mHealth for diabetes support: a systematic review of apps available on the Italian market

Experiences of health tracking in mobile apps for multiple sclerosis: A qualitative content analysis of user reviews

BACKGROUND

Mobile health applications (apps) are promising condition self-management tools for people living with multiple sclerosis (MS). However, most existing apps do not include health tracking features. This gap has been raised as a priority research topic, but the development of new self-management apps will require designers to understand the context and needs of those living with MS. Our aim was to conduct a content analysis of publicly available user reviews of existing MS self-management apps to understand desired features and guide the design of future apps.

METHODS

We systematically reviewed MS self-management apps which were publicly available in English on the Google Play and iOS app stores. We then conducted sentiment and content analysis of recent user reviews which referenced health tracking and data visualization to understand self-reported experiences and feedback.

RESULTS

Searches identified 75 unique apps, of which six met eligibility criteria and had reviews. One hundred and thirty-seven user reviews of these apps were eligible, though most were associated with a single app (n=108). Overall, ratings and sentiment scores skewed highly positive (Median [IQR]: Ratings - 5 [4-5], Sentiment scores - 0.70 [0.44-0.86]), though scores of individual apps varied. Content analysis revealed five themes: reasons for app usage, simple user experience, customization and flexibility, feature requests, and technical issues. Reviewers suggested that app customization, interconnectivity, and consolidated access to desired features should be considered in the design of future apps. User ratings weakly correlated with review sentiment scores (ρ = 0.27 [0.11-0.42]).

CONCLUSIONS

Self-tracking options in MS apps are currently limited, though the apps that offer these functions are considered useful by individuals with MS. Additional qualitative research is required to understand how specific app features and opportunities for personalization should be incorporated into new self-management tools for this population.

Usage of Mobile Applications or Mobile Health Technology to Improve Diet Quality in Adults

The use of mobile applications for dietary purposes has dramatically increased along with the consistent development of mobile technology. Assessing diet quality as a dietary pattern or an indicator across key food groups in comparison to those recommended by dietary guidelines is useful for identifying optimal nutrient intake. This systematic review aims to explore mobile applications and their impact on the diet quality of the user. The electronic databases of The Cumulative Index to Nursing and Allied Health Literature (Cinahl), The American Psychological Association’s (APA Psycinfo), and PubMed were systematically searched for randomised and non-randomised controlled trials to retrieve papers from inception to November 2021. Ten studies with 1638 participants were included. A total of 5342 studies were retrieved from the database searches, with 10 articles eligible for final inclusion in the review. The sample sizes ranged from 27 to 732 participants across the included studies, with 1638 total participants. The ratio of female to male participants in the studies was 4:1. The majority of the mobile applications or M-health interventions were used to highlight dietary health changes (six studies), with the remainder used to reduce weight or blood sugar levels (four studies). Each study used a different measure to quantify diet quality. Studies were either assessed by diet quality scoring or individual dietary assessment, of the ten studies, six studies reported an improvement in diet quality following diet-related mobile application use. Mobile applications may be an effective way to improve diet quality in adults; however, there is a need for more targeted and longer-term studies that are expressly designed to investigate the impact using mobile applications has on diet quality.

Remote Healthcare for Elderly People Using Wearables: A Review

The growth of health care spending on older adults with chronic diseases faces major concerns that require effective measures to be adopted worldwide. Among the main concerns is whether recent technological advances now offer the possibility of providing remote health care for the aging population. The benefits of suitable prevention and adequate monitoring of chronic diseases by using emerging technological paradigms such as wearable devices and the Internet of Things (IoT) can increase the detection rates of health risks to raise the quality of life for the elderly. Specifically, on the subject of remote health monitoring in older adults, a first approach is required to review devices, sensors, and wearables that serve as tools for obtaining and measuring physiological parameters in order to identify progress, limitations, and areas of opportunity in the development of health monitoring schemes. For these reasons, a review of articles on wearable devices was presented in the first instance to identify whether the selected articles addressed the needs of aged adults. Subsequently, the direct review of commercial and prototype wearable devices with the capability to read physiological parameters was presented to identify whether they are optimal or usable for health monitoring in older adults.

Effectiveness of mobile applications in diabetic patients' healthy lifestyles: A review of systematic reviews

OBJECTIVE

(1) Examine the mobile applications that address lifestyles to improve the metabolic control of adult patients with diabetes mellitus. (2) Describe the characteristics of the used mobile applications, identify the healthy lifestyles they target, and describe any of their adverse effects.

METHODS

Review systematic reviews. We included studies that used any mobile application to help patients improve diabetes mellitus self-management by focusing on healthy lifestyles. Studies needed to include a control group receiving regular care with no mobile devices. In May 2018, Medline, Embase, Cochrane, LILACS, PsychINFO, Cinahl and Science Direct were searched, updated in June 2021. The methodological quality of the studies was assessed by the Amstar-2 tool.

RESULTS

First 804 articles were analyzed to select 17 systematic reviews, of which the methodological quality of seven was high or moderate. Interventions lasted 1-12 months. Twenty-three different mobile applications were identified that were all related to eating and physical activity. Significant changes were noted in HbA1c values. No clear improvement was observed for weight/BMI, lipid profile, quality of life or blood pressure. No adverse effects were found.

CONCLUSIONS

Managing the lifestyle of patients with diabetes using mobile applications improves short-term glycemic control, but the long-term results are not conclusive. The identified mobile applications focus on food and physical activity. Most are free. No adverse effects caused by using them were identified.

PROSPERO REGISTER

CRD42019133685.

Analysis of Effectiveness and Psychological Techniques Implemented in mHealth Solutions for Middle-Aged and Elderly Adults with Type 2 Diabetes: A Narrative Review of the Literature

BACKGROUND

in diabetes, multiple mHealth solutions were produced and implemented for self-management behaviors. However, little research on the effectiveness of psychological techniques implemented within these mHealth solutions was carried out, and even less with the elderly population where technological barriers might exist. Reliable evidence generated through a comprehensive evaluation of mHealth interventions may accelerate its growth for successful long-term implementation and to help to experience mHealth benefits in an enhanced way in all ages.

OBJECTIVE

this study aimed to review mHealth solutions for diabetes self-management in older adults (adherence to treatments and glycemic control) by analyzing the effectiveness of specific psychological techniques implemented.

METHODS

a narrative review was conducted following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. PubMed (Medline) and American Psychological Association (APA) PsycInfo databases were searched for published papers that addressed eHealth solutions' effectiveness for diabetes self-management. Studies in English, Spanish, and/or German of any design were screened, with no time constraints regarding the year of publication. A qualitative analysis of the selected papers was conducted in several steps.

RESULTS

this review found 38 studies setting up and analyzing mHealth solutions for older adults. Most research showed improvements in HbA1c, self-management behaviors, and medication adherence in T2DM patients post intervention. However, different mid-to-long term effects were found across studies, specifically concerning the maintenance and adherence to healthy behaviors. The most employed psychological framework was CBT, including techniques such as self-monitoring of outcome behaviors (mostly targeting glycemia measurements and healthy habits as physical activity and/or diet), tailored motivational feedback from medical staff, and psychoeducation or health coaches. The most successful mHealth intervention combined the feature of tailored feedback messages, interactive communication with healthcare professionals, and multifaceted functions.

CONCLUSIONS

there is a lack of elaborate and detailed information in the literature regarding the factors considered in the design and development of mHealth solutions used as interventions for T2DM self-management in the elderly. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of useful and user-friendly self-management apps that can enhance the quality of life for diabetes patients. Further research adapting mHealth solutions to older adults' sensory deficits is necessary.

Issues in reporting of systematic review methods in health app-focused reviews: A scoping review

No guidelines exist for the conduct and reporting of manuscripts with systematic searches of app stores for, and then appraisal of, mobile health apps ('health app-focused reviews'). We undertook a scoping review including a systematic literature search for health app-focused reviews describing systematic app store searches and app appraisal, for apps designed for patients or clinicians. We created a data extraction template which adapted data elements from the PRISMA guidelines for systematic literature reviews to data elements operationalised for health app-focused reviews. We extracted the data from included health app-focused reviews to describe: (1) which elements of the adapted 'usual' methods of systematic review are used; (2) methods of app appraisal; and (3) reporting of clinical efficacy and recommendations for app use. From 2798 records, the 26 included health app-focused reviews showed incomplete or unclear reporting of review protocol registration; use of reporting guidelines; processes of screening apps; data extraction; and appraisal tools. Reporting of clinical efficacy of apps or recommendations for app use were infrequent. The reporting of methods in health app-focused reviews is variable and could be improved by developing a consensus reporting standard for health app-focused reviews.

Factors Influencing Motivation and Engagement in Mobile Health Among Patients With Sickle Cell Disease in Low-Prevalence, High-Income Countries: Qualitative Exploration of Patient Requirements

Background

Sickle cell disease (SCD) is a hematological genetic disease affecting over 25 million people worldwide. The main clinical manifestations of SCD, hemolytic anemia and vaso-occlusion, lead to chronic pain and organ damages. With recent advances in childhood care, high-income countries have seen SCD drift from a disease of early childhood mortality to a neglected chronic disease of adulthood. In particular, coordinated, preventive, and comprehensive care for adults with SCD is largely underresourced. Consequently, patients are left to self-manage. Mobile health (mHealth) apps for chronic disease self-management are now flooding app stores. However, evidence remains unclear about their effectiveness, and the literature indicates low user engagement and poor adoption rates. Finally, few apps have been developed for people with SCD and none encompasses their numerous and complex self-care management needs.

Objective

This study aimed to identify factors that may influence the long-term engagement and user adoption of mHealth among the particularly isolated community of adult patients with SCD living in low-prevalence, high-income countries.

Methods

Semistructured interviews were conducted. Interviews were audiotaped, transcribed verbatim, and analyzed using thematic analysis. Analysis was informed by the Braun and Clarke framework and mapped to the COM-B model (capability, opportunity, motivation, and behavior). Results were classified into high-level functional requirements (FRs) and nonfunctional requirements (NFRs) to guide the development of future mHealth interventions.

Results

Overall, 6 males and 4 females were interviewed (aged between 21 and 55 years). Thirty FRs and 31 NFRs were extracted from the analysis. Most participants (8/10) were concerned about increasing their physical capabilities being able to stop pain symptoms quickly. Regarding the psychological capability aspects, all interviewees desired to receive trustworthy feedback on their self-care management practices. About their physical opportunities, most (7/10) expressed a strong desire to receive alerts when they would reach their own physiological limitations (ie, during physical activity). Concerning social opportunity, most (9/10) reported wanting to learn about the self-care practices of other patients. Relating to motivational aspects, many interviewees (6/10) stressed their need to learn how to avoid the symptoms and live as normal a life as possible. Finally, NFRs included inconspicuousness and customizability of user experience, automatic data collection, data shareability, and data privacy.

Conclusions

Our findings suggest that motivation and engagement with mHealth technologies among the studied population could be increased by providing features that clearly benefit them. Self-management support and self-care decision aid are patients’ major demands. As the complexity of SCD self-management requires a high cognitive load, pervasive health technologies such as wearable sensors, implantable devices, or inconspicuous conversational user interfaces should be explored to ease it. Some of the required technologies already exist but must be integrated, bundled, adapted, or improved to meet the specific needs of people with SCD.

Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis

BACKGROUND

Low engagement and attrition from app interventions is an increasingly recognized challenge for interpreting and translating the findings from digital health research. Focusing on randomized controlled trials (RCTs) of smartphone apps for depressive symptoms, we aimed to establish overall dropout rates, and how this differed between different types of apps.

METHODS

A systematic review of RCTs of apps targeting depressive symptoms in adults was conducted in May 2019. Random-effects meta-analysis were applied to calculate the pooled dropout rates in intervention and control conditions. Trim-and-fill analyses were used to adjust estimates after accounting for publication bias.

RESULTS

The systematic search retrieved 2,326 results. 18 independent studies were eligible for inclusion, using data from 3,336 participants randomized to either smartphone interventions for depression (n = 1,786) or control conditions (n = 1,550). The pooled dropout rate was 26.2%. This increased to 47.8% when adjusting for publication bias. Study retention rates did not differ between depression vs. placebo apps, clinically-diagnosed vs. self-reported depression, paid vs. unpaid assessments, CBT vs. non-CBT apps, or mindfulness vs. non-mindfulness app studies. Dropout rates were higher in studies with large samples, but lower in studies offering human feedback and in-app mood monitoring.

DISCUSSION

High dropout rates present a threat to the validity of RCTs of mental health apps. Strategies to improve retention may include providing human feedback, and enabling in-app mood monitoring. However, it critical to consider bias when interpreting results of apps for depressive symptoms, especially given the strong indication of publication bias, and the higher attrition in larger studies.

How Do Smart Device Apps for Diabetes Self-Management Correspond with Theoretical Indicators of Empowerment? An Analysis of App Features

OBJECTIVES

Smart device apps for diabetes have the potential to support patients in their daily disease management. However, uncertainty exists regarding their suitability for empowering patients to improve self-management behaviors. This paper addresses a general research gap regarding theoretically based examinations of empowerment in diabetes research, by examining how diabetes app features correspond with conceptual indicators of empowerment.

METHODS

We examined features of 121 apps for diabetes self-management available in Singapore, with the second highest proportion of diabetes among developed nations, for psychological empowerment (feeling of empowerment) and for behavioral empowerment (social support).

RESULTS

Diabetes apps studied offered a narrow range of features, with limited feature-sets corresponding to indicators of empowerment. Customization as a strategy to improve perceived relevance of diabetes self-management as an indicator of psychological empowerment was especially limited. Moreover, there was a lack of features supporting patients' communication with healthcare professionals and within their private social networks.

CONCLUSIONS

Mobile apps for diabetes self-management failed to provide relevant features for empowering patients. Specific practical recommendations target improved adoption, sustained usage, and effectiveness of diabetes self-management apps.

A Comparison of Functional Features in Chinese and US Mobile Apps for Diabetes Self-Management: A Systematic Search in App Stores and Content Analysis

BACKGROUND

Mobile health interventions are widely used for self-management of diabetes, which is one of the most burdensome noncommunicable chronic diseases worldwide. However, little is known about the distribution of characteristics and functions of in-store mobile apps for diabetes.

OBJECTIVE

This study aimed to investigate the distribution of characteristics and functions of the in-store mobile apps for self-management of diabetes in the United States and China using a predefined functional taxonomy, which was developed and published in our previous study.

METHODS

We identified apps by searching diabetes in English or Chinese in the Apple iTunes Store and Android Markets (both in the United States and China) and included apps for diabetes self-management. We examined the validity and reliability of the predefined functional taxonomy with 3 dimensions: clinical module, functional module, and potential risk. We then classified all functions in the included apps according to the predefined taxonomy and compared the differences in the features of these apps between the United States and China.

RESULTS

We included 171 mobile diabetes apps, with 133 from the United States and 38 from China. Apps from both countries faced the challenges of evidence-based information, proper risk assessment, and declaration, especially Chinese apps. More Chinese apps provide app-based communication functions (general communication: Chinese vs US apps, 39%, 15/38 vs 18.0%, 24/133; P=.006 and patient-clinician communication: Chinese vs US apps, 68%, 26/38 vs 6.0%, 8/133; P<.001), whereas more US apps provide the decision-making module (Chinese vs US apps, 0%, 0/38 vs 23.3%, 31/133; P=.001), which is a high-risk module. Both complication prevention (Chinese vs US apps, 8%, 3/38 vs 3.8%, 5/133; P=.50) and psychological care (Chinese vs US apps, 0%, 0/38 vs 0.8%, 1/133; P>.99) are neglected by the 2 countries.

CONCLUSIONS

The distribution of characteristics and functions of in-store mobile apps for diabetes self-management in the United States was different from China. The design of in-store diabetes apps needs to be monitored closely.

Understanding the quality, effectiveness and attributes of top-rated smartphone health apps

Objective

This study aimed to understand the attributes of popular apps for mental health and comorbid medical conditions, and how these qualities relate to consumer ratings, app quality and classification by the WHO health app classification framework.

Methods

We selected the 10 apps from the Apple iTunes store and the US Android Google Play store on 20 July 2018 from six disease states: depression, anxiety, schizophrenia, addiction, diabetes and hypertension. Each app was downloaded by two authors who provided information on the apps’ attributes, functionality, interventions, popularity, scientific backing and WHO app classification rating.

Results

A total of 120 apps were examined. Although none of these apps had Food and Drug Administration marketing approval, nearly 50% made claims that appeared medical. Most apps offered a similar type of services with 87.5% assigned WHO classification 1.4.2 ‘self-monitoring of health or diagnostic data by a client’ or 1.6.1 ‘client look-up of health information’. The ‘last updated’ attribute was highly correlated with a quality rating of the app although no apps features (eg, uses Global Positioning System, reminders and so on) were.

Conclusion

Due to the heterogeneity of the apps, we were unable to define a core set of features that would accurately assess app quality. The number of apps making unsupported claims combined with the number of apps offering questionable content warrants a cautious approach by both patients and clinicians in selecting safe and effective ones.

Clinical Implications

‘Days since last updated’ offers a useful and easy clinical screening test for health apps, regardless of the condition being examined.

eHealth for improving quality of life in breast cancer patients: A systematic review

Breast cancer patients (and survivors) use to deal with important challenges daily, such as coping with stress and depression, and adopting healthy lifestyles in order to improve treatment effectiveness; moreover, some experiential issues are quite specific of this disease, such as sexuality and fertility disfunctions after hormonal therapy, and distortions in body image after breast surgery. Recent literature highlighted the utility of eHealth or the use of new technologies to promote health management and quality of life in chronic diseases generally. The present contribution aims at (1) exploring usage and effectiveness of eHealth resources to improve breast cancer patients/survivors' quality of life, and (2) describing whether existing eHealth interventions addressed specific characteristics of breast cancer, or employed a generic approach only. A systematic literature search according to PRISMA guidelines was performed. Twenty-four studies met inclusion criteria and were included. Discussion highlights a majority of encouraging results about eHealth in breast cancer patients' health management, especially in those interventions featuring eHealth tools for improving patients' abilities (e.g., coping) and complex eHealth systems with multiple resources. However, generic use of eHealth is still predominant over disease-focused solutions. Guidelines for future eHealth research and development are listed in order to promote technology design centered on the lived experience of specific illness.

Medical Correctness and User Friendliness of Available Apps for Cardiopulmonary Resuscitation: Systematic Search Combined With Guideline Adherence and Usability Evaluation

Background

In case of a cardiac arrest, start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Mobile phone apps offering real-time step-by-step instructions might be a valuable source of information.

Objective

The aim of this study was to examine mobile phone apps offering real-time instructions in German or English in case of a cardiac arrest, to evaluate their adherence to current resuscitation guidelines, and to test their usability.

Methods

Our 3-step approach combines a systematic review of currently available apps guiding a medical layperson through a resuscitation situation, an adherence testing to medical guidelines, and a usability evaluation of the determined apps. The systematic review followed an adapted preferred reporting items for systematic reviews and meta-analyses flow diagram, the guideline adherence was tested by applying a conformity checklist, and the usability was evaluated by a group of mobile phone frequent users and emergency physicians with the system usability scale (SUS) tool.

Results

The structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. As a result, 34 apps meeting all inclusion criteria were identified. These included apps were analyzed to determine medical accuracy as defined by the European Resuscitation Council’s guidelines. Only 5 out of 34 apps (15%, 5/34) fulfilled all criteria chosen to determine guideline adherence. All other apps provided no or wrong information on at least one relevant topic. The usability of 3 apps was evaluated by 10 mobile phone frequent users and 9 emergency physicians. Of these 3 apps, solely the app “HELP Notfall” (median=87.5) was ranked with an SUS score above the published average of 68. This app was rated significantly superior to “HAMBURG SCHOCKT” (median=55; asymptotic Wilcoxon test: z=−3.63, P<.01, n=19) and “Mein DRK” (median=32.5; asymptotic Wilcoxon test: z=−3.83, P<.01, n=19).

Conclusions

Implementing a systematic quality control for health-related apps should be enforced to ensure that all products provide medically accurate content and sufficient usability in complex situations. This is of exceptional importance for apps dealing with the treatment of life-threatening events such as cardiac arrest.