Potential for the use of mHealth in the management of cardiovascular disease in Kerala: a qualitative study

The role(s) of community health workers in primary health care reform in Kerala, before and during the COVID 19 pandemic: a qualitative study

Background

Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts.

Methods

We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

Results

Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done.

Conclusion

The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

Factors Influencing the Acceptance and Adoption of Mobile Health Apps by Physicians During the COVID-19 Pandemic: Systematic Review

BACKGROUND

During the COVID-19 pandemic, the provision of and access to health care have been uniquely challenging, particularly during lockdowns or when dealing with COVID-19 cases. Health care professionals have had to provide patients with the necessary health care. However, delivering health care services while reducing face-to-face interaction puts an immense strain on health systems that are already overburdened. Against this backdrop, it is now more critical than ever to ensure the accessibility of health care services. Such access has been made increasingly available through mobile health (mHealth) apps. These apps have the potential to significantly improve health care outcomes and expectations and address some of the challenges confronting health care systems worldwide. Despite the advantages of mHealth, its acceptance and adoption remain low. Hence, health care organizations must consider the perceptions and opinions of physicians if the technology is to be successfully implemented.

OBJECTIVE

The objective of this systematic review was to explore and synthesize the scientific literature on the factors influencing the acceptance and adoption of mHealth among physicians during the COVID-19 pandemic.

METHODS

A systematic review of the studies published between March 2020 and December 2022 was conducted using the MEDLINE, Scopus, Embase, and ProQuest databases. The database search yielded an initial sample of 455 potential publications for analysis, of which 9 (2%) met the inclusion criteria. The methodology of this review was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

RESULTS

The factors influencing mHealth acceptance and adoption by physicians were divided into perceived barriers and perceived facilitators, which were further grouped into the following 3 major thematic categories: technological, individual, and organizational barriers and facilitators, respectively. The technological barriers were accessibility, technical issues, usefulness, and data management; individual barriers were perceived patient barriers, time and workload pressure, technical literacy, knowledge of mHealth, and peer support; and organizational barriers were financial factors, management support and engagement, data security, telemonitoring policy, and collaboration. The technological facilitators of uptake were technical factors, clinical usefulness, and data management; individual facilitators were patient-related care, intrinsic motivation, collaboration, and data sharing (individual); and organizational facilitators were workflow-related determinants, organizational financial support, recommendation of mHealth services, and evidence-based guidelines.

CONCLUSIONS

This review summarized the evidence on the factors influencing mHealth acceptance and adoption by physicians during the COVID-19 pandemic. The main findings highlighted the importance of addressing organizational readiness to support physicians with adequate resources, shifting the focus from technological to patient-centered factors, and the seamless integration of mHealth into routine practice during and beyond the pandemic.

TRIAL REGISTRATION

PROSPERO CRD42022356125; https://tinyurl.com/2mmhn5yu.

Use of Smart Devices to Track Cardiovascular Health Goals in the United States

BACKGROUND

Smartphone-based health applications are increasingly popular, but their real-world use for cardiovascular risk management remains poorly understood.

OBJECTIVES

The purpose of this study was to investigate the patterns of tracking health goals using smart devices, including smartphones and/or tablets, in the United States.

METHODS

Using the nationally representative Health Information National Trends Survey for 2017 to 2020, we examined self-reported tracking of health-related goals (optimizing body weight, increasing physical activity, and/or quitting smoking) using smart devices among those with cardiovascular disease (CVD) or cardiovascular risk factors of hypertension, diabetes, obesity, and/or smoking. Survey analyses were used to obtain national estimates of use patterns and identify features associated with the use of these devices for tracking health goals.

RESULTS

Of 16,092 Health Information National Trends Survey participants, 10,660 had CVD or cardiovascular risk factors, representing 154.2 million (95% CI: 149.2-159.3 million) U.S. adults. Among the general U.S. adult population, 46% (95% CI: 44%-47%) tracked their health goals using their smart devices, compared with 42% (95% CI: 40%-43%) of those with or at risk of CVD. Younger age, female, Black race, higher educational attainment, and greater income were independently associated with tracking of health goals using smart devices.

CONCLUSIONS

Two in 5 U.S. adults with or at risk of CVD use their smart devices to track health goals. While representing a potential avenue to improve care, the lower use of smart devices among older and low-income individuals, who are at higher risk of adverse cardiovascular outcomes, requires that digital health interventions are designed so as not to exacerbate existing disparities.

Utilizing telehealth intervention to support patients with cardiovascular diseases in Jordan: A qualitative study

INTRODUCTION

Telemedicine is one of the new technological solutions used to facilitate treatment and intervention in patients with Cardiovascular Diseases (CVD). Nevertheless, the utilization of telehealth in Jordan is under-researched.

PURPOSE

To explore the perspectives and experiences of patients with cardiovascular disease (CVD) and healthcare providers on how telehealth can help manage critical and long-term CVD health problems.

METHOD

A qualitative, descriptive approach was employed, whereby individual interviews were conducted with 12 healthcare providers and 12 cardiac patients from Abdali and Prince Hamzah Hospitals in Jordan. The derived data were analyzed using thematic analysis, according to the method expounded by Braun and Clarke (2014).

RESULTS

The analysis of collected data revealed that telehealth deployment exhibited several advantages from the participants' perspectives, these can be divided into the following six themes: mitigating associated risks, qualified and friendly staff, streamlined work processes, effective and structured services, accessibility and privacy of patient information, affordable and convenient services.

CONCLUSION

The current study suggests that telehealth can be helpful and convenient in many aspects of the health care services for patients with CVD, mainly during the crucial times of the COVID pandemic. With this study, stakeholders and Jordanian managers can better understand the telehealth advantages. This will enable them to improve the quality of care in their health organizations in the future.

The use of E-health during the COVID-19 pandemic: a case study in China's Hubei province

Globally, the use of e-health has accelerated dramatically during the coronavirus pandemic. Based on both quantitative and qualitative data collected in China's Hubei province (i.e. the first epicentre of COVID-19), this research explores how the pandemic influences the practices of e-health from the perspective of users. Through analysis of 1,033 surveys and 14 in-depth interviews, we find that e-health has played a crucial role in residents' healthcare during the COVID-19 pandemic. Certain external factors influence the choice of digital health, including the high risk of infection outdoors, the shutting down of transport systems, and dysfunctional healthcare facilities that neglect non-COVID-19 patients' clinical demands. Against this backdrop, we argue digital health acts as a functional equivalent to traditional medical treatment and has largely satisfied patients and users in the crisis period. Additionally, the COVID-19 pandemic has unintentionally sped up the diffusion of digital medicine over the long term as respondents expressed their willingness to continue use of e-health in the post-COVID-19 phase. However, we assert that despite the increasing use of e-health, it cannot fully substitute traditional offline treatment. Thus, we suggest a combination of online and offline healthcare will be more commonly practiced in the future.

Assessing the potential of wearable health monitors for health system strengthening in low- and middle-income countries: a prospective study of technology adoption in Cambodia

Wearable health monitors are a rapidly evolving technology that may offer new opportunities for strengthening health system responses to cardiovascular and other non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). In light of this, we explored opportunities for, and potential challenges to, technology adoption in Cambodia, considering the complexity of contextual factors that may influence product uptake and sustainable health system integration. Data collection for this study involved in-depth interviews with national and international stakeholders and a literature review. The analytical approach was guided by concepts and categories derived from the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework-an evidence-based framework that was developed for studying health technology adoption and the challenges to scale-up, spread and sustainability of such technologies in health service organizations. Three potential applications of health wearables for the prevention and control of NCDs in Cambodia were identified: health promotion, follow-up and monitoring of patients and surveys of NCD risk factors. However, several challenges to technology adoption emerged across the research domains, associated with the intended adopters, the organization of the national health system, the wider infrastructure, the regulatory environment and the technology itself. Our findings indicate that, currently, wearables could be best used to conduct surveys of NCD risk factors in Cambodia and in other LMICs with similar health system profiles. In the future, a more integrated use of wearables to strengthen monitoring and management of patients could be envisaged, although this would require careful consideration of feasibility and organizational issues.

mHealth Applications to Monitor Lifestyle Behaviors and Circadian Rhythm in Clinical Settings: Current Perspective and Future Directions

Metabolic diseases are a global rising health burden, mainly due to the deleterious interaction of current lifestyles with the underlying biology of these diseases. Daily habits and behaviors, such as diet, sleep, and physical exercise impact the whole-body circadian system through the synchronization of the peripheral body clocks that contribute to metabolic homeostasis. The disruption of this system may promote the development of metabolic diseases, including obesity and diabetes, emphasizing the importance of assessing and monitoring variables that affect circadian rhythms. Advances in technology are generating innovative resources and tools for health care management and patient monitoring, particularly important for chronic conditions. The use of mobile health technologies, known as mHealth, is increasing and these approaches are contributing to aiding both patients and healthcare professionals in disease management and education. The mHealth solutions allow continuous monitoring of patients, sharing relevant information and data with physicians and other healthcare professionals and accessing education resources to support informed decisions. Thus, if properly used, these tools empower patients and help them to adopt healthier lifestyles. This article aims to give an overview of the influence of circadian rhythms disruption and lifestyle habits in the progression of metabolic diseases while also reviewing some of the mobile applications available to monitor lifestyle behaviors and individual chronobiology. Herein is also described the design and development of the NutriClock system, an mHealth solution developed by our team to monitor these variables.

Feasibility Testing of Tubes@HOME: A Mobile Application to Support Family-Delivered Enteral Care

BACKGROUND

Assistance from medical devices is common for children with medical complexity (CMC) but introduces caregiving challenges. We tested the feasibility of "Tubes@HOME," a mobile application supporting CMC family-delivered care using enteral care as a model.

METHODS

Caregivers of CMC with enteral tubes participated in a 30-day feasibility study of Tubes@HOME November 2020 through January 2021. Tubes@HOME was available on mobile devices and designed to support collaborative care and tracking over time. Key features include child profile, caregiving network management, care routines, feedback loop, and action plans. Care routines delineated nutrition, medication, and procedural tasks needed for the child: frequencies, completions, and reminders. Metadata summarized feature use among users. Feasibility was evaluated with postuse questionnaires and interviews. Measures of Tubes@HOME's usability and usefulness included the NASA Task Load Index (TLX), System Usability Scale (SUS), and Acceptability and Use of Technology Questionnaire (AUTQ).

RESULTS

Among n = 30 children, there were 30 primary (eg, parent) and n = 22 nonprimary caregivers using Tubes@HOME. Children had a median (IQR) 10 (5.5-13) care routines created. For care routines created, 93% were marked complete at least once during the study period, with participants engaging with routines throughout study weeks 2 to 4. Results (mean [SD]) indicated low mental workload (TLX) 30.9 (12.2), good usability (SUS) 75.4 (14.7), and above-average usefulness (AUTQ) 4.0 (0.7) associated with Tubes@HOME, respectively. Interviews contextualized usefulness and suggested improvements.

CONCLUSIONS

Longitudinal use of Tubes@HOME among caregiving networks appeared feasible. Efficacy testing is needed, and outcomes could include reliability of care delivered in home and community.

Sociotechnical Factors Affecting Patients' Adoption of Mobile Health Tools: Systematic Literature Review and Narrative Synthesis

BACKGROUND

Mobile health (mHealth) tools have emerged as a promising health care technology that may contribute to cost savings, better access to care, and enhanced clinical outcomes; however, it is important to ensure their acceptance and adoption to harness this potential. Patient adoption has been recognized as a key challenge that requires further exploration.

OBJECTIVE

The aim of this review was to systematically investigate the literature to understand the factors affecting patients' adoption of mHealth tools by considering sociotechnical factors (from technical, social, and health perspectives).

METHODS

A structured search was completed following the participants, intervention, comparators, and outcomes framework. We searched the MEDLINE, PubMed, Cochrane Library, and SAGE databases for studies published between January 2011 and July 2021 in the English language, yielding 5873 results, of which 147 studies met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Handbook were followed to ensure a systematic process. Extracted data were analyzed using NVivo (QSR International), with thematic analysis and narrative synthesis of emergent themes.

RESULTS

The technical factors affecting patients' adoption of mHealth tools were categorized into six key themes, which in turn were divided into 20 subthemes: usefulness, ease of use, data-related, monetary factors, technical issues, and user experience. Health-related factors were categorized into six key themes: the disease or health condition, the care team's role, health consciousness and literacy, health behavior, relation to other therapies, integration into patient journey, and the patients' insurance status. Social and personal factors were divided into three key clusters: demographic factors, personal characteristics, and social and cultural aspects; these were divided into 19 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

CONCLUSIONS

This review builds on the growing body of research that investigates patients' adoption of mHealth services and highlights the complexity of the factors affecting adoption, including personal, social, technical, organizational, and health care aspects. We recommend a more patient-centered approach by ensuring the tools' fit into the overall patient journey and treatment plan, emphasizing inclusive design, and warranting comprehensive patient education and support. Moreover, empowering and mobilizing clinicians and care teams, addressing ethical data management issues, and focusing on health care policies may facilitate adoption.

Acceptability of a mHealth strategy for hypertension management in a low-income and middle-income country setting: a formative qualitative study among patients and healthcare providers

BACKGROUND

Understanding contextual needs and preferences is important for a successful design and effective outcome of a mHealth strategy.

OBJECTIVES

This formative study aimed to explore the perspectives of patients and providers on the acceptability of a mHealth (text message) strategy and elicit preferred features of a mHealth strategy for hypertension management.

DESIGN

A qualitative study was conducted using in-depth interviews and focus group discussions guided by the technology acceptance model.

SETTING

The study was conducted at primary healthcare facilities and at a tertiary level referral hospital in Kathmandu, Nepal.

PARTICIPANTS

A total of 61 participants, patients with hypertension (n=41), their family members (n=5), healthcare workers (n=11) and key informants (n=4) were included. We purposively recruited patients with hypertension aged 30-70 who attended the selected healthcare facilities to obtain maximum variation based on their age, sex and literacy.

RESULTS

The respondents perceived the mHealth strategy to be useful as it would reinforce medication compliance and behaviour change. Participants valued the trustworthiness of information from health authorities that could be delivered privately. Some implementation challenges were identified including a lack of technical manpower, resources for software development, gaps in recording a patient's essential information and digital illiteracy. Solutions proposed were having system-level preparedness for recording the patient's details, establishing a separate technical department in the hospital and involving a family member to assist illiterate/elderly patients. In addition, participants preferred text messages in the local language, containing comprehensive contextual content (disease, treatment, cultural foods and misconceptions) delivered at regular intervals (2-3 times/week) preferably in the morning or evening.

CONCLUSIONS

We found that a simple text messaging strategy was acceptable for hypertension management in this low/middle-income country setting. However, meticulous planning must address the needs of a diverse range of participants to ensure the mHealth strategy is acceptable to wider groups.

Community Health Worker Evaluation of Implementing an mHealth Application to Support Maternal Health Care in Rural India

Introduction: PIERS on the Move (POM) is a mobile health (mHealth) application developed for a smartphone to support community health workers (CHWs) for identification and management of women at risk of adverse outcomes from pre-eclampsia. POM was implemented as an addition to routine antenatal care by accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs) during the community level intervention for pre-eclampsia (CLIP) Trial in Karnataka state, India (NCT01911494). The objective of this study was to evaluate the experiences of CHWs of using POM in rural India and their perceptions of acceptability and feasibility of this mHealth intervention.

Methods: A posttrial mixed-methods evaluation was designed to measure CHW knowledge and self-efficacy regarding the care of women with pre-eclampsia and perceptions of CHWs on the ease of use and usefulness of POM. A structured survey with open-ended questions was conducted between October and November 2017. The median values on a 5-point Likert scale for knowledge and self-efficacy questions were compared between trial arms by Mann–Whitney U test (p < 0.05 significant). Qualitative analysis was undertaken on NVivo 12 (QSR International, Melbourne, Australia).

Results: A total of 48 ASHAs and ANMs were interviewed, including 24 who used POM (intervention arm) and 24 who did not (control arm). Self-reported knowledge and self-efficacy for the care of women with pre-eclampsia did not differ between groups. The qualitative analysis highlighted that health workers who used POM reported improved interactions with women and families in their communities. POM strengthened the role of ASHA as a CHW beyond a “link-worker” accompanying women to health services. With training, the mHealth application was easy to use even for CHWs who did not have much experience with smartphones.

Conclusions: Community health workers found the POM app easy to use, useful, and well-received by women and their families. POM did not improve care through increased knowledge but built capacity by increasing the recognition of the ASHA and ANM as critical members of the continuum of antenatal healthcare within their communities. These findings support the important role that mHealth technologies can play in strengthening health systems to reach rural, remote, and marginalized populations to reduce disparities in health.

Efficacy of IVRS-based mHealth intervention in reducing cardiovascular risk in metabolic syndrome: A cluster randomized trial

AIMS

Efficacy of mobile-phone based intervention for reducing cardiovascular risk in metabolic syndrome (MetSyn).

METHODS

We screened adults 20-60 years in 10 villages in India for MetSyn using stratified cluster sampling. Lifestyle and biochemical risk factors were assessed. International Harmonized Criteria were used for diagnosis. Villages were randomized with 5 each in control and intervention groups. Interactive voice response system (IVRS) in Hindi was developed. In intervention clusters two messages for promotion of healthy lifestyle and medical treatment were broadcast daily over 12-months and risk factors reassessed.

RESULTS

1012/1200(84%) persons were screened and MetSyn diagnosed in 286(28.3%). Villages were divided into 5 control(n = 136) and 5 intervention(n = 147) clusters. Baseline characteristics in both clusters were similar. Acceptability of intervention was >60% in 80% participants. At 12 months, significantly greater participants in intervention vs control clusters had healthier lifestyle (healthy diet 28.8vs14.7%, physical activity 25.9vs13.1%, tobacco 13.7vs32.5%), anthropometry (waist circumference 85.7 ± 6.3vs88.6 ± 14.0 cm, body mass index 21.9 ± 2.8vs23.1 ± 2.9 kg/m²), systolic BP 123.6 ± 7.7vs128.6 ± 14.1 mmHg, fasting glucose 95.6 ± 19.4vs109.4 ± 43.7 mg/dl, cholesterol 175.5 ± 36.5vs186.4 ± 43.3 mg/dl, and triglycerides 147.6 ± 48.3vs159.5 ± 60.7 mg/dl (p < 0.01). Prevalence of metabolic syndrome declined in intervention group by 22.3%vs3.9%, p < 0.001).

CONCLUSION

An interactive voice response system based technology significantly reduced multiple cardiovascular risk factors and prevalence of metabolic syndrome.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.

Mobile health applications for disease screening and treatment support in low-and middle-income countries: A narrative review

The advances in mobile technologies and applications are driving the transformation in health services delivery globally. Mobile phone penetration is increasing exponentially in low-and middle-income countries, hence using mobile phones for healthcare services could reach more people in resource-limited settings than the traditional forms of healthcare provision. The review presents recent literature on facilitators and barriers of implementing mHealth for disease screening and treatment support in low-and middle-income countries. We searched for relevant literature from the following electronic databases: MEDLINE; CINAHL with full text via EBSCOhost; Science Direct; PubMed; Google Scholar and Web of Science using the keywords for relevant studies. We searched for published studies from 2015 to August 2020 with no language limitations. A total of 721 articles identified, 125 articles met the inclusion criteria and were included in the qualitative synthesis. The review demonstrates relevant facilitators for the implementation of mHealth, which includes knowledge, attitudes, and perceptions of stakeholders on the use of mHealth and the performance of mHealth for disease diagnosis in low and-middle-income countries. Barriers and challenges hindering the implementation of mHealth applications were also identified. We proposed a framework for improving the implementation of mHealth for disease screening and treatment support in low-and middle-income countries.

Barriers to and Facilitators of Technology in Cardiac Rehabilitation and Self-Management: Systematic Qualitative Grounded Theory Review

Background

Dealing with cardiovascular disease is challenging, and people often struggle to follow rehabilitation and self-management programs. Several systematic reviews have explored quantitative evidence on the potential of digital interventions to support cardiac rehabilitation (CR) and self-management. However, although promising, evidence regarding the effectiveness and uptake of existing interventions is mixed. This paper takes a different but complementary approach, focusing on qualitative data related to people’s experiences of technology in this space.

Objective

Through a qualitative approach, this review aims to engage more directly with people’s experiences of technology that supports CR and self-management. The primary objective of this paper is to provide answers to the following research question: What are the primary barriers to and facilitators and trends of digital interventions to support CR and self-management? This question is addressed by synthesizing evidence from both medical and computer science literature. Given the strong evidence from the field of human-computer interaction that user-centered and iterative design methods increase the success of digital health interventions, we also assess the degree to which user-centered and iterative methods have been applied in previous work.

Methods

A grounded theory literature review of articles from the following major electronic databases was conducted: ACM Digital Library, PsycINFO, Scopus, and PubMed. Papers published in the last 10 years, 2009 to 2019, were considered, and a systematic search with predefined keywords was conducted. Papers were screened against predefined inclusion and exclusion criteria. Comparative and in-depth analysis of the extracted qualitative data was carried out through 3 levels of iterative coding and concept development.

Results

A total of 4282 articles were identified in the initial search. After screening, 61 articles remained, which were both qualitative and quantitative studies and met our inclusion criteria for technology use and health condition. Of the 61 articles, 16 qualitative articles were included in the final analysis. Key factors that acted as barriers and facilitators were background knowledge and in-the-moment understanding, personal responsibility and social connectedness, and the need to support engagement while avoiding overburdening people. Although some studies applied user-centered methods, only 6 involved users throughout the design process. There was limited evidence of studies applying iterative approaches.

Conclusions

The use of technology is acceptable to many people undergoing CR and self-management. Although background knowledge is an important facilitator, technology should also support greater ongoing and in-the-moment understanding. Connectedness is valuable, but to avoid becoming a barrier, technology must also respect and enable individual responsibility. Personalization and gamification can also act as facilitators of engagement, but care must be taken to avoid overburdening people. Further application of user-centered and iterative methods represents a significant opportunity in this space.

Application of WeChat-assisted peri-operative care in children with congenital megacolon

AIM

This study explored the clinical effects of WeChat-based peri-operative care on parents of children with congenital megacolon.

METHODS

Participants were randomly divided into WeChat group and telephone group. This study explored parents' knowledge of the care of children with megacolon, the follow-up rate of children, post-operative defaecation function and complications.

RESULTS

WeChat group scored better in nursing knowledge than telephone group, and the difference was statistically significant. The lost follow-up rate in WeChat group was lower than that in telephone group, and the difference was statistically significant. Post-operative defaecation was also better in the WeChat group than in the phone group. Most complications in the phone group were significantly higher than those in the WeChat group.

CONCLUSION

Peri-operative care for parents of children with megacolon through WeChat can effectively enhance the level of parental care knowledge, improve defaecation, reduce the occurrence of certain complications and reduce lost follow-up.

Personal digital health hubs for multiple conditions

Multimorbidity is the presence of more than one chronic disease condition in an individual. Health-related, socioeconomic, cultural and environmental factors, as well as patient behaviour, all influence the outcomes of multimorbidity. Addressing these complex and often interacting biopsychosocial factors therefore requires a shift in treatment from a physical damage model towards person-centred integrated care with increased patient agency. Education influences behaviour and can be used to empower patients and their carers with greater agency, thus allowing greater responsibility for and control over the management of patient care. In this paper we reflect on our own learning as a community of health practitioners from different disciplines. Recognizing the increasing importance of patient agency in driving the evolution of health care, we describe the concept of a web-based personal digital health hub for integrated patient care. Informed by collaboration between patient, health and education communities, we share our early experience in the implementation of a health hub around a cohort of patients with hip fractures. We also describe a vision for future health care based on the co-creation of digital health hubs centred on patients' and carers' needs. The health hub could allow important advances and efficiencies to be achieved in workforce practice and education; patient and carer engagement in self-care; and the collection of patient-reported health data required for ongoing research and improvements in health care.

Codesign and Usability Testing of a Mobile Application to Support Family-Delivered Enteral Tube Care

BACKGROUND

Enteral tubes are prevalent among children with medical complexity (CMC), and complications can lead to costly health care use. Our objective was to design and test the usability of a mobile application (app) to support family-delivered enteral tube care.

METHODS

Human-centered design methods (affinity diagramming, persona development, and software development) were applied with family caregivers of CMC to develop a prototype. During 3 waves of usability testing with design refinement between waves, screen capture software collected user-app interactions and inductive content analysis of narrative feedback identified areas for design improvement. The National Aeronautics and Space Administration Task Load Index and the System Usability Scale quantified mental workload and ease of use.

RESULTS

Design participants identified core app functions, including displaying care routines, reminders, tracking inventory and health data, caregiver communication, and troubleshooting. Usability testing participants were 80% non-Hispanic white, 28% lived in rural settings, and 20% had not completed high school. Median years providing enteral care was 2 (range 1-14). Design iterations improved app function, simplification, and user experience. The mean System Usability Scale score was 76, indicating above-average usability. National Aeronautics and Space Administration Task Load Index revealed low mental demand, frustration, and effort. All 14 participants reported that they would recommend the app, and that the app would help with organization, communication, and caregiver transitions.

CONCLUSIONS

Using a human-centered codesign process, we created a highly usable mobile application to support enteral tube caregiving at home. Future work involves evaluating the feasibility of longitudinal use and effectiveness in improving self-efficacy and reduce device complications.

Impact of Age on Patients' Communication and Technology Preferences in the Era of Meaningful Use: Mixed Methods Study

BACKGROUND

Identifying effective means of communication between patients and their health care providers has a positive impact on patients' satisfaction, adherence, and health-related outcomes.

OBJECTIVE

This study aimed to identify the impact of patients' age on their communication and technology preferences when managing their health. We hypothesize that a patient's age affects their communication and technology preferences when interacting with clinicians and managing their health.

METHODS

A mixed methods study was conducted to identify the preferences of patients with cardiovascular diseases. Results were analyzed based on the patients' age. Grounded theory was used to analyze the qualitative data. Patients were recruited based on age, gender, ethnicity, and zip code.

RESULTS

A total of 104 patients were recruited: 34 young adults (19-39 years), 33 middle aged (40-64), and 37 senior citizens (>65). Young adults (mean 8.29, SD 1.66) reported higher computer self-efficacy than middle-aged participants (mean 5.56, SD 3.43; P<.05) and senior citizens (mean 47.55, SD 31.23; P<.05). Qualitative analysis identified the following three themes: (1) patient engagement (young adults favored mobile technologies and text messaging, middle-aged patients preferred phone calls, and senior citizens preferred direct interactions with the health care provider); (2) patient safety (young adults preferred electronic after-visit summaries [AVS] and medication reconciliation over the internet; middle-aged patients preferred paper-based or emailed AVS and medication reconciliation in person; senior citizens preferred paper-based summaries and in-person medication reconciliation); (3) technology (young adults preferred smartphones and middle-aged patients and senior citizens preferred tablets or PCs). Middle-aged patients were more concerned about computer security than any other group. A unique finding among senior citizens was the desire for caregivers to have access to their personal health record (PHR).

CONCLUSIONS

Patients of different ages have different communication and technology preferences and different preferences with respect to how they would like information presented to them and how they wish to interact with their provider. The PHR is one approach to improving patient engagement, but nontechnological options need to be sustained to support all patients.

Home Blood Pressure Monitoring by a Mobile-Based Model in Chongqing, China: A Feasibility Study

Purpose: Increasing attention is being paid to the role of the intelligent self-management of hypertension under the context of increasing prevalence but limited medical resources. However, heterogeneity in interventions and outcome measures has hindered the interpretation of research evaluating mobile health technologies for hypertension control, and little study of such technology has been performed in China. Objective: This was a feasibility study aimed to understand patient and medical practitioners' acceptance and experience of a mobile-phone based platform for the management of hypertensive patients. Methods: The model used behavioral incentives for daily blood pressure measurement and physician-facing prioritization of patients based on level of blood-pressure control. Patients were enrolled by purposive sampling. The platform was used for two-week blood pressure monitoring through WeChat, which simulated our future app. Qualitative interviews with patients and providers were conducted in time. Results: Twenty hypertensive patients and two providers were enrolled and used the platform throughout the two weeks. Patients reported daily home blood pressure monitoring to be simple, feasible and increased their health awareness. Specifically, patients self-reported that reminders, the daily frequency and time of monitoring, and positive reinforcement were important for maintaining adherence. Providers reported that they could manage patients more quickly and accurately, but reasonable feedback information was needed to avoid excessive increases in workload. Conclusion: The adoption of mobile-based technology to monitor patient's blood pressure may provide a practical solution for managing patients in Chongqing, China. Patient health education and enhanced app functionality could improve patient compliance and satisfaction while reducing provider workload.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective

BACKGROUND

As India's accredited social health activist (ASHA) community health worker (CHW) programme enters its second decade, we take stock of the research undertaken and whether it examines the health systems interfaces required to sustain the programme at scale.

METHODS

We systematically searched three databases for articles on ASHAs published between 2005 and 2016. Articles that met the inclusion criteria underwent analysis using an inductive CHW-health systems interface framework.

RESULTS

A total of 122 academic articles were identified (56 quantitative, 29 mixed methods, 28 qualitative, and 9 commentary or synthesis); 44 articles reported on special interventions and 78 on the routine ASHA program. Findings on special interventions were overwhelmingly positive, with few negative or mixed results. In contrast, 55% of articles on the routine ASHA programme showed mixed findings and 23% negative, with few indicating overall positive findings, reflecting broader system constraints. Over half the articles had a health system perspective, including almost all those on general ASHA work, but only a third of those with a health condition focus. The most extensively researched health systems topics were ASHA performance, training and capacity-building, with very little research done on programme financing and reporting, ASHA grievance redressal or peer communication. Research tended to be descriptive, with fewer influence, explanatory or exploratory articles, and no predictive or emancipatory studies. Indian institutions and authors led and partnered on most of the research, wrote all the critical commentaries, and published more studies with negative results.

CONCLUSION

Published work on ASHAs highlights a range of small-scale innovations, but also showcases the challenges faced by a programme at massive scale, situated in the broader health system. As the programme continues to evolve, critical comparative research that constructively feeds back into programme reforms is needed, particularly related to governance, intersectoral linkages, ASHA solidarity, and community capacity to provide support and oversight.

Perspectives on Acceptance and Use of a Mobile Health Intervention for the Prevention of Atherosclerotic Cardiovascular Disease in Singapore: Mixed-Methods Study

BACKGROUND

Cardiovascular disease, including atherosclerotic cardiovascular disease (ASCVD), is a growing public health threat globally and many individuals remain undiagnosed, untreated, and uncontrolled. Simultaneously, mobile health (mHealth) interventions using short messaging service (SMS) have gained popularity globally. There is an opportunity for innovative approaches such as mHealth to encourage and enable adherence to medications for ASCVD and its risk factors.

OBJECTIVE

This study aimed to understand mobile technology acceptance, use, and facilitating conditions among the study population ahead of the design of an mHealth intervention.

METHODS

Using data from a mixed-methods study conducted in Singapore, we conducted a cross-sectional survey with 100 participants and in-depth, semistructured interviews with 20 patients. All participants were over the age of 40 years with ASCVD or its risk factors. Interviews were conducted in English and Mandarin and if needed translated to English. Nvivo 11 (QSR International) was used for analyses.

RESULTS

Participants reported their perspectives on technology use and preferences, including low or sporadic mobile phone use and usability concerns including small screen and text size, among others; the benefit of previous mHealth use in creating a favorable opinion of SMS for health information; trust in both the source of mHealth SMS, as well as in treatment; the formation of habits; and fear of sequelae or death for facilitating intention to use an mHealth intervention and adhere to medication. We also highlighted a case that underscored the importance of the period after diagnosis in habit forming as an opportunity for an mHealth intervention.

CONCLUSIONS

We explored both technology- and adherence-related factors that influence a patient's intention to use an mHealth intervention for adherence to ASCVD medication in Singapore. We highlighted the importance of identifying the right opportunity to engage with patients and promote an mHealth intervention for adherence, such as immediately following diagnosis when patients are establishing medication-taking habits.

Sociodemographic Factors Influencing the Use of eHealth in People with Chronic Diseases

Alongside the growing number of older persons, the prevalence of chronic diseases is increasing, leading to higher pressure on health care services. eHealth is considered a solution for better and more efficient health care. However, not every patient is able to use eHealth, for several reasons. This study aims to provide an overview of: (1) sociodemographic factors that influence the use of eHealth; and (2) suggest directions for interventions that will improve the use of eHealth in patients with chronic disease. A structured literature review of PubMed, ScienceDirect, Association for Computing Machinery Digital Library (ACMDL), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted using four sets of keywords: "chronic disease", "eHealth", "factors", and "suggested interventions". Qualitative, quantitative, and mixed-method studies were included. Four researchers each assessed quality and extracted data. Twenty-two out of 1639 articles were included. Higher age and lower income, lower education, living alone, and living in rural areas were found to be associated with lower eHealth use. Ethnicity revealed mixed outcomes. Suggested solutions were personalized support, social support, use of different types of Internet devices to deliver eHealth, and involvement of patients in the development of eHealth interventions. It is concluded that eHealth is least used by persons who need it most. Tailored delivery of eHealth is recommended.

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review

Background

With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems.

Objective

We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature.

Methods

A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools.

Results

The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease–focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories.

Conclusions

In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.

Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial

INTRODUCTION

eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project ('EXTEND') that aims to evaluate the impact of eHealth tools on health system functions and health outcomes.

METHODOLOGY AND ANALYSIS

This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases-baseline, midline and endline evaluations-that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes.

ETHICS AND DISSEMINATION

Ethics approvals were obtained from the University of Leeds and three States' Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN32105372; Pre-results.

Assessment of knowledge about healthy heart habits in urban and rural population of Punjab after SMS campaign-A cross-sectional study

Objective

The prevalence of cardiovascular diseases (CVD) is increasing in developing countries but the awareness regarding prevention and treatment of these diseases is still low. Therefore the present study was conducted with the aim of imparting health education regarding certain changes in lifestyle and dietary habits among general population through the use of short message service (SMS) that may lead to improved knowledge about prevention of cardiovascular diseases.

Methods

This cross-sectional study was conducted over a period of seven months. In the first phase, health education messages were sent through SMS to about 40,000 individuals from urban and rural population in Punjab. Twenty eight messages were sent to each individual and hence more than eleven lakh messages were sent over a period of six months. A questionnaire containing 11 questions based on these health education SMS was generated. Every 40th individual enrolled in the study was contacted on phone, and their responses noted. The data so collected was analyzed for correct responses.

Results

Complete responses could be obtained from 800 participants (males: 561 and females: 239). The participants giving correct responses to different questions ranged from 43% to 94%. Majority of participants could retain knowledge about many aspects of healthy heart habits provided by SMS except for topics concerning foods to be avoided, target for normal BP and precautions to be taken before BP measurement.

Conclusions

Health related information imparted through SMS can act as a very effective tool for disseminating knowledge about prevention of heart diseases in general population.

Mobile Technology for Community Health in Ghana: what happens when technical functionality threatens the effectiveness of digital health programs?

BACKGROUND

Despite the growing use of technology in the health sector, little evidence is available on the technological performance of mobile health programs nor on the willingness of target users to utilize these technologies as intended (behavioral performance). In this case study of the Mobile Technology for Health (MOTECH) program in Ghana, we assess the platform's effectiveness in delivering messages, along with user response across sites in five districts from 2011 to 2014.

METHODS

MOTECH is comprised of "Client Data Application" (CDA) which allows providers to digitize and track service delivery information for women and infants and "Mobile Midwife" (MM) which sends automated educational voice messages to the mobile phones of pregnant and postpartum women. Using a naturalist study design, we draw upon system generated data to evaluate message delivery, client engagement, and provider responsiveness to MOTECH over time and by level of facility.

RESULTS

A total of 7,370 women were enrolled in MM during pregnancy and 14,867 women were enrolled postpa1rtum. While providers were able to register and upload patient-level health information using CDA, the majority of these uploads occurred in Community-based facilities versus Health Centers. For MM, 25% or less of expected messages were received by pregnant women, despite the majority (>77%) owning a private mobile phone. While over 80% of messages received by pregnant women were listened to, postpartum rates of listening declined over time. Only 25% of pregnant women received and listened to at least 1 first trimester message. By 6-12 months postpartum, less than 6% of enrolled women were exposed to at least one message.

CONCLUSIONS

Caution should be exercised in assuming that digital health programs perform as intended. Evaluations should measure the technological, behavioral, health systems, and/or community factors which may lead to breaks in the impact pathway and influence findings on effectiveness. The MOTECH platform's technological limitations in 'pushing' out voice messages highlights the need for more timely use of data to mitigate delivery challenges and improve exposure to health information. Alternative message delivery channels (USSD or SMS) could improve the platform's ability to deliver messages but may not be appropriate for illiterate users.

TRIAL REGISTRATION

Not applicable.

Potential for mobile health (mHealth) prevention of cardiovascular diseases in Kerala: A population-based survey

BACKGROUND

India's southern state of Kerala stands at the forefront of India's epidemic of cardiovascular disease (CVD), among other non-communicable diseases (NCDs). Mobile phone use in healthcare (mHealth) has shown promise in India, including NCDs. However, suitability and acceptability of m-Health interventions is poorly researched, particularly in rural settings.

OBJECTIVES

METHODS: A questionnaire regarding mobile phone usage and possible use in healthcare was verbally administered in five primary health centres and by home visits in five village councils ("panchayats") of Ernakulam, Kerala. Adults who spoke Malayalam or English, with access to a mobile phone were recruited by convenience sampling in partnership with accredited social health activists (ASHAs). Quantitative data analysis was conducted using SPSS software.

RESULTS

262 participants were recruited. 87% routinely used and 88% owned a mobile phone. 92% were willing to receive mHealth advice, and 94% favoured mobile medication reminders. 70.3% and 73% preferred voice calls over short messaging service (SMS) for delivering health information and medication reminders, respectively. 85.9% would send home recorded information on their blood pressure, weight, medication use and lifestyle to a doctor or ASHA. 75.2% trusted the confidentiality of mHealth data, while 77.1% had no concerns about the privacy of their information.

CONCLUSIONS

The majority of this population approve mHealth interventions. While further investigation of mHealth as a health education tool is warranted, SMS interventions may fail to maximise equity and penetration across all patient groups.