develop a mobile game to motivate players to learn more about herbal medicines.

METHODS

Game development comprised of storyboarding, user interface design, database development, server development and distribution. A pilot usability study was conducted for the game prototype. Data was gathered through user registration, background data collection and a post-game survey containing a quiz on herbs encountered in the game. Mann-Whitney U test, chi-squared test and Spearman's correlation coefficient were used for data analysis.

RESULTS

"Herbopolis" is an in-house developed mobile game of the simulation genre. Players are tasked to manage a city specializing in the production and sale of herbal products. Nineteen out of 24 participants downloaded and played the game, and completed the post-game survey. Heuristic evaluations for usability, playability and educability were generally positive. Strong positive associations were observed between player level (r = 0.810, p < 0.001) and gameplay time (r = 0.757, p < 0.001) with quiz scores. Female players scored higher in the quiz (p = .044), played for more days (p = .010) and attained higher levels (p = .010) than male players.

CONCLUSION

Players are motivated to learn about herb-related information through playing "Herbopolis". Our results support its use for improving knowledge on herbal medicines. Future game iterations to improve robustness and performance will likely to improve its reception and effectiveness in learning.