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Lee VV, Vijayakumar S, Lau NY, Blasiak A, Siah KTH, Ho D. Understanding the user: Patients’ perception, needs, and concerns of health apps for chronic constipation. Digit Health 2022; 8:20552076221104673. [PMID: 35663236 PMCID: PMC9158402 DOI: 10.1177/20552076221104673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/14/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Chronic constipation is a prevalent gastrointestinal disorder that requires long-term management and treatment adherence. With increasing smartphone usage, health app adoption represents an opportunity to incorporate personalized, patient-led care into chronic constipation management. Despite the number of apps available targeting patients with constipation, studies have not yet examined user needs and barriers towards successful app adoption and sustained usage. Accordingly, the current study explored user perception, needs, and concerns of health apps in patients with chronic constipation. Methods Fifteen participants with chronic constipation (age range = 28–79 years, 10 females) in Singapore completed a 60 min semi-structured qualitative interview exploring participant's experiences with and attitudes towards chronic constipation and health apps. Participants also completed two questionnaires regarding their constipation symptoms and general technology usage. Interviews were audio-recorded, transcribed verbatim, and coded using NVivo. Results Four themes and 10 sub-themes were identified using inductive thematic analysis. Themes and sub-themes cover importance of patient identity, disease-based expectations of health apps, barriers towards adoption and sustained usage of health apps, necessary conditions when adopting health apps (including perception of supportive benefits, clear understanding of app intention, personalized technology, and trusted sources), and push factor expectations which includes creative engagement and incentivization embedded within the app. Conclusion The findings captured barriers and key elements necessary for successful health app adoption and continued usage by patients with chronic constipation. Identified elements that matter to patients can provide app developers with user-focused insights and recommendations to develop effective health apps that sustain user engagement.
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Affiliation(s)
- V Vien Lee
- The N.1 Institute for Health, National University of Singapore, Singapore
| | | | - Ni Yin Lau
- The N.1 Institute for Health, National University of Singapore, Singapore
| | - Agata Blasiak
- The N.1 Institute for Health, National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Pharmacology; Singapore’s Health District @ Queenstown, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kewin Tien Ho Siah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Dean Ho
- The N.1 Institute for Health, National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
- The Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Pharmacology; Singapore’s Health District @ Queenstown, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Fritsch CG, Ferreira PH, Prior JL, Vesentini G, Schlotfeldt P, Eyles J, Robbins S, Yu S, Mills K, Taylor DA, Lambert TE, Clavisi O, Bywaters L, Chow CK, Redfern J, McLachlan AJ, Ferreira ML. TEXT4myBACK - The Development Process of a Self-Management Intervention Delivered Via Text Message for Low Back Pain. Arch Rehabil Res Clin Transl 2021; 3:100128. [PMID: 34179764 PMCID: PMC8212000 DOI: 10.1016/j.arrct.2021.100128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To develop a bank of text messages for a lifestyle-based self-management intervention for people with low back pain (LBP). DESIGN Iterative development process. SETTING Community and primary care. PARTICIPANTS Fifteen researchers, clinicians, and consumer representatives participated in the concept and initial content development phase. Twelve experts (researchers and clinicians) and 12 consumers participated in the experts and consumers review phase. Full study sample of participants was N=39. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We first conducted two 2-hour workshops to identify important domains for people with LBP, sources of content, appropriate volume, and timing of the messages. The messages were then drafted by a team of writers. Second, we invited expert researchers and clinicians to review and score the messages using a 5-item psychometric scale according to (1) the appropriateness of the content and (2) the likelihood of clinical effectiveness and to provide written feedback. Messages scoring ≤8 out of 10 points would be modified accordingly. Consumers were invited to review the messages and score them using a 5-item psychometric scale according to the utility of the content, the understanding of the content, and language acceptability and to provide feedback. Messages scoring ≤12 out of 15 points would be improved. RESULTS Exercise, education, mood, sleep, use of care, and medication domains were identified and 82 domain-specific evidence-based messages were written. Messages received a mean score of 8.3 out of 10 points by experts. Twenty-nine messages were modified accordingly. The mean score of the messages based on consumers feedback was of 12.5 out of 15 points. Thirty-six messages were improved. CONCLUSIONS We developed a bank of text messages for an evidence-based self-management intervention using a theory-based, iterative, codesign process with researchers, consumers, and clinicians. This article provides scientific support for future development of text message interventions within the pain field.
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Affiliation(s)
- Carolina G. Fritsch
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
| | - Paulo H. Ferreira
- Musculoskeletal Health Research Group, Faculty of Health Sciences, The University of Sydney, Sydney, Australia
| | - Joanna L. Prior
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
| | - Giovana Vesentini
- Department of Gynaecology and Obstetrics, Botucatu Medical School, São Paulo State University, Botucatu, Brazil
| | | | - Jillian Eyles
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
| | - Sarah Robbins
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
| | - Shirley Yu
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
| | - Kathryn Mills
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Deborah A. Taylor
- Department of Physiotherapy, Royal North Shore Hospital, Sydney, Australia
| | - Tara E. Lambert
- Department of Physiotherapy, Royal North Shore Hospital, Sydney, Australia
| | | | | | - Clara K. Chow
- Westmead Applied Research Centre and Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Julie Redfern
- Westmead Applied Research Centre and Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Andrew J. McLachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Manuela L. Ferreira
- Faculty of Medicine and Health, The University of Sydney, Institute of Bone and Joint Research, The Kolling Institute, Sydney, Australia
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Klimis H, Thiagalingam A, Chow CK. Text messages for primary prevention of cardiovascular disease: the TextMe2 randomised controlled trial protocol. BMJ Open 2020; 10:e036767. [PMID: 32341047 PMCID: PMC7204915 DOI: 10.1136/bmjopen-2020-036767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Mobile health may be an effective means of delivering customised individually directed health promotion interventions for cardiovascular disease (CVD) primary prevention. The aim of this study is to evaluate the effectiveness of a lifestyle-focused text messaging programme for primary CVD prevention. METHODS AND ANALYSIS Single-blind randomised controlled trial with 6 months' follow-up in 246 patients with moderate-high absolute cardiovascular risk and without coronary heart disease recruited from a rapid access cardiology clinic. Participants will be randomised to receive either usual care or TextMe2 (text message-based prevention programme). The TextMe2 programme provides support, motivation and education on five topics: diet, physical activity, smoking, general cardiovascular health and medication adherence, and is delivered in four text messages per week over 6 months. The primary outcome is change in the proportion of patients who have three or more of five key modifiable risk factors that are uncontrolled (low-density lipoprotein >2.0 mmol/L, systolic blood pressure >140 mm Hg, body mass index >24.9 kg/m2, physical activity (less than the equivalent of 150 min of moderate intensity each week), current smoker). Secondary outcomes are changes in single biomedical risk factors, behavioural risk factors, quality of life, depression/anxiety scores, medication adherence, cardiovascular health literacy and hospital readmissions/representations. Analysis will be according to the intention-to-treat principle and full statistical analysis plan developed prior to data lock. ETHICS AND DISSEMINATION This study has been approved by the Western Sydney Local Health District Human Research Ethics Committee at Westmead (AU/RED/HREC/17/WMEAD/186). Results will be presented at scientific meetings and published in peer-reviewed publications. TRIAL REGISTRATION NUMBER ACTRN12618001153202.
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Affiliation(s)
- Harry Klimis
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Aravinda Thiagalingam
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
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Cheung NW, Redfern J, Thiagalingam A, Hng TM, Islam SMS, Haider R, Faruquie S, Chow C. Text messaging support for patients with diabetes or coronary artery disease (SupportMe): protocol for a pragmatic randomised controlled trial. BMJ Open 2019; 9:e025923. [PMID: 31221870 PMCID: PMC6589039 DOI: 10.1136/bmjopen-2018-025923] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/06/2019] [Accepted: 05/23/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Low-cost interventions providing self-management support are needed for people with coronary artery disease (CAD) and diabetes. Mobile phone text messaging provides a potential vehicle for this. The SupportMe Trial aims to assess the feasibility of embedding a text messaging programme into routine clinical practice and will determine if this improves cardiovascular risk factor and diabetes control among patients with CAD or type 2 diabetes. METHODS AND ANALYSIS SupportMe is a randomised controlled trial to be conducted within the framework of a health district-wide integrated care programme for people with CAD or type 2 diabetes mellitus. One thousand subjects will be recruited, with at least 500 in each group. Intervention subjects will receive four text messages a week for 6 months, which provide advice, motivation, information and support for disease management and healthy behaviour. The primary outcome is systolic blood pressure at 6 months. Secondary outcomes include body mass index, waist circumference, low-density lipoprotein cholesterol, physical activity levels, dietary intake, quality of life, mood and smoking cessation, and for subjects with diabetes, glycosylated haemoglobin and fasting serum glucose. A process and economic evaluation will also be conducted. ETHICS AND DISSEMINATION The study has been approved by the Western Sydney Local Health District Human Research Ethics Committee (AU RED HREC/16/WMEAD/331). Results will be disseminated via the scientific forums including peer-reviewed publications and presentations at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12616001689460.
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Affiliation(s)
- Ngai Wah Cheung
- Diabetes & Endocrinology, University of Sydney, Westmead, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Julie Redfern
- Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Aravinda Thiagalingam
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tien-Ming Hng
- Diabetes & Endocrinology, Blacktown Mount Druitt Hospital, Blacktown, New South Wales, Australia
| | | | - Rabbia Haider
- Diabetes & Endocrinology, University of Sydney, Westmead, New South Wales, Australia
| | - Sonia Faruquie
- Diabetes & Endocrinology, University of Sydney, Westmead, New South Wales, Australia
| | - Clara Chow
- Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
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5
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Bassi A, John O, Praveen D, Maulik PK, Panda R, Jha V. Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review. JMIR Mhealth Uhealth 2018; 6:e11440. [PMID: 30368435 PMCID: PMC6229512 DOI: 10.2196/11440] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/12/2018] [Accepted: 08/13/2018] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Abhinav Bassi
- George Institute for Global Health, India, New Delhi, India
| | - Oommen John
- George Institute for Global Health, India, New Delhi, India.,University of New South Wales, Sydney, Australia
| | - Devarsetty Praveen
- University of New South Wales, Sydney, Australia.,George Institute for Global Health, India, Hyderabad, India
| | - Pallab K Maulik
- George Institute for Global Health, India, New Delhi, India.,University of New South Wales, Sydney, Australia.,George Institute for Global Health, Oxford University, Oxford, United Kingdom
| | - Rajmohan Panda
- George Institute for Global Health, India, New Delhi, India
| | - Vivekanand Jha
- George Institute for Global Health, India, New Delhi, India.,University of Oxford, Oxford, United Kingdom
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6
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Asan O, Cooper Ii F, Nagavally S, Walker RJ, Williams JS, Ozieh MN, Egede LE. Preferences for Health Information Technologies Among US Adults: Analysis of the Health Information National Trends Survey. J Med Internet Res 2018; 20:e277. [PMID: 30341048 PMCID: PMC6245956 DOI: 10.2196/jmir.9436] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/19/2018] [Accepted: 05/10/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and facilitating adherence to chronic disease management. However, there is a lack of studies on differences in the preference for using information exchange technologies between patients with chronic and nonchronic diseases and factors affecting these differences. OBJECTIVE The purpose of this paper is to understand the preferences and use of information technology for information exchange among a nationally representative sample of adults with and without 3 chronic disease conditions (ie, cardiovascular disease [CVD], diabetes, and hypertension) and to assess whether these preferences differ according to varying demographic variables. METHODS We utilized data from the 2012 and 2014 iteration of the Health Information National Trends Survey (N=7307). We used multiple logistic regressions, adjusting for relevant demographic covariates, to identify the independent factors associated with lower odds of using health information technology (HIT), thus, identifying targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race, and US census region. RESULTS Of 7307 participants, 3529 reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with diabetes, CVD, or hypertension were more likely to report using email to exchange medical information with their provider and less likely to not use any of the technology in health information exchange, as well as more likely to say it was not important for them to access personal medical information electronically. In the unadjusted model, additional significant odds ratio (OR) values were observed. However, after adjustment, most relationships regarding the use and interest in exchanging information with the provider were no longer significant. In the adjusted model, individuals with CVD, diabetes, or hypertension were more likely to access Web-based personal health information through a website or app. Furthermore, we assessed adjusted ORs for demographic variables. Those aged >65 years and Hispanic people were more likely to report no use of email to exchange medical information with their provider. Minorities (Hispanic, non-Hispanic black, and Asian people) were less likely to indicate they had no interest in exchanging general health tips with a provider electronically. CONCLUSIONS The analysis did not show any significant association among those with comorbidities and their proclivity toward health information, possibly implying that HIT-related interventions, particularly design of information technologies, should focus more on demographic factors, including race, age, and region, than on comorbidities or chronic disease status to increase the likelihood of use. Future research is needed to understand and explore more patient-friendly use and design of information technologies, which can be utilized by diverse age, race, and education or health literacy groups efficiently to further bridge the patient-provider communication gap.
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Affiliation(s)
- Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, United States
| | - Farion Cooper Ii
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Sneha Nagavally
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Rebekah J Walker
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joni S Williams
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Mukoso N Ozieh
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
| | - Leonard E Egede
- Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, WI, United States
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Thakkar J, Barry T, Thiagalingam A, Redfern J, McEwan AL, Rodgers A, Chow CK. Design Considerations in Development of a Mobile Health Intervention Program: The TEXT ME and TEXTMEDS Experience. JMIR Mhealth Uhealth 2016; 4:e127. [PMID: 27847350 PMCID: PMC5128723 DOI: 10.2196/mhealth.5996] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/31/2016] [Accepted: 10/18/2016] [Indexed: 12/24/2022] Open
Abstract
Background Mobile health (mHealth) has huge potential to deliver preventative health services. However, there is paucity of literature on theoretical constructs, technical, practical, and regulatory considerations that enable delivery of such services. Objectives The objective of this study was to outline the key considerations in the development of a text message-based mHealth program; thus providing broad recommendations and guidance to future researchers designing similar programs. Methods We describe the key considerations in designing the intervention with respect to functionality, technical infrastructure, data management, software components, regulatory requirements, and operationalization. We also illustrate some of the potential issues and decision points utilizing our experience of developing text message (short message service, SMS) management systems to support 2 large randomized controlled trials: TEXT messages to improve MEDication adherence & Secondary prevention (TEXTMEDS) and Tobacco, EXercise and dieT MEssages (TEXT ME). Results The steps identified in the development process were: (1) background research and development of the text message bank based on scientific evidence and disease-specific guidelines, (2) pilot testing with target audience and incorporating feedback, (3) software-hardware customization to enable delivery of complex personalized programs using prespecified algorithms, and (4) legal and regulatory considerations. Additional considerations in developing text message management systems include: balancing the use of customized versus preexisting software systems, the level of automation versus need for human inputs, monitoring, ensuring data security, interface flexibility, and the ability for upscaling. Conclusions A merging of expertise in clinical and behavioral sciences, health and research data management systems, software engineering, and mobile phone regulatory requirements is essential to develop a platform to deliver and manage support programs to hundreds of participants simultaneously as in TEXT ME and TEXTMEDS trials. This research provides broad principles that may assist other researchers in developing mHealth programs.
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Affiliation(s)
- Jay Thakkar
- The George Institute for Global Health, Camperdown, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Tony Barry
- Westmead Hospital, Sydney, Australia.,The University of Sydney, Sydney, Australia
| | - Aravinda Thiagalingam
- Sydney Medical School, The University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Julie Redfern
- The George Institute for Global Health, Camperdown, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | | | - Anthony Rodgers
- The George Institute for Global Health, Camperdown, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Clara K Chow
- The George Institute for Global Health, Camperdown, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia.,Westmead Hospital, Sydney, Australia
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