Scaling up mHealth: where is the evidence?

Evaluating barriers to reaching women with public health information in remote communities in Mali

Telecommunications offers an alternative or supplement to community-based interventions as a means of extending healthcare services and improving health outcomes in remote settings but can fail to reach target communities and achieve the desired impact if barriers to access are not overcome. We conducted seven focus group discussions and 26 interviews with community health workers, community leaders, and female members of the public who declared that they had or had not previously accessed free audio health messages provided via a mobile platform in two rural communities of Mali, Koulikoro and Bougouni. A content analysis showed that participants accessed and trusted health information from a range of sources, including radio, telephone and television, as well as town criers, local relays and community health centres. Barriers to access faced by women included economic factors, lack of network or electricity, and social factors such as illiteracy, cultural restrictions and being unaware of mobile communication. Through analysis and interpretation of the participants' responses, we have made recommendations for future campaigns for the dissemination of health-related information for women in remote settings.

Availability of published evidence on coverage, cost components, and funding support for digitalisation of infectious disease surveillance in Africa, 2003-2022: a systematic review

BACKGROUND

The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear.

OBJECTIVES

To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support.

METHODS

We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa.

RESULTS

A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5-40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies.

CONCLUSIONS

The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable.

Sharing Culture and Management of Sex Work Information on Mobile Phones by Female Sex Workers in Nepal: Implications for mHealth Practice and Research

Female sex workers (FSWs) in Nepal continue to be disproportionately at risk for Sexually Transmitted Infections (STIs), including HIV. Due to stigma related to sex work and HIV, FSWs keep their sex work information hidden, which poses a barrier to seeking health services. Emerging research indicates a high uptake of mobile phones among FSWs in Nepal. Mobile health (mHealth) interventions can provide health information and linkage to care. However, largely missing from the literature is FSWs' experience of managing the information about their involvement in sex work in a culture where sharing personal information and belongings is a part of the social norm, and maintaining privacy could have negative social repercussions. The current study aims to understand how FSWs perceive and manage privacy when they share their mobile phones. Using the Communication Privacy Management theory, we explore FSWs' perception of the threat to their privacy posed by mobile phones. We conducted 30 in-depth interviews among FSWs in Kathmandu, Nepal. Results showed that all participants owned mobile phones, and sharing devices was common. Mobile phones pose a considerable challenge in keeping sex work information private, and FSWs use various communication strategies to circumvent privacy threats. The findings highlight the mental and emotional burden FSWs face trying to conceal their private information in a sharing culture. The study discusses the importance of theorizing privacy in the cultural context of the Global South and the practical implications for developing mHealth interventions for this population.

Comprehensive Cardiovascular Risk Factor Control With a Mobile Health Cardiovascular Risk Self-Management Program

BACKGROUND

Mobile health technology's impact on cardiovascular risk factor control is not fully understood. This study evaluates the association between interaction with a mobile health application and change in cardiovascular risk factors.

METHODS AND RESULTS

Participants with hypertension with or without dyslipidemia enrolled in a workplace-deployed mobile health application-based cardiovascular risk self-management program between January 2018 and December 2022. Retrospective evaluation explored the influence of application engagement on change in blood pressure (BP), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and weight. Multiple regression analyses examined the influence of guideline-based, nonpharmacological lifestyle-based digital coaching on outcomes adjusting for confounders. Of 102 475 participants, 49.1% were women. Median age was 53 (interquartile range, 43-61) years, BP was 134 (interquartile range, 124-144)/84 (interquartile range, 78-91) mm Hg, TC was 183 (interquartile range, 155-212) mg/dL, LDL-C was 106 (82-131) mg/dL, and body mass index was 30 (26-35) kg/m2. At 2 years, participants with baseline systolic BP ≥140 mm Hg reduced systolic BP by 18.6 (SEM, 0.3) mm Hg. At follow up, participants with baseline TC ≥240 mg/dL reduced TC by 65.7 (SEM, 4.6) mg/dL, participants with baseline LDL-C≥160 mg/dL reduced LDL-C by 66.6 (SEM, 6.2) mg/dL, and participants with baseline body mass index ≥30 kg/m2 lost 12.0 (SEM, 0.3) pounds, or 5.1% of body weight. Interaction with digital coaching was associated with greater reduction in all outcomes.

CONCLUSIONS

A mobile health application-based cardiovascular risk self-management program was associated with favorable reductions in BP, TC, LDL-C, and weight, highlighting the potential use of this technology in comprehensive cardiovascular risk factor control.

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review

BACKGROUND

Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years.

METHODS

A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures.

RESULTS

From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive.

CONCLUSIONS

This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.

Building consensus on common features and interoperability use cases for community health information systems: a Delphi study

INTRODUCTION

Information systems for community health have become increasingly sophisticated and evidence-based in the last decade and they are now the most widely used health information systems in many low-income and middle-income countries. This study aimed to establish consensus regarding key features and interoperability priorities for community health information systems (CHISs).

METHODS

A Delphi study was conducted among a systematically selected panel of CHIS experts. This impressive pool of experts represented a range of leading global health institutions, with gender and regional balance as well as diversity in their areas of expertise. Through five rounds of iterative surveys and follow-up interviews, the experts established a high degree of consensus. We supplemented the Delphi study findings with a series of focus group discussions with 10 community health worker (CHW) leaders.

RESULTS

CHISs today are expected to adapt to a wide range of local contextual requirements and to support and improve care delivery. While once associated with a single role type (CHWs), these systems are now expected to engage other end users, including patients, supervisors, clinicians and data managers. Of 30 WHO-classified digital health interventions for care providers, experts identified 23 (77%) as being important for CHISs. Case management and care coordination features accounted for more than one-third (14 of 37, 38%) of the core features expected of CHISs today, a higher proportion than any other category. The highest priority use cases for interoperability include CHIS to health management information system monthly reporting and CHIS to electronic medical record referrals.

CONCLUSION

CHISs today are expected to be feature-rich, to support a range of user roles in community health systems, and to be highly adaptable to local contextual requirements. Future interoperability efforts, such as CHISs in general, are expected not only to move data efficiently but to strengthen community health systems in ways that measurably improve care.

Usage Behaviour and Adoption Criteria for Mobile Health Solutions in Patients with Chronic Diseases in Gastroenterology

Introduction

Mobile Health (mHealth) applications allow for new possibilities and opportunities in patient care. Their potential throughout the whole patient journey is undisputed. However, the eventual adoption by patients depends on their acceptance of and motivation to use mHealth applications as well as their adherence. Therefore, we investigated the motivation and drivers of acceptance for mHealth and developed an adapted model of the Unified Theory of Acceptance and Use of Technology (UTAUT2).

Methods

We evaluated 215 patients with chronic gastroenterological diseases who answered a questionnaire including all model constructs with 7-point Likert scale items. Our model was adapted from the Unified Theory of Acceptance and Use in Technology 2 and includes influencing factors such as facilitating conditions, performance expectancy, hedonic motivation, social influence factors, effort expectancy, as well as personal empowerment and data protection concerns. Model evaluation was performed with structural equation modelling with PLS-SEM. Bootstrapping was performed for hypothesis testing.

Results and Conclusion

Patients had a median age of 55.5 years, and the gender ratio was equally distributed. Forty percent received a degree from a university, college, technical academy, or engineering school. The majority of patients suffered from chronic liver disease, but patients with inflammatory bowel diseases, GI cancers, and pancreatic diseases were also included. Patients considered their general technology knowledge as medium to good or very good (78%). Actual usage of mHealth applications in general was rare, while the intention to use them was high. The leading acceptance factor for mHealth applications in our patient group was feasibility, both in terms of technical requirements and the intuitiveness and manageability of the application. Concerns about data privacy did not significantly impact the intention to use mobile devices. Neither the gamification aspect nor social influence factors played a significant role in the intention to use mHealth applications.

Interpretation

Most of our patients were willing to spend time on a mHealth application specific to their disease on a regular basis. Acceptance and adherence are ensured by efficient utilization that requires minimum effort and compatible technologies as well as support in case of difficulties. Social influence and hedonic motivation, which were part of UTAUT2, as well as data security concerns, were not significantly influencing our patients' intention to use mHealth applications. A literature review revealed that drivers of acceptance vary considerably among different population and patient groups. Therefore, healthcare and mHealth providers should put effort into understanding their specific target groups' drivers of acceptance. We provided those for a cohort of patients from gastroenterology in this project.

Association of mobile health (mHealth) use with health status and COVID-19-related concerns by people with mobility impairments

PURPOSE

Mobile health (mHealth) technology has increased dramatically in the wake of the pandemic. Less research has focused on people with mobility impairing (PMI) disabilities. This study determined the prevalence of mHealth use among PMI adults during the COVID-19 escalation and examines demographic, health and COVID-19 concerns correlates.

METHODS

PMI adults (N = 304) completed an online survey investigating mHealth use and COVID-19 concerns related to food access in June of 2020. Smartphone and mHealth use were measured with an adapted version of the survey used in the Pew Internet & American Life project. Descriptive and multivariable analyses were conducted to determine associations of demographics, health status, and COVID-19 concerns with mHealth use. About two-thirds (N = 201) of the sample were mHealth users (owned a smartphone and engaged in health-promoting behaviors with the smartphone; e.g., sought online information, tracked health behaviors, used patient portals).

RESULTS

Having hypertension was associated with higher mHealth use, and having higher COVID-19 concerns about food access was associated with higher mHealth use. Those who used mHealth were also more engaged with smartphone apps for communication, services, and entertainment. Only the association between educational attainment and mHealth use remained significant after adjusting for other covariates in multivariable logistic regression models.

DISCUSSION

PMIs continue to need support in the use of mHealth technology to help maximize access to potentially important tools for rehabilitation and health management. There is a need to continue to investigate mHealth and its applications for people with disabilities.Implications for RehabilitationMany people with mobility impairing disabilities may be missing opportunities for mHealth rehabilitation and healthcare.COVID-19 has widened existing gaps in access and use of mHealth technology among people with mobility impairing disabilities.Focused education is needed to help people with disabilities exploit the full range of services of their smartphones to increase access to care, social connectivity, and other important goods and services to enhance rehabilitation and health management.

Preferences in the Willingness to Download an mHealth App: Discrete Choice Experimental Study in Spain, Germany, and the Netherlands

BACKGROUND

Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the adoption of mHealth is low, and only a limited number of studies have examined the intention to download mHealth apps.

OBJECTIVE

In this study, we investigated individuals' preferences in the adoption of a health app.

METHODS

We conducted a discrete choice experimental study in 3 countries (Spain: n=800, Germany: n=800, and the Netherlands: n=416) with 4 different attributes and levels (ie, price: €1.99 vs €4.99 [a currency exchange rate of €1=US $1.09 is applicable] vs for free, data protection: data protection vs no information, recommendation: patients' association vs doctors, and manufacturer: medical association vs pharmaceutical company). Participants were randomly assigned. For the analyses, we used the conditional logistic model separately for each country.

RESULTS

The results showed that price and data protection were considered important factors that significantly increased the probability to download an mHealth app. In general, the source of the recommendation and the manufacturer affected the probability to download the mHealth app less. However, in Germany and the Netherlands, we found that if the app was manufactured by a pharmaceutical company, the probability to download the mHealth app decreased.

CONCLUSIONS

mHealth tools are highly promising to reduce health care costs and increase the effectiveness of traditional health interventions and therapies. Improving data protection, reducing costs, and creating sound business models are the major driving forces to increase the adoption of mHealth apps in the future. It is thereby essential to create trustworthy standards for mobile apps, whereby prices, legislation concerning data protection, and health professionals can have a leading role to inform the potential consumers.

The Development and Validation of Data Elements and Process Steps for an Electronic Health Record for Hand Surgery Outreach Trips

Background  The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods  We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results  In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion  This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

User-Centered Design of a Gamified Mental Health App for Adolescents in Sub-Saharan Africa: Multicycle Usability Testing Study

BACKGROUND

There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa.

OBJECTIVE

This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing.

METHODS

An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development.

RESULTS

A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules ("episodes") played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement.

CONCLUSIONS

The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms.

The Most Popular Commercial Weight Management Apps in the Chinese App Store: Analysis of Quality, Features, and Behavior Change Techniques

BACKGROUND

Many smartphone apps designed to assist individuals in managing their weight are accessible, but the assessment of app quality and features has predominantly taken place in Western countries. Nevertheless, there is a scarcity of research evaluating weight management apps in China, which highlights the need for further investigation in this area.

OBJECTIVE

This study aims to conduct a comprehensive search for the most popular commercial Chinese smartphone apps focused on weight management and assess their quality, behavior change techniques (BCTs), and content-related features using appropriate evaluation scales. Additionally, the study sought to investigate the associations between the quality of various domains within weight management apps and the number of incorporated BCTs and app features.

METHODS

In April 2023, data on weight management apps from the iOS and Android app stores were downloaded from the Qimai Data platform. Subsequently, a total of 35 weight management apps were subjected to screening and analysis by 2 researchers. The features and quality of the apps were independently assessed by 6 professionals specializing in nutrition management and health behavioral change using the Mobile Application Rating Scale (MARS). Two registered dietitians, who had experience in app development and coding BCTs, applied the established 26-item BCT taxonomy to verify the presence of BCTs. Mean (SD) scores and their distributions were calculated for each section and item. Spearman correlations were used to assess the relationship between an app's quality and its technical features, as well as the number of incorporated BCTs.

RESULTS

The data set included a total of 35 apps, with 8 available in the Android Store, 10 in the Apple Store, and 17 in both. The overall quality, with a mean MARS score of 3.44 (SD 0.44), showed that functionality was the highest scoring domain (mean 4.18, SD 0.37), followed by aesthetics (mean 3.43, SD 0.42), engagement (mean 3.26, SD 0.64), and information (mean 2.91, SD 0.52), which had the lowest score. The mean number of BCTs in the analyzed apps was 9.17 (range 2-18 BCTs/app). The most common BCTs were "prompt review of behavioral goals" and "provide instruction," present in 31 apps (89%). This was followed by "prompt self-monitoring of behavior" in 30 apps (86%), "prompt specific goal setting" in 29 apps (83%), and "provide feedback on performance" in 27 apps (77%). The most prevalent features in the analyzed apps were the need for web access (35/35, 100%), monitoring/tracking (30/35, 86%), goal setting (29/35, 83%), and sending alerts (28/35, 80%). The study also revealed strong positive correlations among the number of BCTs incorporated, app quality, and app features. This suggests that apps with a higher number of BCTs tend to have better overall quality and more features.

CONCLUSIONS

The study found that the overall quality of weight management apps in China is moderate, with a particular weakness in the quality of information provided. The most prevalent BCTs in these apps were reviewing behavioral goals, providing guidance, self-monitoring of behavior, goal setting, and offering performance feedback. The most common features were the need for web access, monitoring and tracking, goal setting, and sending alerts. Notably, higher-quality weight management apps in China tended to incorporate more BCTs and features. These findings can be valuable for developers looking to improve weight management apps and enhance their potential to drive behavioral change in weight management.

Mobile Health (mHealth) Interventions to Increase Cancer Screening Rates in Hispanic/Latinx Populations: A Scoping Review

Hispanic/Latinx persons have disproportionately lower breast, cervical, and colorectal cancer screening rates than non-Hispanic White (NHW) persons. This low participation in cancer screening results in late-stage cancer diagnosis among Hispanic persons compared to NHW persons. Mobile health (mHealth) interventions effectively improve cancer screening rates in the general population; however, few reviews about mHealth interventions are tailored to Hispanic populations. This is important to investigate given that Hispanic persons differ from NHW persons with regard to culture, language, and health care utilization. Therefore, in this study, we investigated: (a) What types of mHealth interventions have been undertaken to increase cancer screening rates among Hispanic persons in the United States? (b) How effective have these interventions been? and (c) What features of these interventions help increase cancer screening rates? Searches conducted during December 2020 identified 10 articles published between January 2017 and December 2020 that met our inclusion criteria. The review revealed that mHealth interventions mainly provided education about cancer and cancer screening using videos, PowerPoint slides, and interactive multimedia. mHealth interventions that effectively improved screening behavior were mainly for easy-to-screen cancers like skin and cervical cancer. Finally, reviewed studies did not provide details on how cultural adaptations were made, and it is unclear what specific features of mHealth interventions increase cancer screening rates among Hispanic persons. Future research should identify and evaluate the effects of different components of culturally tailored interventions on cancer screening. Public health practitioners and health care providers should tailor mHealth approaches to their clients or patients and practice environment.

Cognitive reappraisal in mHealth interventions to foster mental health in adults: a systematic review and meta-analysis

Background

An increasing number of mHealth interventions aim to contribute to mental healthcare of which interventions that foster cognitive reappraisal may be particularly effective.

Objectives

To evaluate the efficacy of mHealth interventions enhancing cognitive reappraisal to improve mental health in adult populations.

Methods

The literature search (four databases) yielded 30 eligible randomized controlled trials (comprising 3,904 participants). We performed a multi-level meta-analysis to examine differences between intervention and comparator conditions at post-intervention assessment. Moderator analyses were conducted for potential moderator variables (e.g., type of comparators).

Results

Most interventions were CBT-based with other training components in addition to cognitive reappraisal. We found preliminary evidence for a small to medium effect favouring mHealth interventions to enhance cognitive reappraisal over comparators, M(SMD) = 0.34, p = .002. When analysing single symptoms, there was evidence for a small to medium effect of mHealth interventions on anxiety and depressive symptoms, but not for psychological distress and well-being. All analyses showed substantial heterogeneity. Moderator analyses revealed evidence for more favourable effects in studies with passive comparators. There was an overall high risk of bias in most of the studies.

Conclusions

We found preliminary evidence for a small to medium effect of mHealth interventions including a cognitive reappraisal component to improve mental health. However, most of the interventions were complex (i.e., reappraisal was provided alongside other components), which prevents us from examining reappraisal-specific effects beyond general mental health promotion in mHealth. Dismantling studies examining the effects of single intervention components are warranted to corroborate these promising results.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=142149, identifier [CRD42019142149].

Supporting Pain Self-Management in Patients With Cancer: App Development Based on a Theoretical and Evidence-Driven Approach

BACKGROUND

To inform the development of an intervention, it is essential to have a well-developed theoretical understanding of how an intervention causes change, as stated in the UK Medical Research Council guidelines for developing complex interventions. Theoretical foundations are often ignored in the development of mobile health apps intended to support pain self-management for patients with cancer.

OBJECTIVE

This study aims to systematically set a theory- and evidence-driven design for a pain self-management app and specify the app's active features.

METHODS

The Behavior Change Wheel (BCW) framework, a step-by-step theoretical approach to the development of interventions, was adopted to achieve the aim of this study. This started by understanding and identifying sources of behavior that could be targeted to support better pain management. Ultimately, the application of the BCW framework guided the identification of the active contents of the app, which were characterized using the Behavior Change Technique Taxonomy version 1.

RESULTS

The theoretical analysis revealed that patients may have deficits in their capability, opportunity, and motivation that prevent them from performing pain self-management. The app needs to use education, persuasion, training, and enablement intervention functions because, based on the analysis, they were found the most likely to address the specified factors. Eighteen behavior change techniques were selected to describe precisely how the intervention functions can be presented to induce the desired change regarding the intervention context. In other words, they were selected to form the active contents of the app, potentially reducing barriers and serving to support patients in the self-management of pain while using the app.

CONCLUSIONS

This study fully reports the design and development of a pain self-management app underpinned by theory and evidence and intended for patients with cancer. It provides a model example of the BCW framework application for health app development. The work presented in this study is the first systematic theory- and evidence-driven design for a pain app for patients with cancer. This systematic approach can support clarity in evaluating the intervention's underlying mechanisms and support future replication.

Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care

Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.

Exploring Perceptions and Needs of Mobile Health Interventions for Nutrition, Anemia, and Preeclampsia among Pregnant Women in Underprivileged Indian Communities: A Cross-Sectional Survey

According to the National Family Health Survey of 2021, about 57% of women aged 15-49 in India currently suffer from anemia, marking a significant increase from the 53% recorded in 2016. Similarly, a study conducted in southern India reported a 32.60% prevalence of preeclampsia. Several community-based initiatives have been launched in India to address these public health challenges. However, these interventions have yet to achieve the desired results. Could the challenges faced by traditional healthcare interventions be overcome through a technological leap? This study assesses pregnant mothers' perceptions regarding mobile health interventions for managing anemia and preeclampsia. Additionally, the study captures their health awareness and knowledge. We conducted a survey with 131 pregnant mothers in three underserved villages in Jharkhand, India. Statistical analysis was conducted using the SEMinR package in R (Version 2023.06.0), utilizing the non-parametric partial least squares-structural equation modeling. We found that every household had at least one smartphone, with the respondents being the primary users. The main uses of smartphones were for calling, messaging, and social media. A total of 61% of respondents showed interest in a nutrition and pregnancy app, while 23.66% were uncertain. Regarding nutritional knowledge during pregnancy, 68.7% reported having some knowledge, but only 11.45% claimed comprehensive knowledge. There was a considerable knowledge gap regarding the critical nutrients needed during pregnancy and the foods recommended for a healthy pregnancy diet. Awareness of pregnancy-related conditions such as anemia and preeclampsia was low, with most respondents unsure of these conditions' primary causes, impacts, and symptoms. This study serves as a critical step towards leveraging technology to enhance public health outcomes in low-resource settings. With the accessibility of mobile devices and an apparent willingness to utilize mHealth apps, compounded by the pressing need for improved maternal health, the impetus for action is indisputable. It is incumbent upon us to seize this opportunity, ensuring that the potential of technology is fully realized and not squandered, thus circumventing the risk of a burgeoning digital divide.

Design and Early Use of the Nationally Implemented Healthier You National Health Service Digital Diabetes Prevention Programme: Mixed Methods Study

BACKGROUND

The Healthier You National Health Service Digital Diabetes Prevention Programme (NHS-digital-DPP) is a 9-month digital behavior change intervention delivered by 4 independent providers that is implemented nationally across England. No studies have explored the design features included by service providers of digital diabetes prevention programs to promote engagement, and little is known about how participants of nationally implemented digital diabetes prevention programs such as this one make use of them.

OBJECTIVE

This study aimed to understand engagement with the NHS-digital-DPP. The specific objectives were to describe how engagement with the NHS-digital-DPP is promoted via design features and strategies and describe participants' early engagement with the NHS-digital-DPP apps.

METHODS

Mixed methods were used. The qualitative study was a secondary analysis of documents detailing the NHS-digital-DPP intervention design and interviews with program developers (n=6). Data were deductively coded according to an established framework of engagement with digital health interventions. For the quantitative study, anonymous use data collected over 9 months for each provider representing participants' first 30 days of use of the apps were obtained for participants enrolled in the NHS-digital-DPP. Use data fields were categorized into 4 intervention features (Track, Learn, Coach Interactions, and Peer Support). The amount of engagement with the intervention features was calculated for the entire cohort, and the differences between providers were explored statistically.

RESULTS

Data were available for 12,857 participants who enrolled in the NHS-digital-DPP during the data collection phase. Overall, 94.37% (12,133/12,857) of those enrolled engaged with the apps in the first 30 days. The median (IQR) number of days of use was 11 (2-25). Track features were engaged with the most (number of tracking events: median 46, IQR 3-22), and Peer Support features were the least engaged with, a median value of 0 (IQR 0-0). Differences in engagement with features were observed across providers. Qualitative findings offer explanations for the variations, including suggesting the importance of health coaches, reminders, and regular content updates to facilitate early engagement.

CONCLUSIONS

Almost all participants in the NHS-digital-DPP started using the apps. Differences across providers identified by the mixed methods analysis provide the opportunity to identify features that are important for engagement with digital health interventions and could inform the design of other digital behavior change interventions.

From trials to communities: implementation and scale-up of health behaviour interventions

BACKGROUND

To maximise their potential benefits to communities, effective health behaviour interventions need to be implemented, ideally 'at scale', and are often adapted as part of this. To inform future implementation and scale-up efforts, this study broadly sought to understand (i) how often health behaviour interventions are implemented in communities, (ii) the adaptations that occur; (iii) how frequency it occurred 'at scale'; and (iv) factors associated with 'scale-up'.

METHODS

A cross-sectional survey was conducted of corresponding authors of trials (randomised or non-randomised) assessing the effects of preventive health behaviour interventions. Included studies of relevant Cochrane reviews served as a sampling frame. Participants were asked to report on the implementation and scale-up (defined as investment in large scale delivery by a (non)government organisation) of their intervention in the community following trial completion, adaptations made, and any research dissemination strategies employed. Information was extracted from published reports of the trial including assessments of effectiveness and risk of bias.

RESULTS

Authors of 104 trials completed the survey. Almost half of the interventions were implemented following trial completion (taking on average 19 months), and 54% of those were adapted prior to doing so. The most common adaptations were adding intervention components, and adapting the intervention to fit within the local service setting. Scale-up occurred in 33% of all interventions. There were no significant associations between research trial characteristics such as intervention effectiveness, risk of bias, setting, involvement of end-user, and incidence of scale-up. However the number of research dissemination strategies was positively associated to the odds of an intervention being scaled-up (OR = 1.50; 95% CI: 1.19, 1.88; p < 0.001).

CONCLUSIONS

Adaptation of implemented trials is often undertaken. Most health behaviour interventions are not implemented or scaled-up following trial completion. The use of a greater number of dissemination strategies may increase the likelihood of scaled up.

Behavioral Predictors of Intention to Use a Text Messaging Reminder System Among People Living With HIV in Rural Uganda: Survey Study

BACKGROUND

The expansion of cellular phones in sub-Saharan Africa spurred the development of SMS text message-based mobile health (mHealth) technology. Numerous SMS text message-based interventions have attempted to increase retention in care for people living with HIV in sub-Saharan Africa. Many of these interventions have failed to scale. Understanding theory-grounded factors leading to mHealth acceptability is needed to create scalable, contextually appropriate, and user-focused interventions to improve longitudinal HIV care for people living with HIV in sub-Saharan Africa.

OBJECTIVE

In this study, we aimed to understand the relationship between constructs from the Unified Theory of Acceptance and Use of Technology (UTAUT), constructs identified in previous qualitative research, and behavioral intention to use a novel SMS text message-based mHealth intervention designed to improve care retention among people living with HIV initiating treatment in rural Uganda.

METHODS

We conducted a survey of people living with HIV who were newly initiating HIV care in Mbarara, Uganda, and had agreed to use a novel SMS text message-based system that notified them of abnormal laboratory results and reminded them to return to the clinic. Survey items assessed behavioral intention to use the SMS text messaging system; constructs from UTAUT; and demographics, literacy, SMS text messaging experience, HIV status disclosure, and social support. We used factor analysis and logistic regression to estimate the relationships between UTAUT constructs and the behavioral intention to use the SMS text messaging system.

RESULTS

A total of 249 participants completed the surveys, of whom 115 (46.2%) expressed high behavioral intention to use the SMS text messaging intervention. In a multivariable analysis, we found that performance expectancy (adjusted odds ratio [aOR] of the scaled factor score 5.69, 95% CI 2.64-12.25; P<.001), effort expectancy (aOR of the scaled factor score 4.87, 95% CI 1.75-13.51; P=.002), and social influence (measured as a 1-unit Likert score increase in the perception that clinical staff have been helpful in the use of the SMS text messaging program; aOR 3.03, 95% CI 1.21-7.54; P=.02) were significantly associated with high behavioral intention to use the SMS text messaging program. SMS text messaging experience (aOR/1-unit increase 1.48, 95% CI 1.11-1.96; P=.008) and age (aOR/1-year increase 1.07, 95% CI 1.03-1.13; P=.003) were also significantly associated with increased odds of high intention to use the system.

CONCLUSIONS

Performance expectancy, effort expectancy, and social influence, as well as age and SMS experience, were drivers of high behavioral intention to use an SMS text messaging reminder system among people living with HIV initiating treatment in rural Uganda. These findings highlight salient factors associated with SMS intervention acceptability in this population and indicate attributes that are likely to be key to the successful development and scaling of novel mHealth interventions.

Susceptibility to Breast Cancer Misinformation Among Chinese Patients: Cross-sectional Study

BACKGROUND

Currently, breast cancer is the most commonly diagnosed cancer and the sixth-leading cause of cancer-related deaths among Chinese women. Worse still, misinformation contributes to the aggravation of the breast cancer burden in China. There is a pressing need to investigate the susceptibility to breast cancer misinformation among Chinese patients. However, no study has been performed in this respect.

OBJECTIVE

This study aims to ascertain whether some demographics (age, gender, and education), some health literacy skills, and the internal locus of control are significantly associated with the susceptibility to misinformation about all types of breast cancers among randomly sampled Chinese patients of both genders in order to provide insightful implications for clinical practice, health education, medical research, and health policy making.

METHODS

We first designed a questionnaire comprising 4 sections of information: age, gender, and education (section 1); self-assessed disease knowledge (section 2); the All Aspects of Health Literacy Scale (AAHLS), the eHealth Literacy Scale (eHEALS), the 6-item General Health Numeracy Test (GHNT-6), and the "Internal" subscale of the Multidimensional Health Locus of Control (MHLC) scales (section 3); and 10 breast cancer myths collected from some officially registered and authenticated websites (section 4). Subsequently, we recruited patients from Qilu Hospital of Shandong University, China, using randomized sampling. The questionnaire was administered via wenjuanxing, the most popular online survey platform in China. The collected data were manipulated in a Microsoft Excel file. We manually checked the validity of each questionnaire using the predefined validity criterion. After that, we coded all valid questionnaires according to the predefined coding scheme, based on Likert scales of different point (score) ranges for different sections of the questionnaire. In the subsequent step, we calculated the sums of the subsections of the AAHLS and the sums of the 2 health literacy scales (the eHEALS and GHNT-6) and the 10 breast cancer myths. Finally, we applied logistic regression modeling to relate the scores in section 4 to the scores in sections 1-3 of the questionnaire to identify what significantly contributes to the susceptibility to breast cancer misinformation among Chinese patients.

RESULTS

All 447 questionnaires collected were valid according to the validity criterion. The participants were aged 38.29 (SD 11.52) years on average. The mean score for their education was 3.68 (SD 1.46), implying that their average educational attainment was between year 12 and a diploma (junior college). Of the 447 participants, 348 (77.85%) were women. The mean score for their self-assessed disease knowledge was 2.50 (SD 0.92), indicating that their self-assessed disease knowledge status was between "knowing a lot" and "knowing some." The mean scores of the subconstructs in the AAHLS were 6.22 (SD 1.34) for functional health literacy, 5.22 (SD 1.54) for communicative health literacy, and 11.19 (SD 1.99) for critical health literacy. The mean score for eHealth literacy was 24.21 (SD 5.49). The mean score for the 6 questions in the GHNT-6 was 1.57 (SD 0.49), 1.21 (SD 0.41), 1.24 (SD 0.43), 1.90 (SD 0.30), 1.82 (SD 0.39), and 1.73 (SD 0.44), respectively. The mean score for the patients' health beliefs and self-confidence was 21.19 (SD 5.63). The mean score for their response to each myth ranged from 1.24 (SD 0.43) to 1.67 (SD 0.47), and the mean score for responses to the 10 myths was 14.03 (SD 1.78). Through interpreting these descriptive statistics, we found that Chinese female patients' limited ability to rebut breast cancer misinformation is mainly attributed to 5 factors: (1) lower communicative health literacy, (2) certainty about self-assessed eHealth literacy skills, (3) lower general health numeracy, (4) positive self-assessment of general disease knowledge, and (5) more negative health beliefs and lower levels of self-confidence.

CONCLUSIONS

Drawing on logistic regression modeling, we studied the susceptibility to breast cancer misinformation among Chinese patients. The predicting factors of the susceptibility to breast cancer misinformation identified in this study can provide insightful implications for clinical practice, health education, medical research, and health policy making.

Leveraging Mobile Technology for Public Health Promotion: A Multidisciplinary Perspective

Health behaviors are inextricably linked to health and well-being, yet issues such as physical inactivity and insufficient sleep remain significant global public health problems. Mobile technology-and the unprecedented scope and quantity of data it generates-has a promising but largely untapped potential to promote health behaviors at the individual and population levels. This perspective article provides multidisciplinary recommendations on the design and use of mobile technology, and the concomitant wealth of data, to promote behaviors that support overall health. Using physical activity as anexemplar health behavior, we review emerging strategies for health behavior change interventions. We describe progress on personalizing interventions to an individual and their social, cultural, and built environments, as well as on evaluating relationships between mobile technology data and health to establish evidence-based guidelines. In reviewing these strategies and highlighting directions for future research, we advance the use of theory-based, personalized, and human-centered approaches in promoting health behaviors.

Perceptions of Mobile Health Technology in Elective Surgery: A Qualitative Study of North American Surgeons

OBJECTIVES

To explore the surgeon-perceived added value of mobile health technologies (mHealth), and determine facilitators of and barriers to implementing mHealth.

BACKGROUND

Despite the growing popularity of mHealth and evidence of meaningful use of patient-generated health data in surgery, implementation remains limited.

METHODS

This was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify surgeons across the United States and Canada. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Video-based interviews were conducted (September-November 2020) and interview transcripts were thematically analyzed.

RESULTS

Thirty surgeons from 8 specialties and 6 North American regions were interviewed. Surgeons identified opportunities to integrate mHealth data pre- operatively (eg, expectation-setting, decision-making) and during recovery (eg, remote monitoring, earlier detection of adverse events) among higher risk patients. Perceived advantages of mHealth data compared with surgical and patient-reported outcomes included easier data collection, higher interpretability and objectivity of mHealth data, and the potential to develop more patientcentered and functional measures of health. Surgeons identified a variety of implementation facilitators and barriers around surgeon- and patient buy-in, integration with electronic medical records, regulatory/reimbursement concerns, and personnel responsible for mHealth data. Surgeons described similar considerations regarding perceptions of mHealth among patients, including the potential to address or worsen existing disparities in surgical care.

CONCLUSIONS

These findings have the potential to inform the effective and equitable implementation of mHealth for the purposes of supporting patients and surgical care teams throughout the delivery of surgical care.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Iterative Development, Validation, and Certification of a Smartphone System to Assess Neonatal Jaundice: Development and Usability Study

BACKGROUND

Medical device development is an area facing multiple challenges, resulting in a high number of products not reaching the clinical setting. Neonatal hyperbilirubinemia, manifesting as neonatal jaundice (NNJ), is an important cause of newborn morbidity and mortality. It is important to identify infants with neonatal hyperbilirubinemia at an early stage, but currently there is a lack of tools that are both accurate and affordable.

OBJECTIVE

This study aimed to develop a novel system to assess the presence of NNJ. The device should provide accurate results, be approved as a medical device, be easy to use, and be produced at a price that is affordable even in low-resource settings.

METHODS

We used an iterative approach to develop a smartphone-based system to detect the presence of NNJ. We performed technical development, followed by clinical and usability testing in parallel, after which we initiated the regulatory processes for certification. We updated the system in each iteration, and the final version underwent a clinical validation study on healthy term newborns aged 1 to 15 days before all documentation was submitted for conformity assessment to obtain Conformité Européenne (CE) certification. We developed a system that incorporates a smartphone app, a color calibration card, and a server.

RESULTS

Three iterations of the smartphone-based system were developed; the final version was approved as a medical device after complying with Medical Device Regulation guidelines. A total of 201 infants were included in the validation study. Bilirubin values using the system highly correlated with total serum or plasma bilirubin levels (r=0.84). The system had a high sensitivity (94%) to detect severe jaundice, defined as total serum or plasma bilirubin >250 µmol/L, and maintained a high specificity (71%).

CONCLUSIONS

Our smartphone-based system has a high potential as a tool for identifying NNJ. An iterative approach to product development, conducted by working on different tasks in parallel, resulted in a functional and successful product. By adhering to the requirements for regulatory approval from the beginning of the project, we were able to develop a market-ready mobile health solution.

Development of the key performance indicators for digital health interventions: A scoping review

Background

Digital health interventions offer new methods for delivering healthcare, with the potential to innovate healthcare services. Key performance indicators play a role in the evaluation, measurement, and improvement in healthcare quality and service performance. The aim of this scoping review was to identify current knowledge and evidence surrounding the development of key performance indicators for digital health interventions.

Methods

A literature search was conducted across ten key databases: AMED - The Allied and Complementary Medicine Database, CINAHL - Complete, Health Source: Nursing/Academic Edition, MEDLINE, APA PsycINFO, EMBASE, EBM Reviews - Cochrane Database of Systematic Reviews, EBM Reviews - Database of Abstracts of Reviews of Effects, EBM Reviews - Health Technology Assessment, and IEEE Xplore.

Results

Five references were eligible for the review. Two were articles on original research studies of a specific digital health intervention, and two were overviews of methods for developing digital health interventions (not specific to a single digital health intervention). All the included reports discussed the involvement of stakeholders in developing key performance indicators for digital health interventions. The step of identifying and defining the key performance indicators was completed using various methodologies, but all centred on a form of stakeholder involvement. Potential options for stakeholder involvement for key performance indicator identification include the use of an elicitation framework, a factorial survey approach, or a Delphi study.

Conclusions

Few articles were identified, highlighting a significant gap in evidence-based knowledge in this domain. All the included articles discussed the involvement of stakeholders in developing key performance indicators for digital health interventions, which were performed using various methodologies. The articles acknowledged a lack of literature related to key performance indicator development for digital health interventions. To allow comparability between key performance indicator initiatives and facilitate work in the field, further research would be beneficial to develop a common methodology for key performance indicators development for digital health interventions.

Factors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff

BACKGROUND

Digital interventions for health financing, if implemented at scale, have the potential to improve health system performance by reducing transaction costs and improving data-driven decision-making. However, many interventions never reach sustainability, and evidence on success factors for scale is scarce. The Insurance Management Information System (IMIS) is a digital intervention for health financing, designed to manage an insurance scheme and already implemented on a national scale in Tanzania. A previous study found that the IMIS claim function was poorly adopted by health care workers (HCWs), questioning its potential to enable strategic purchasing and succeed at scale.

OBJECTIVE

This study aimed to understand why the adoption of the IMIS claim function by HCWs remained low in Tanzania and to assess implications for use at scale.

METHODS

We conducted 21 semistructured interviews with HCWs and management staff in 4 districts where IMIS was first implemented. We sampled respondents by using a maximum variation strategy. We used the framework method for data analysis, applying a combination of inductive and deductive coding to organize codes in a socioecological model. Finally, we related emerging themes to a framework for digital health interventions for scale.

RESULTS

Respondents appreciated IMIS's intrinsic software characteristics and technical factors and acknowledged IMIS as a valuable tool to simplify claim management. Human factors, extrinsic ecosystem, and health care ecosystem were considered as barriers to widespread adoption.

CONCLUSIONS

Digital interventions for health financing, such as IMIS, may have the potential for scale if careful consideration is given to the environment in which they are placed. Without a sustainable health financing environment, sufficient infrastructure, and human capacity, they cannot unfold their full potential to improve health financing functions and ultimately contribute to universal health coverage.

Effect of receiving mobile text messages on cortisol concentrations in students at the University of the Free State

Background

Texting has become central to social life, with adverse effects on physiological functioning. Research into the impact of texting on cortisol secretion is limited.

Aim

Thus study aimed to determine how receiving mobile text messages affected salivary cortisol concentrations and investigate the moderating effects of stress, anxiety and depression on cortisol secretion.

Setting

Undergraduate physiology students attending physiology lectures at the Faculty of Health Sciences, University of the Free State, 2016.

Methods

An experimental, crossover, quantitative design was used. Participants were involved over two consecutive days, receiving mobile text messages (intervention) on one day and acting as their own control on the other. Self-reported data on stress, anxiety, depression and subjective experience of the study, and saliva samples were collected. Text frequency and wording (neutral, positive, negative) were varied among participants.

Results

Forty-eight students participated in the study. Salivary cortisol concentrations did not differ significantly between the intervention and control days. High anxiety levels were associated with increased cortisol concentrations. No associations with cortisol concentrations were documented in low to moderate anxiety, stress, depression or how participants experienced the intervention. There were no significant differences between text frequency, text emotion and change in cortisol concentrations on the intervention day.

Conclusion

Receiving mobile text messages did not elicit a significant cortisol response in participants.

Contribution

Findings added to the body of knowledge about the effect of texting on student learning by measuring salivary cortisol concentrations in a lecture setting, with investigation into the moderating effects of stress, anxiety, depression and participants' subjective experience.

A Proof-of-Concept Pilot Test of a Behavioral Intervention to Improve Adherence to Dietary Recommendations for Cancer Prevention

OBJECTIVES

Prevention programs that can help adults improve the quality of their diets to reduce cancer risk are needed. This Phase IIa study prospectively tested a mHealth intervention designed to improve adherence to dietary quality guidelines for cancer prevention.

METHODS

All participants (N = 62) received nutrition education and a self-regulation skills curriculum, with a primary target of changing grocery shopping behavior. Using a randomized, factorial design, the study varied whether each of the following 4 components were added to the 20-week intervention: (1) location-triggered app messaging, delivered when individuals arrived at grocery stores, (2) reflections on benefits of change, delivered with extra coaching time and tailored app messages, (3) coach monitoring, in which food purchases were digitally monitored by a coach, and (4) involvement of a household member in the intervention.

RESULTS

Benchmarks were successfully met for recruitment, retention, and treatment acceptability. Across conditions, there were significant reductions in highly processed food intake (P < .001, η2 = .48), red and processed meat intake (P < .001, η2 = .20), and sugar-sweetened beverage intake (P = .008, η2 = .13) from pre-to post-treatment. Analyses examining whether each intervention component influenced change across time found that participants who received coach monitoring increased their intake of fruits, vegetables, and fiber, whereas those with no coach monitoring had less improvement (P = .01, η2 = .14). The improvement in red and processed meat was stronger among participants with household support ON, at a marginally significant level, than those with household support OFF (P = .056, η2 = .07).

CONCLUSION

This study showed feasibility, acceptability, and preliminary signals of efficacy of a remotely delivered intervention to facilitate adherence to dietary guidelines for cancer prevention and that coach monitoring and household support may be especially effective strategies. A fully powered clinical trial is warranted to test an optimized version of the intervention that includes nutrition education, self-regulation skills training, coach monitoring, and household member involvement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04947150.

Exploring the barriers and facilitators for supporting adolescents with knee pains adherence to mobile health apps: A think-aloud study

Background

Mobile health (mHealth) applications have the potential to support adolescents' self-management of knee pain. However, ensuring adherence remains a barrier when designing mHealth concepts for adolescents.

Objective

This study aimed to explore barriers and facilitators for adhering to mHealth interventions to inform design principles.

Methods

Think-aloud tests were conducted with 12 adolescents (aged 12.5 years median) with knee pain, using a low-fidelity prototype. The prototype was informed by the authors previous work, rapid prototyping sessions with seven health professionals, and synthesis via the Behavioral Intervention Technology Model. The think-aloud tests were video recorded and analyzed thematically to identify design principles.

Results

The analysis based on user testing with adolescents with knee pain identified three themes: "user experience and feedback," "contextual challenges," and "new features" and nine subthemes. Adolescents were able to use mHealth behavioral features such as self-tracking, goal setting, education, and data visualization to capture and reflect on their knee pain developments, which facilitated use. However, adolescents struggle with timing interventions, breaking down management behaviors, and biases towards interventions were identified as internal threats to adherence. Competing activities, parental meddling, and privacy concerns were external adherence barriers. Twelve design principles were identified for integrating these insights into mHealth designs.

Conclusion

Participants' motivations for adherence were influenced by internal and external factors. While adolescents were able to use mHealth behavioral features to capture and reflect on knee pain developments, understanding how to accommodate adolescents' cognitive abilities, competing activities, and need for independence is quintessential to enhance adherence in everyday contexts.

Effectiveness of Mindfulness and Positive Strengthening mHealth Interventions for the Promotion of Subjective Emotional Wellbeing and Management of Self-Efficacy for Chronic Cardiac Diseases

Intervention in health prevention and treatment via mobile phones is becoming a key element on health promotion. Testing the efficacy of these mobile health (mHealth) psychological interventions for cardiovascular health is necessary as it is a chronic pathology, and it can influence the affective and cognitive states of patients. This research aimed to analyze the effectiveness of two brief psychological interventions-mindfulness and positive strengthening-to promote subjective emotional wellbeing and disease management self-efficacy using mHealth. This was a three-arm intervention and feasibility study, with a pre-post design and three follow-up measures with 105 patients (93 completed all phases) with cardiovascular diseases. Group 1 and 2 received the mindfulness or strengthening intervention, and Group 3 was the control group. The positive-negative affect and management self-efficacy for chronic and cardiovascular diseases were analyzed over time, while anxiety and depression levels were assessed at the beginning of the study. The results showed that mindfulness and positive strengthening interventions both had a positive effect on participants' affective state and management self-efficacy for the disease in comparison with the control group over time, even after controlling for baseline anxiety and depression levels. Positive strengthening seems to be more effective for improving cardiac self-efficacy, while mindfulness practice was significantly more effective at reducing negative affect at the first face-to-face evaluation.

Use of mHealth tools to register birth outcomes in low-income and middle-income countries: a scoping review

OBJECTIVE

Accurate reporting of birth outcomes in low-income and middle-income countries (LMICs) is essential. Mobile health (mHealth) tools have been proposed as a replacement for conventional paper-based registers. mHealth could provide timely data for individual facilities and health departments, as well as capture deliveries outside facilities. This scoping review evaluates which mHealth tools have been reported to birth outcomes in the delivering room in LMICs and documents their reported advantages and drawbacks.

DESIGN

A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Joanna Briggs Institute guidelines for scoping reviews and the mHealth evidence reporting and assessment checklist for evaluating mHealth interventions.

DATA SOURCES

PubMed, CINAHL and Global Health were searched for records until 3 February 2022 with no earliest date limit.

ELIGIBILITY CRITERIA

Studies were included where healthcare workers used mHealth tools in LMICs to record birth outcomes. Exclusion criteria included mHealth not being used at the point of delivery, non-peer reviewed literature and studies not written in English.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened studies and extracted data. Common themes among studies were identified.

RESULTS

640 records were screened, 21 of which met the inclusion criteria, describing 15 different mHealth tools. We identified six themes: (1) digital tools for labour monitoring (8 studies); (2) digital data collection of specific birth outcomes (3 studies); (3) digital technologies used in community settings (6 studies); (4) attitudes of healthcare workers (10 studies); (5) paper versus electronic data collection (3 studies) and (6) infrastructure, interoperability and sustainability (8 studies).

CONCLUSION

Several mHealth technologies are reported to have the capability to record birth outcomes at delivery, but none were identified that were designed solely for that purpose. Use of digital delivery registers appears feasible and acceptable to healthcare workers, but definitive evaluations are lacking. Further assessment of the sustainability of technologies and their ability to integrate with existing health information systems is needed.

Promoting Adolescent Sexual and Reproductive Health in North America Using Free Mobile Apps: Environmental Scan

BACKGROUND

Neglecting adolescents' sexual and reproductive health (SRH) can affect multiple domains of development. Promoting healthy adolescent SRH is increasingly done using mobile phone apps. Providing SRH information via mobile phones can positively influence SRH outcomes including improving knowledge, reducing sexual risk behavior, and increasing the use of health services. A systematic approach to establishing and evaluating the quality of adolescent SRH mobile apps is urgently needed to rigorously evaluate whether they are a viable and effective strategy for reaching adolescents and improving adolescent SRH knowledge and behaviors in particular.

OBJECTIVE

This study aimed to conduct an environmental scan to produce an inventory of adolescent SRH-specific mobile apps with descriptions of their purpose, structure, operations, and quality of evidence.

METHODS

We used a literature review to develop 15 search terms for adolescent SRH-related apps in the Canadian and US Apple and Google app stores. After generating the search results, inclusion and exclusion criteria were applied. Using the remaining apps, we built an evidence table of app information, and app reviewers assessed each included app using the Mobile App Rating Scale. App assessments were then used to highlight trends between apps and identify gaps in app quality.

RESULTS

In total, 2761 apps were identified by our searches, of which 1515 were duplicates. Of the 1246 remaining apps, 15 met the criteria for further assessment. Across all subdomains, on a scale of 1-5, the mean app score was 3.4/5. The Functionality subdomain had the highest mean score of 4.1/5, whereas the Engagement subdomain had the lowest score of 2.9/5. The top 4 apps were Tia: Female Health Advisor (4.7/5), Under the Stethoscope (4.2/5), Condom Credit Card (4.1/5), and Shnet (3.7/5).

CONCLUSIONS

This environmental scan aimed to provide a comprehensive overview of the mobile apps developed to promote adolescent SRH knowledge and outcomes. Of the 15 mobile apps available to provide information related to adolescent SRH, few provided comprehensive, reliable, and evidence-based SRH information. Areas of strength included the apps' gestural design, performance, ease of use, and navigation. Areas of weakness included app goals, evidence base, and app customization options. These results can be used to conduct future studies evaluating the use and efficacy of mobile apps on health knowledge and behaviors and promote adolescent SRH.

Mobile for Mothers mHealth Intervention to Augment Maternal Health Awareness and Behavior of Pregnant Women in Tribal Societies: Randomized Quasi-Controlled Study

Background

Despite several initiatives taken by government bodies, disparities in maternal health have been noticeable across India’s socioeconomic gradient due to poor health awareness.

Objective

The aim of this study was to implement an easy-to-use mobile health (mHealth) app—Mobile for Mothers (MfM)—as a supporting tool to improve (1) maternal health awareness and (2) maternal health–related behavioral changes among tribal and rural communities in India.

Methods

Pregnant women, aged 18 to 45 years, were selected from two rural villages of Jharkhand, India: (1) the intervention group received government-mandated maternal care through an mHealth app and (2) the control group received the same government-mandated care via traditional means (ie, verbally). A total of 800 accredited social health activists (ASHAs) were involved, of which 400 were allocated to the intervention group. ASHAs used the MfM app to engage with pregnant women during each home visit in the intervention group. The mHealth intervention commenced soon after the baseline survey was completed in February 2014. The end-line data were collected between November 2015 and January 2016. We calculated descriptive statistics related to demographics and the percentage changes for each variable between baseline and end line per group. The baseline preintervention groups were compared to the end-line postintervention groups using Pearson chi-square analyses. Mantel-Haenszel tests for conditional independence were conducted to determine if the pre- to postintervention differences in the intervention group were significantly different from those in the control group.

Results

Awareness regarding the five cleans (5Cs) in the intervention group increased (P<.001) from 143 (baseline) to 555 (end line) out of 740 participants. Awareness about tetanus vaccine injections and the fact that pregnant women should receive two shots of tetanus vaccine in the intervention group significantly increased (P<.001) from 73 out of 740 participants (baseline) to 372 out of 555 participants (end line). In the intervention group, awareness regarding the fact that problems like painful or burning urination and itchy genitals during pregnancy are indicative of a reproductive tract infection increased (P<.001) from 15 (baseline) to 608 (end line) out of 740 participants. Similarly, knowledge about HIV testing increased (P<.001) from 39 (baseline) to 572 (end line) out of 740 participants. We also noted that the number of pregnant women in the intervention group who consumed the prescribed dosage of iron tablets increased (P<.001) from 193 (baseline) out of 288 participants to 612 (end line) out of 663 participants.

Conclusions

mHealth interventions can augment awareness of, and persistence in, recommended maternal health behaviors among tribal communities in Jharkhand, India. In addition, mHealth could act as an educational tool to help tribal societies break away from their traditional beliefs about maternal health and take up modern health care recommendations.

Trial Registration

OSF Registries 9U8D5; https://doi.org/10.17605/OSF.IO/9U8D5

Role of Social and App-Related Factors in Behavioral Engagement With mHealth for Improved Well-being Among Chronically Ill Patients: Scenario-Based Survey Study

Background

The last decade has seen a considerable increase in the number of mobile health (mHealth) apps in everyday life. These mHealth apps have the potential to significantly improve the well-being of chronically ill patients. However, behavioral engagement with mHealth apps remains low.

Objective

The aim of this study was to describe the behavioral engagement of chronically ill patients with mHealth apps by investigating (1) how it is affected by social factors (ie, physician recommendation) and app-related factors (ie, app integration) and (2) how it affects patient well-being. This study also considers the moderating effect of attachment to traditional health care and the mobile app experience among patients.

Methods

We carried out a scenario-based survey study of chronically ill patients (N=521). A Bayesian structural equation modeling with mediation and moderation analysis was conducted in MPlus.

Results

Both physician recommendations for mHealth app use and app integration have positive effects on the behavioral engagement of chronically ill patients with mHealth apps. Higher behavioral engagement positively affects the hedonic well-being (extent of pleasure) and the eudaemonic well-being (extent of self-efficacy) of chronically ill patients. Mobile app experience, however, positively moderates the relationship between app integration and behavioral engagement, whereas patient attachment to traditional care does not moderate the relationship between physician recommendation and behavioral engagement. Taken together, the proportion of variance explained (R²) equals 21% for behavioral engagement and 52.8% and 62.2% for hedonic and eudaemonic well-being, respectively, thereby providing support for the strong influence of app integration and physician recommendation via the mediation of the patients’ behavioral engagement on both patients’ hedonic and eudaemonic well-being.

Conclusions

Physician recommendation and app integration enable behavioral engagement and promote well-being among chronically ill patients. It is thus important to take social and app-related factors into consideration during and after the development of mHealth apps.

The role of digital innovation in improving healthcare quality in extreme adversity: an interpretative phenomenological analysis study

Background

High quality is a necessary feature of healthcare delivery. Healthcare quality challenges are particularly present in conditions of extreme adversity, such as conflict settings or sustained humanitarian crises. Digital health technologies have recently emerged as an innovation to deliver care around the world in a variety of settings. However, there is little insight into how digital health technologies can be used to improve the quality of care where extreme adversity introduces unique challenges. This study aimed to identify how digital health technologies may be most impactful in improving the quality of care and evaluate opportunities for accelerated and meaningful digital innovation in adverse settings.

Methods

A phenomenological approach (Interpretative Phenomenological Approach [IPA]), using semi-structured interviews, was adopted. Six individuals were interviewed in person based on their expertise in global health, international care delivery, and the application of digital health technologies to improve the quality of care in extreme adversity settings. The interviews were informed by a semi-structured topic guide with open-ended questions. The transcripts were compiled verbatim and were systematically examined by two authors, using the framework analysis method to extract themes and subthemes.

Results

The participants identified several areas in which digital health technologies could be most impactful, which include engagement in care, continuity of care, workforce operations, and data collection. Opportunities for accelerated digital innovation include improving terminology, identity, ownership, and interoperability, identifying priority areas for digital innovation, developing tailored solutions, coordination and standardisation, and sustainability and resilience.

Conclusions

These results suggest that there are conditions that favour or challenge the application of digital health technologies, even in specific areas in which they could be useful. A better understanding of the drivers and barriers to digitally driven quality improvement in settings of extreme adversity could inform international policies and optimisation strategies for the future.

Willingness to Use and Pay for Digital Healthcare Services According to Four Scenarios: Results from a National Survey (Preprint)

BACKGROUND

Smartphones and their associated technology have evolved to an extent where these devices can be used to provide digital health interventions. However, few studies have been conducted on the willingness to use (WTU) and willingness to pay (WTP) for digital health interventions.

OBJECTIVE

The purpose of this study was to investigate how previous service experience, the content of the services, and individuals' health status affect WTU and WTP.

METHODS

We conducted a nationwide web-based survey in 3 groups: nonusers (n=506), public service users (n=368), and private service users (n=266). Participants read scenarios about an imagined health status (such as having a chronic illness) and the use of digital health intervention models (self-management, expert management, and medical management). They were then asked to respond to questions on WTU and WTP.

RESULTS

Public service users had a greater intention to use digital health intervention services than nonusers and private service users: scenario A (health-risk situation and self-management), nonusers=odd ratio [OR] .239 (SE .076; P<.001) and private service users=OR .138 (SE .044; P<.001); scenario B (health-risk situation and expert management), nonusers=OR .175 (SE .040; P<.001) and private service users=OR .219 (SE .053; P<.001); scenario C (chronic disease situation and expert management), nonusers=OR .413 (SE .094; P<.001) and private service users=OR .401 (SE .098; P<.001); and scenario D (chronic disease situation and medical management), nonusers=OR .480 (SE .120; P=.003) and private service users=OR .345 (SE .089; P<.001). In terms of WTP, in scenarios A and B, those who used the public and private services had a higher WTP than those who did not (scenario A: β=-.397, SE .091; P<.001; scenario B: β=-.486, SE .098; P<.001). In scenario C, private service users had greater WTP than public service users (β=.264, SE .114; P=.02), whereas public service users had greater WTP than nonusers (β=-.336, SE .096; P<.001). In scenario D, private service users were more WTP for the service than nonusers (β=-.286, SE .092; P=.002).

CONCLUSIONS

We confirmed that the WTU and WTP for digital health interventions differed based on individuals' prior experience with health care services, health status, and demographics. Recently, many discussions have been made to expand digital health care beyond the early adapters and fully into people's daily lives. Thus, more understanding of people's awareness and acceptance of digital health care is needed.

Optimization of the Chronic Kidney Disease-Peritoneal Dialysis App to Improve Care for Patients on Peritoneal Dialysis in Northeast Thailand: User-Centered Design Study

Background

The prevalence of peritoneal dialysis (PD) in Thailand is increasing rapidly in part because of Thailand’s Peritoneal Dialysis First policy. PD is a home-based renal replacement therapy in which patients with chronic kidney disease perform up to 4 exchanges of dialysate fluid per day in the peritoneal cavity. Overhydration is one of the most common complications in patients on PD and is associated with increased morbidity and mortality. To monitor hydration status, patients collect hydration metrics, including body weight, blood pressure, urine output, and ultrafiltration volume, from each dialysis cycle and enter this information into a PD logbook. This information is reviewed bimonthly at PD clinic appointments. The chronic kidney disease-PD (CKD-PD) app with near-field communication (NFC) and optical character recognition (OCR) was developed to automate hydration metric collection. The information was displayed in the app for self-monitoring and uploaded to a database for real-time monitoring by the PD clinic staff. Early detection and treatment of overhydration could potentially reduce the morbidity and mortality related to overhydration.

Objective

This study aims to identify usability issues and technology adoption barriers for the CKD-PD app with NFC and OCR and a monitoring system and to use this information to make rapid cycle improvements.

Methods

A multidisciplinary team of nephrologists, PD clinic nurses, computer programmers, and engineers trained and observed 2 groups of 5 participants in the use of the CKD-PD app with NFC and OCR and a monitoring system. The participants were observed using technology in their homes in 3 phases. The data collected included the Unified Theory of Acceptance and Use of Technology questionnaire, think-aloud observation, user ratings, completion of hydration metrics, and upload of hydration metrics to the central database. These results were used by the team between phases to improve the functionality and usefulness of the app.

Results

The CKD-PD app with NFC and OCR and a monitoring system underwent 3 rapid improvement cycles. Issues were identified regarding the usability of the NFC and OCR data collection, app stability, user interface, hydration metric calculation, and display. NFC and OCR improved hydration metric capture; however, issues remained with their usability. App stability and user interface issues were corrected, and hydration metrics were successfully uploaded by the end of phase 3. Participants’ scores on technology adoption decreased but were still high, and there was enthusiasm for the self-monitoring and clinical communication features.

Conclusions

Our rapid cycle process improvement methodology identified and resolved key barriers and usability issues for the CKD-PD app with NFC and OCR and a monitoring system. We believe that this methodology can be accomplished with limited training in data collection, statistical analysis, and funding.

Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review

BACKGROUND

While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs).

METHODS AND FINDINGS

On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework.

CONCLUSIONS

Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.

Using the Consolidated Framework for Implementation Research to Inform the Design of the Mobile Inspección Visual con Ácido Acético System: Mixed Methods Case Study

Background

There is growing evidence supporting the use of mobile health (mHealth) interventions in low- and middle-income countries to address resource limitations in the delivery of health information and services to vulnerable populations. In parallel, there is an increasing emphasis on the use of implementation science tools and frameworks for the early identification of implementation barriers and to improve the acceptability, appropriateness, and adoption of mHealth interventions in resource-limited settings. However, there are limited examples of the application of implementation science tools and frameworks to the formative phase of mHealth design for resource-limited settings despite the potential benefits of this work for enhancing subsequent implementation, scale-up, and sustainability.

Objective

We presented a case study on the use of an implementation science framework in mHealth design. In particular, we illustrated the usability of the Consolidated Framework for Implementation Research (CFIR) for organizing and interpreting formative research findings during the design of the mobile Inspección Visual con Ácido Acético (mIVAA) system in Lima, Peru.

Methods

We collected formative data from prospective users of the mIVAA intervention using multiple research methodologies, including structured observations, surveys, group and individual interviews, and discussions with local stakeholders at the partnering organization in Peru. These activities enabled the documentation of clinical workflows, perceived barriers to and facilitators of mIVAA, overarching barriers to cervical cancer screening in community-based settings, and related local policies and guidelines in health care. Using a convergent mixed methods analytic approach and the CFIR as an organizing framework, we mapped formative research findings to identify key implementation barriers and inform iterations of the mIVAA system design.

Results

In the setting of our case study, most implementation barriers were identified in the CFIR domains of intervention characteristics and inner setting. All but one barrier were addressed before mIVAA deployment by modifying the system design and adding supportive resources. Solutions involved improvements to infrastructure, including cellular data plans to avoid disruption from internet failure; improved process and flow, including an updated software interface; and better user role definition for image capture to be consistent with local health care laws.

Conclusions

The CFIR can serve as a comprehensive framework for organizing formative research data and identifying key implementation barriers during mHealth intervention design. In our case study of the mIVAA system in Peru, formative research contributing to the CFIR domains of intervention characteristics and inner setting elicited the most key barriers to implementation. The early identification of barriers enabled design iterations before system deployment. Future efforts to develop mHealth interventions for low- and middle-income countries may benefit from using the approach presented in this case study as well as prioritizing the CFIR domains of intervention characteristics and inner setting.

Lessons learned in the Apple Heart Study and implications for the data management of future digital clinical trials

The digital clinical trial is fast emerging as a pragmatic trial that can improve a trial's design including recruitment and retention, data collection and analytics. To that end, digital platforms such as electronic health records or wearable technologies that enable passive data collection can be leveraged, alleviating burden from the participant and study coordinator. However, there are challenges. For example, many of these data sources not originally intended for research may be noisier than traditionally obtained measures. Further, the secure flow of passively collected data and their integration for analysis is non-trivial. The Apple Heart Study was a prospective, single-arm, site-less digital trial designed to evaluate the ability of an app to detect atrial fibrillation. The study was designed with pragmatic features, such as an app for enrollment, a wearable device (the Apple Watch) for data collection, and electronic surveys for participant-reported outcomes that enabled a high volume of patient enrollment and accompanying data. These elements led to challenges including identifying the number of unique participants, maintaining participant-level linkage of multiple complex data streams, and participant adherence and engagement. Novel solutions were derived that inform future designs with an emphasis on data management. We build upon the excellent framework of the Clinical Trials Transformation Initiative to provide a comprehensive set of guidelines for data management of the digital clinical trial that include an increased role of collaborative data scientists in the design and conduct of the modern digital trial.

Mobile Health Apps Providing Information on Drugs for Adult Emergency Care: Systematic Search on App Stores and Content Analysis

Background

Drug-referencing apps are among the most frequently used by emergency health professionals. To date, no study has analyzed the quantity and quality of apps that provide information on emergency drugs.

Objective

This study aimed to identify apps designed to assist emergency professionals in managing drugs and to describe and analyze their characteristics.

Methods

We performed an observational, cross-sectional, descriptive study of apps that provide information on drugs for adult emergency care. The iOS and Android platforms were searched in February 2021. The apps were independently evaluated by 2 hospital clinical pharmacists. We analyzed developer affiliation, cost, updates, user ratings, and number of downloads. We also evaluated the main topic (emergency drugs or emergency medicine), the number of drugs described, the inclusion of bibliographic references, and the presence of the following drug information: commercial presentations, usual dosage, dose adjustment for renal failure, mechanism of action, therapeutic indications, contraindications, interactions with other medicinal products, use in pregnancy and breastfeeding, adverse reactions, method of preparation and administration, stability data, incompatibilities, identification of high-alert medications, positioning in treatment algorithms, information about medication reconciliation, and cost.

Results

Overall, 49 apps were identified. Of these 49 apps, 32 (65%) were found on both digital platforms; 11 (22%) were available only for Android, and 6 (12%) were available only for iOS. In total, 41% (20/49) of the apps required payment (ranging from €0.59 [US $0.64] to €179.99 [US $196.10]) and 22% (11/49) of the apps were developed by non–health care professionals. The mean weighted user rating was 4.023 of 5 (SD 0.71). Overall, 45% (22/49) of the apps focused on emergency drugs, and 55% (27/49) focused on emergency medicine. More than half (29/47, 62%) did not include bibliographic references or had not been updated for more than a year (29/49, 59%). The median number of drugs was 66 (range 4 to >5000). Contraindications (26/47, 55%) and adverse reactions (24/47, 51%) were found in only half of the apps. Less than half of the apps addressed dose adjustment for renal failure (15/47, 32%), interactions (10/47, 21%), and use during pregnancy and breastfeeding (15/47, 32%). Only 6% (3/47) identified high-alert medications, and 2% (1/47) included information about medication reconciliation. Health-related developer, main topic, and greater amount of drug information were not statistically associated with higher user ratings (P=.99, P=.09, and P=.31, respectively).

Conclusions

We provide a comprehensive review of apps with information on emergency drugs for adults. Information on authorship, drug characteristics, and bibliographic references is frequently scarce; therefore, we propose recommendations to consider when developing an app of these characteristics. Future efforts should be made to increase the regulation of drug-referencing apps and to conduct a more frequent and documented review of their clinical content.

Quantitative User Data From a Chatbot Developed for Women With Gestational Diabetes Mellitus: Observational Study

Background

The rising prevalence of gestational diabetes mellitus (GDM) calls for the use of innovative methods to inform and empower these pregnant women. An information chatbot, Dina, was developed for women with GDM and is Norway’s first health chatbot, integrated into the national digital health platform.

Objective

The aim of this study is to investigate what kind of information users seek in a health chatbot providing support on GDM. Furthermore, we sought to explore when and how the chatbot is used by time of day and the number of questions in each dialogue and to categorize the questions the chatbot was unable to answer (fallback). The overall goal is to explore quantitative user data in the chatbot’s log, thereby contributing to further development of the chatbot.

Methods

An observational study was designed. We used quantitative anonymous data (dialogues) from the chatbot’s log and platform during an 8-week period in 2018 and a 12-week period in 2019 and 2020. Dialogues between the user and the chatbot were the unit of analysis. Questions from the users were categorized by theme. The time of day the dialogue occurred and the number of questions in each dialogue were registered, and questions resulting in a fallback message were identified. Results are presented using descriptive statistics.

Results

We identified 610 dialogues with a total of 2838 questions during the 20 weeks of data collection. Questions regarding blood glucose, GDM, diet, and physical activity represented 58.81% (1669/2838) of all questions. In total, 58.0% (354/610) of dialogues occurred during daytime (8 AM to 3:59 PM), Monday through Friday. Most dialogues were short, containing 1-3 questions (340/610, 55.7%), and there was a decrease in dialogues containing 4-6 questions in the second period (P=.013). The chatbot was able to answer 88.51% (2512/2838) of all posed questions. The mean number of dialogues per week was 36 in the first period and 26.83 in the second period.

Conclusions

Frequently asked questions seem to mirror the cornerstones of GDM treatment and may indicate that the chatbot is used to quickly access information already provided for them by the health care service but providing a low-threshold way to access that information. Our results underline the need to actively promote and integrate the chatbot into antenatal care as well as the importance of continuous content improvement in order to provide relevant information.

Mobile Health (m-Health) in Retrospect: The Known Unknowns

For nearly two decades, mobile health or (m-Health) was hailed as the most innovative and enabling area for the digital transformation of healthcare globally. However, this profound vision became a fleeting view since the inception and domination of smart phones, and the reorientation of the concept towards the exclusivity of global smart phone application markets and services. The global consumerization of m-Health in numerous disciplines of healthcare, fitness and wellness areas is unprecedented. However, this divergence between 'mobile health capitalism' and the 'science of mobile health' led to the creation of the 'm-Health schism'. This schism was sustained by the continued domination of the former on the expense of the latter. This also led to increased global m-Health inequality and divide between the much-perceived health and patient benefits and the markets of m-Health. This divergence was more evident in low and middle income (LMIC) countries compared to the developed world. This powerful yet misguided evolution of the m-Health was driven essentially by complex factors. These are presented in this paper as the 'known unknowns' or 'the obvious but sanctioned facts' of m-Health. These issues had surreptitiously contributed to this reorientation and the widening schism of m-Health. The collateral damage of this process was the increased shift towards understanding 'digital health' as a conjecture term associated with mobile health. However, to date, no clear or scientific views are discussed or analyzed on the actual differences and correlation aspects between digital and mobile health. This particular 'known unknown' is presented in detail in order to provide a rapprochement framework of this correlation and valid presentations between the two areas. The framework correlates digital health with the other standard ICT for the healthcare domains of telemedicine, telehealth and e-health. These are also increasingly used in conjunction with digital health, without clear distinctions between these terms and digital health. These critical issues have become timelier and more important to discuss and present, particularly after the world has been caught off guard by the COVID-19 pandemic. The much hyped and the profiteering digital health solutions developed in response of this pandemic provided a modest impact, and the benefits were mostly inadequate in mitigating the massive health, human, and economic impact of this pandemic. This largely commercial reorientation of mobile health was unable not only to predict the severity of the pandemic, but also unable to provide adequate digital tools or effective pre-emptive digital epidemiological shielding and guarding mechanisms against this devastating pandemic. There are many lessons to be learnt from the COVID-19 pandemic from the mobile and digital health perspectives, and lessons must be learnt from the past and to address the critical aspects discussed in this paper for better understanding of mobile health and effective tackling of future global healthcare challenges.

Development of an mHealth Intervention to Improve PrEP Knowledge Among Young Black Women in Family Planning Clinics (Preprint)

Background

Young Black women between the ages of 18 and 24 years are disproportionately impacted by HIV, yet they have a low self-perception of HIV risk and limited exposure to prevention strategies. Pre-exposure prophylaxis (PrEP) is a safe and effective biomedical HIV prevention strategy for those at risk for HIV infection, but uptake has been slow among cisgender women. Family planning clinics are a primary source of health care access for young women, providing an ideal opportunity to integrate PrEP information and care into existing clinic practices.

Objective

The aim of this study was to use a multistage, community-engaged process to develop a mobile health app and to evaluate the feasibility and acceptability of the app.

Methods

Using user-centered design, the In the Loop app was developed in collaboration with a community advisory board of young Black women. This study employed a multistage design, which included community-engaged app development, user testing, and evaluation of the app’s feasibility and acceptability. A pre- and postdesign was used to assess the impact of the app on PrEP knowledge immediately after app use. Descriptive statistics (eg, mean, SD, and percentage values) were used to describe the sample, and Wilcoxon matched-pairs signed-ranks test was used to detect changes in PrEP knowledge before and immediately after using the app.

Results

A total of 50 sexually active, young Black women, aged 18-24 (mean 21, SD 1.9) years, were enrolled in this study. Analysis comparing scores before and immediately after use of the app revealed a significant increase in PrEP content knowledge scores on a 7-item true or false scale (z=–6.04, P<.001). Overall, participants considered the In the Loop app feasible and acceptable to use while waiting for a family planning visit. The majority of participants (n=46, 92%) agreed that they would recommend In the Loop to friends to learn more about PrEP. Participants rated the overall quality of the app 4.3 on a 1-5 scale (1=very poor and 5=very good). Of 50 participants, 40 (80%) agreed that the app was easy to use, and 48 (96%) agreed that they found the information in the app easy to understand. Finally, 40 (80%) agreed that they had enjoyed using the app while waiting for their family planning visit.

Conclusions

Our findings suggest that young Black women waiting for family planning visits found the In the Loop app to be feasible and acceptable. This study demonstrates the value of engaging young Black women in the app design process. As family planning clinics are a primary source of health care access for young women, they provide an ideal setting to integrate PrEP information and care into existing clinic practices. Next steps in the development of the In the Loop app include implementing user-suggested improvements and conducting efficacy testing in a randomized controlled trial to determine the app’s impact on PrEP uptake.

Willingness to pay for an mHealth anti-retroviral therapy adherence and information tool: Transitioning to sustainability, Call for life randomised study experience in Uganda

Introduction

Evidence shows benefit of digital technology for people living with human immunodeficiency virus on antiretroviral therapy adherence and retention in care, however, scalability and sustainability have scarcely been evaluated. We assessed participants’ willingness to pay a fee for mHealth “Call for life Uganda” support, a mobile-phone based tool with the objective to assess sustainability and scalability.

Methods

“Call for Life study”, approved by Makerere University, School of Public Health research & ethics committee, at 2 sites in Uganda, evaluated a MoTech based software “CONNECT FOR LIFE™” mHealth tool termed “Call for life Uganda”. It provides short messages service or Interactive Voice Response functionalities, with a web-based interface, allows a computer to interact with humans through use of voice and tones input via keypad. Participants were randomized at 1:1 ratio to Standard of Care or standard of care plus Call for life Uganda. This sends pill reminders, visit reminders, voice messages and self-reported symptom support. At study visits 18 and 24 months, through mixed method approach we assessed mHealth sustainability and scalability. Participants were interviewed on desire to have or continue adherence support and willingness to pay a nominal fee for tool. We computed proportions willing to pay (± 95% confidence interval), stratified by study arm and predictors of willingness to continue and to pay using multivariate logistic regression model backed up by themes from qualitative interviews.

Results

95% of participants were willing to continue using C4LU with 77.8% willing to pay for the service. Persons receiving care at the peri-urban clinic (OR 3.12, 95% CI 1.43–9.11.86) and those with exposure to the C4LU intervention (OR 4.2, 95% CI 1.55–11.84) were more likely to continue and pay for the service. Qualitative interviews revealed mixed feelings regarding amounts to pay, those willing to pay, argued that since they have been paying for personal phone calls/messages, they should not fail to pay for Call for life.

Conclusions

Payment for the service offers opportunities to scale up and sustain mHealth interventions which may not be priorities for government funding. A co-pay model could be acceptable to PLHIV to access mHealth services in low resource settings.

Clinical Trial Number NCT 02953080.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01782-0.

Mobile Apps for Hematological Conditions: Review and Content Analysis Using the Mobile App Rating Scale

Background

Hematological conditions are prevalent disorders that are associated with significant comorbidities and have a major impact on patient care. Concerning new tools for the care of these patients, the number of health apps aimed at hematological patients is growing. Currently, there are no quality analyses or classifications of apps for patients diagnosed with hematological conditions.

Objective

The aim of this study is to analyze the characteristics and quality of apps designed for patients diagnosed with hematological conditions by using the Mobile App Rating Scale (MARS).

Methods

We performed an observational, cross-sectional descriptive study of all smartphone apps for patients diagnosed with hematological conditions. A search was conducted in March 2021 using the following terms: anemia, blood cancer, blood disorder, hematological cancer, hematological malignancy, hematological tumor, hematology, hemophilia, hemorrhage, lymphoma, leukemia, multiple myeloma, thalassemia, thrombocytopenia, and thrombosis. The apps identified were downloaded and evaluated by 2 independent researchers. General characteristics were registered, and quality was analyzed using MARS scores. Interrater reliability was measured by using the Cohen κ coefficient.

Results

We identified 2100 apps in the initial search, and 4.19% (88/2100) of apps met the inclusion criteria and were analyzed. Of the 88 apps, 61% (54/88) were available on Android, 30% (26/88) were available on iOS, and 9% (8/88) were available on both platforms. Moreover, 7% (6/88) required payment, and 49% (43/88) were updated in the last year. Only 26% (23/88) of the apps were developed with the participation of health professionals. Most apps were informative (60/88, 68%), followed by preventive (23/88, 26%) and diagnostic (5/88, 6%). Most of the apps were intended for patients with anemia (23/88, 26%). The mean MARS score for the overall quality of the 88 apps was 3.03 (SD 1.14), ranging from 1.19 (lowest-rated app) to 4.86 (highest-rated app). Only 47% (41/88) of the apps obtained a MARS score of over 3 points (acceptable quality). Functionality was the best-rated section, followed by aesthetics, engagement, information, and app subjective quality. The five apps with the highest MARS score were the following: Multiple Myeloma Manager, Hodgkin Lymphoma Manager, Focus On Lymphoma, ALL Manager, and CLL Manager. The analysis by operating system, developer, and cost revealed statistically significant differences in MARS scores (P<.001, P<.001, and P=.049, respectively). The interrater agreement between the 2 reviewers was substantial (k=0.78).

Conclusions

There is great heterogeneity in the quality of apps for patients with hematological conditions. More than half of the apps do not meet acceptable criteria for quality and content. Most of them only provide information about the pathology, lacking interactivity and personalization options. The participation of health professionals in the development of these apps is low, although it is narrowly related to better quality.

Effectiveness of eHealth Interventions for HIV Prevention and Management in Sub-Saharan Africa: Systematic Review and Meta-analyses

HIV is still the leading cause of death in Sub-Saharan Africa (SSA), despite medical advances. eHealth interventions are effective for HIV prevention and management, but it is unclear whether this can be generalised to resource-poor settings. This systematic review aimed to establish the effectiveness of eHealth interventions in SSA. Six electronic databases were screened to identify randomised controlled trials (RCTs) published between 2000 and 2020. Meta-analyses were performed, following Cochrane methodology, to assess the impact of eHealth interventions on HIV-related behaviours and biological outcomes. 25 RCTs were included in the review. Meta-analyses show that eHealth interventions significantly improved HIV management behaviours (OR 1.21; 95% CI 1.05-1.40; Z = 2.67; p = 0.008), but not HIV prevention behaviours (OR 1.02; 95% CI 0.78-1.34; Z = 0.17; p = 0.86) or biological outcomes (OR 1.17; 95% CI 0.89-1.54; Z = 1.10; p = 0.27) compared with minimal intervention control groups. It is a hugely important finding that eHealth interventions can improve HIV management behaviours as this is a low-cost way of improving HIV outcomes and reducing the spread of HIV in SSA. PROSPERO registration number: CRD42020186025.

Mobile Phone App Use Among Pregnant Women in China and Associations Between App Use and Perinatal Outcomes: Retrospective Study

BACKGROUND

Maternal and child health (MCH)-related mobile apps are becoming increasingly popular among pregnant women; however, few apps have demonstrated that they lead to improvements in pregnancy outcomes.

OBJECTIVE

This study aims to investigate the use of MCH apps among pregnant women in China and explore associations with pregnancy outcomes.

METHODS

A retrospective study was conducted at 6 MCH hospitals in northern China. Women who delivered a singleton baby at >28 weeks' gestation at the study hospitals were sequentially recruited from postnatal wards from October 2017 to January 2018. Information was collected on the women's self-reported MCH app use during their pregnancy, along with clinical outcomes. Women were categorized as nonusers of MCH apps and users (further divided into intermittent users and continuous users). The primary outcome was a composite adverse pregnancy outcome (CAPO) comprising preterm birth, birth weight <2500 g, birth defects, stillbirth, and neonatal asphyxia. The association between app use and CAPO was explored using multivariable logistic analysis.

RESULTS

The 1850 participants reported using 127 different MCH apps during pregnancy. App use frequency was reported as never, 24.7% (457/1850); intermittent, 47.4% (876/1850); and continuous, 27.9% (517/1850). Among app users, the most common reasons for app use were health education (1393/1393, 100%), self-monitoring (755/1393, 54.2%), and antenatal appointment reminders (602/1393, 43.2%). Nonusers were older, with fewer years of education, lower incomes, and higher parity (P<.01). No association was found between any app use and CAPO (6.8% in nonusers compared with 6.3% in any app users; odds ratio 0.77, 95% CI 0.48-1.25).

CONCLUSIONS

Women in China access a large number of different MCH apps, with social disparities in access and frequency of use. Any app use was not found to be associated with improved pregnancy outcomes, highlighting the need for rigorous development and testing of apps before recommendation for use in clinical settings.

Adapting an evidence-based contraceptive behavioural intervention delivered by mobile phone for young people in Zimbabwe

BACKGROUND

Despite the availability of a range of contraceptive methods, young people around the world still face barriers in accessing and using them. The use of digital technology for the delivery of health interventions has expanded rapidly. Intervention delivery by mobile phone can be a useful way to address young people's needs with regard to sexual and reproductive health, because the information can be digested at a time of the recipients' choosing. This study reports the adaptation of an evidence-based contraceptive behavioural intervention for young people in Zimbabwe.

METHODS

Focus group discussions and in depth interviews were used to evaluate the 'fit' of the existing intervention among young people in Harare, Zimbabwe. This involved determining how aligned the content of the existing intervention was to the knowledge and beliefs of young Zimbabweans plus identifying the most appropriate intervention deliver mode. The verbatim transcripts were analysed using a thematic analysis. The existing intervention was then adapted, tested and refined in subsequent focus group discussions and interviews with young people in Harare and Bulawayo.

RESULTS

Eleven key themes resulted from the discussions evaluating the fit of the intervention. While there were many similarities to the original study population, key differences were that young people in Zimbabwe had lower levels of personal and smart mobile phone ownership and lower literacy levels. Young people were enthusiastic about receiving information about side effects/side benefits of the methods. The iterative testing and refinement resulted in adapted intervention consisting of 97 messages for female recipients (94 for male), delivered over three months and offered in English, Shona and Ndebele.

CONCLUSIONS

Young people in Zimbabwe provided essential information for adapting the existing intervention. There was great support for the adapted intervention among the young people who took part in this study. The adapted intervention is now being implemented within an integrated community-based sexual and reproductive health service in Zimbabwe.