The German Version of the Mobile App Rating Scale (MARS-G): Development and Validation Study

Assessing the accessibility and quality of mobile health applications for the treatment of obesity in the German healthcare market

Introduction

Overweight and obesity are among the most prevalent health problems worldwide leading to various diseases and having a significant impact on the healthcare system. In Germany, the prevalence of obesity among adults is 19%. Mobile health applications offer a new approach to treatment and prevention and have been proven effective in previous studies. However, it is essential to investigate the availability and quality of these digital applications. The aim of this systematic assessment is to evaluate the accessibility and quality of digital health applications in German language designed to treat obesity.

Methods

In January 2024, a systematic search for mobile health applications was conducted on both the Google Play Store and Apple App Store. Just those apps available in German for both iOS and Android were considered acceptable. The German Mobile Application Rating Scale (MARS-G) was used to assess the quality of the apps. The content of mobile health applications was evaluated using the guideline from the German Obesity Society for the treatment of obesity. The characteristics of the apps were summarized and presented, and the results were analyzed using descriptive statistics and presented in tables.

Results

After screening, ten apps were included in the review. The apps varied in terms of calorie tracking, individual workout plans, educational aspects, nutritional plans, and exercises for behavioral change. On average, 6.4 out of 12 items of the German Obesity guideline recommendations were fulfilled. The MARS score (possible range from 1-5) reached a mean of 3.39 (SD = 0.39). The section "Engagement" had the lowest quality score with a mean of 3.14 (SD = 0.57), while the section "Aesthetics" achieved the highest mean of 3.57 (SD = 0.52).

Discussion

Most German mobile health applications for managing obesity meet some guideline recommendations. They demonstrate adequate to good quality according to the MARS score. Assessing the quality of mobile health applications can be challenging for patients, despite being easily accessible and low-threshold. However, such digital health applications, reimbursed by the German SHI, offer evidence-based information, even if access can be associated with higher hurdles.

Improving mental health by improving the mental health literacy? Study protocol for a randomised controlled evaluation of an e-mental health application as a preventive intervention for adolescents and young adults

Background

From the age of 14, many adolescents enter a vulnerable developmental phase, with a sharp increase in mental illness at 16. The COVID19 pandemic has further exacerbated this issue. Hence, universal and easily accessible prevention in the young is needed. E-mental health interventions are on the rise due to numerous benefits such as potential low-costs, low-threshold and high scalability. However, effectiveness and acceptance of mobile health (mHealth) preventive interventions remain unresearched.

Method

In a two-armed, randomised controlled study design adolescents and young adults from 14 years old will be recruited. Following an initial baseline assessment, they will be randomised to a) the intervention group (IG, n = 75), which will receive a mHealth intervention (the application 'Mental Health Guide', co-developed by lived experience experts) or b) the waiting list control group (CG, n = 75). Both groups will be followed up after 3 and 6 months following post assessment. We hypothesize an increase in mental health literacy in the IG compared to the CG for post and follow-up assessment (primary outcome: Mental Health Literacy Scale). In addition, we expect an improvement in mental health and psychological well-being, improved emotion regulation, reduced psychological distress, as well as good quality ratings in usability and acceptance in the use of the 'Mental Health Guide' We performed multiple simulations of possible outcome scenarios, incorporating an array of factors, to generate realistic datasets and obtain accurate estimates of statistical power.

Conclusion

As a first-of-its-kind in this field, this study investigates whether a mHealth intervention based on mental health literacy may improve the mental health literacy and further aspects of psychological functioning of young people in a vulnerable phase. Furthermore, the results promise to provide important knowledge of how universal prevention may be implemented with low costs for diverse populations.

Trial registration

This trial was registered in the DRKS register (DRKS-ID: DRKS00031810) on 23 June 2023.

Daily Time-Use Patterns and Quality of Life in Parents: Protocol for a Pilot Quasi-Experimental, Nonrandomized Controlled Trial Using Ecological Momentary Assessment

BACKGROUND

The gender gap in time use and its impact on health and well-being are still prevalent. Women work longer hours than men when considering both paid and unpaid (eg, childcare and chores) work, and this gender disparity is particularly visible among parents. Less is known about factors that could potentially mediate or moderate this relationship (eg, work-family conflict and gender role beliefs). Ecological momentary assessment (EMA) allows for the documentation of changes in momentary internal states, such as time use, stress, or mood. It has shown particular validity to measure shorter-term activities (eg, unpaid work) and is thus useful to address gender differences.

OBJECTIVE

The feasibility of the daily EMA surveys in a parent sample will be examined. The associations between time use, well-being, and stress will be examined, along with potential moderating and mediating factors such as gender, gender role beliefs, and work-family conflict. Finally, the act of monitoring one's own time use, well-being, and stress will be examined in relation to, for example, the quality of life.

METHODS

We conducted a quasi-experimental, nonrandomized controlled trial with 3 data collection methods, namely, online questionnaires, EMA surveys, and qualitative interviews. The intervention group (n=64) will participate in the online questionnaires and EMA surveys, and a subsample of the intervention group (n=6-17) will also be invited to participate in qualitative interviews. Over a period of 1 week, participants in the intervention group will answer daily EMA surveys (4 times per day). In contrast, the control group (n=17) will only participate in the online questionnaires at baseline and after 1 week. The following constructs were surveyed: sociodemographic background (eg, age, gender, and household composition; baseline questionnaire); mediators and moderators (eg, gender role beliefs and work-family conflict; baseline and follow-up questionnaires); well-being, quality of life, and trait mindfulness (baseline and follow-up questionnaires); momentary activity and well-being, as well as state mindfulness (EMA); and feasibility (baseline and follow-up questionnaires as well as interviews). We anticipate that participants will regard the daily EMA as feasible. Particular daily time-use patterns (eg, high paid and unpaid workload) are expected to be related to lower well-being, higher stress, and health-related quality of life. These associations are expected to be moderated and mediated by factors such as gender, gender role beliefs, work-family conflict, and social support. Participants in the intervention group are expected to show higher values of mindfulness, well-being, health-related quality of life, and lower stress.

RESULTS

Patient recruitment started in November 2023 and ended in mid April 2024. Data analysis commenced in mid April 2024.

CONCLUSIONS

This study aims to provide valuable insights into the feasibility of using EMAs and the potential benefits of activity tracking in various aspects of daily life.

TRIAL REGISTRATION

Open Science Framework 8qj3d; https://osf.io/8qj3d.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54728.

A Web-Based and Mobile Intervention Program Using a Spaced Education Approach for Workplace Mental Health Literacy: Cluster Randomized Controlled Trial

Background

Workplace mental health is an important global health concern.

objectives

This unblinded, phase-III, wait-listed cluster randomized controlled trial aimed to examine the effectiveness of a mobile health (mHealth) psychoeducation program using a spaced education approach on mental health literacy (MHL) in the workplace. The main interest of this paper was the immediate and 3-month medium-term effect of the program on the MHL of workers. The purposely built mHealth platform was also evaluated as a health-related app.

Methods

The mHealth platform was designed using the principle of spaced education as a psychoeducation intervention program, with various modules of web-based and mobile materials presented to the participant in a progressive manner. Short quizzes at the end of each module ensured adequate learning, and successful completion qualified the learner to progress to the next level. The trial recruited 456 employees of specific industries with high levels of work-related stress. Participants who were nested in different offices or units were allocated into the intervention and wait-listed control groups using a block randomization process, with the office or unit as the cluster. A separate sample of 70 individual raters were used for the evaluation of the mHealth platform. The Australian National MHL and Stigma Survey and the Mobile Apps Rating Scale were completed through a web-based self-reported survey to assess MHL and evaluate the app. The trial and follow-up data were analyzed by a generalized linear latent and mixed model with adjustments for the clustering effect of work sites and repeated measures.

Results

Of the 456 participants in the trial, 236 (51.8%) responded to the follow-up survey. Most MHL outcomes obtained significant results immediately after the intervention and across time. After adjusting for the clustering effect, the postintervention weighted mean scores were significantly higher in the intervention group than the control group for correct recognition of a mental health problem, help seeking, and stigmatization by 0.2 (SE 0.1; P=.003), 0.9 (SE 0.2; P<.001), and 1.8 (SE 0.4; P<.001), respectively. After adjusting for the clustering effect, significant differences across time were found in help-seeking intention (P=.01), stigmatization (P<.001), and social distancing (P<.001). The evaluation of the mHealth program resulted in average scores of the 4 major domains ranging from 3.8 to 4.2, with engagement having the lowest score.

Conclusions

The mHealth psychoeducation intervention program using this platform had immediate and 3-month medium-term effects of retaining and improving MHL. The platform was evaluated to have satisfactory performance in terms of functionality, aesthetics, information content, and utility in enhancing MHL. It is anticipated that ongoing development in digital health will provide great benefits in improving the mental health of the global population.

Efficacy of a Digital Diabetes Logbook for People With Type 1, Type 2, and Gestational Diabetes: Results From a Multicenter, Open-Label, Parallel-Group, Randomized Controlled Trial

BACKGROUND

In a randomized controlled trial, the efficacy of a digital diabetes diary regarding a reduction of diabetes distress was evaluated.

METHODS

A randomized controlled trial with a 12-week follow-up was conducted in 41 study sites across Germany. Key eligibility criteria were a diagnosis of type 1, type 2, or gestational diabetes and regular self-monitoring of blood glucose. Participants were randomly assigned (2:1 ratio) to either use the digital diabetes logbook (mySugr PRO), or to the control group without app use. The primary outcome was the reduction in diabetes distress at the 12-week follow-up. All analyses were based on the intention-to-treat population with all randomized participants. The trial was registered at the German Register for Clinical Studies (DRKS00022923).

RESULTS

Between February 11, 2021, and June 24, 2022, 424 participants (50% female, 50% male) were included, with 282 being randomized to the intervention group (66.5%) and 142 to the control group (33.5%). A total of 397 participants completed the trial (drop-out rate: 6.4%). The median reduction in diabetes distress was 2.41 (interquartile range [IQR]: -2.50 to 8.11) in the intervention group and 1.25 (IQR: -5.00 to 7.50) in the control group. The model-based adjusted between-group difference was significant (-2.20, IQR: -4.02 to -0.38, P = .0182) favoring the intervention group. There were 27 adverse events, 17 (6.0%) in the intervention group, and 10 (7.0%) in the control group.

CONCLUSIONS

The efficacy of the digital diabetes logbook was demonstrated regarding improvements in mental health in people with type 1, type 2, and gestational diabetes.

Patient-Centered Chronic Wound Care Mobile Apps: Systematic Identification, Analysis, and Assessment

Background

The prevalence of chronic wounds is predicted to increase within the aging populations in industrialized countries. Patients experience significant distress due to pain, wound secretions, and the resulting immobilization. As the number of wounds continues to rise, their adequate care becomes increasingly costly in terms of health care resources worldwide. eHealth support systems are being increasingly integrated into patient care. However, to date, no systematic analysis of such apps for chronic wounds has been published.

Objective

The aims of this study were to systematically identify and subjectively assess publicly available German- or English-language mobile apps for patients with chronic wounds, with quality assessments performed by both patients and physicians.

Methods

Two reviewers independently conducted a systematic search and assessment of German- or English-language mobile apps for patients with chronic wounds that were available in the Google Play Store and Apple App Store from April 2022 to May 2022. In total, 3 apps met the inclusion and exclusion criteria and were reviewed independently by 10 physicians using the German Mobile App Rating Scale (MARS) and the System Usability Scale (SUS). The app with the highest mean MARS score was subsequently reviewed by 11 patients with chronic wounds using the German user version of the MARS (uMARS) and the SUS. Additionally, Affinity for Technology Interaction (ATI) scale scores were collected from both patients and physicians.

Results

This study assessed mobile apps for patients with chronic wounds that were selected from a pool of 118 identified apps. Of the 73 apps available in both app stores, 10 were patient oriented. After excluding apps with advertisements or costs, 3 apps were evaluated by 10 physicians. Mean MARS scores ranged from 2.64 (SD 0.65) to 3.88 (SD 0.65) out of 5, and mean SUS scores ranged from 50.75 (SD 27) to 80.5 (SD 17.7) out of 100. WUND APP received the highest mean MARS score (mean 3.88, SD 0.65 out of 5) among physicians. Hence, it was subsequently assessed by 11 patients and achieved a similar rating (uMARS score: mean 3.89, SD 0.4 out of 5). Technical affinity, as measured with the ATI scale, was slightly lower in patients (score: mean 3.62, SD 1.35 out of 6) compared to physicians (score: mean 3.88, SD 1.03 out 6).

Conclusions

The quality ratings from physicians and patients were comparable and indicated mediocre app quality. Technical affinity, as assessed by using the ATI scale, was slightly lower for patients. Adequate apps for patients with chronic wounds remain limited, emphasizing the need for improved app development to meet patient needs. The ATI scale proved valuable for assessing technical affinity among different user groups.

[Apps for tinnitus? A systematic review on quality, intervention components, and behavior change techniques]

BACKGROUND

Various smartphone applications (apps) for people with tinnitus are available and promise tinnitus relief. Yet, it is difficult for people suffering from tinnitus and healthcare professionals to estimate their quality, potential, or risks. The current study aims to generate an overview of available tinnitus apps in the German language and to offer orientation for research and healthcare providers.

METHOD

The most prominent stores were searched systematically (November 2020-April 2021; Google Play Store and Apple App Store). Apps specifically developed for tinnitus were evaluated by two independent raters using multiple approaches: a) a quality screening was performed using the German version of the Mobile App Rating Scale (MARS-G), b) intervention components were assessed using a newly developed list of categories, and c) implemented strategies for active tinnitus management were analyzed using behavior change techniques (BCTs).

RESULTS

The search yielded 1073 apps, of which 21 apps were analyzed. The apps' overall quality as assessed by MARS‑G was average (M = 3.37, SD = 039). A lot of apps offered sounds (n = 18) and information (n = 9) or assessed tinnitus characteristics (n = 13). Out of 93 BCTs, 24 were identified at least once. Only one app was evaluated in non-randomized trials.

CONCLUSION

Although a variety of apps are available, most of them focus on a few intervention components (e.g., sounds or information). Therefore, apps do not exploit their potential to impart important evidence-based content for tinnitus management. The app evaluation using multiple approaches points out potential for improvement.

Mobile Apps for COVID-19: A Systematic Review of Reviews

BACKGROUND

One measure national governments took to react to the acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic was mobile applications (apps). This study aims to provide a high-level overview of published reviews of mobile apps used in association with coronavirus disease 19 (COVID-19), examine factors that contributed to the success of these apps, and provide data for further research into this topic.

METHODS

We conducted a systematic review of reviews (also referred to as an umbrella review) and searched two databases, Medline and Embase, for peer-reviewed reviews of COVID-19 mobile apps that were written in English and published between January 1st 2020 and April 25th 2022.

RESULTS

Out of the initial 17,611 studies, 24 studies were eligible for the analysis. Publication dates ranged from May 2020 to January 2022. In total, 54% (n = 13) of the studies were published in 2021, and 33% (n = 8) were published in 2020. Most reviews included in our review of reviews analyzed apps from the USA, the UK, and India. Apps from most of the African and Middle and South American countries were not analyzed in the reviews included in our study. Categorization resulted in four clusters (app overview, privacy and security, MARS rating, and miscellaneous).

CONCLUSIONS

Our study provides a high-level overview of 24 reviews of apps for COVID-19, identifies factors that contributed to the success of these apps, and identifies a gap in the current literature. The study provides data for further analyses and further research.

The German version of the mHealth App Usability Questionnaire (GER-MAUQ): Translation and validation study in patients with cardiovascular disease

Objective

In Germany, only a few standardized evaluation tools for assessing the usability of mobile Health apps exist so far. This study aimed to translate and validate the English patient version for standalone apps of the mHealth App Usability Questionnaire (MAUQ) into a German version.

Methods

Following scientific guidelines for translation and cross-cultural adaptation, the patient version for standalone apps was forward and back-translated from English into German by an expert panel. In total, 53 participants who were recruited as part of the beta testing process of the recently developed mHealth app HerzFit, answered the questions of the German version of the MAUQ (GER-MAUQ) and the System Usability Scale. Subsequently, a descriptive as well as a psychometric analysis was performed to test validity and reliability.

Results

After conducting three cognitive interviews, five items were modified. The values for Cronbach alpha for the entire questionnaire and the three subscales (0.966, 0.814, 0.910, and 0.909) indicate strong internal consistency. The correlation analysis revealed that the scores of the GER-MAUQ, the subscales and the SUS were strongly correlated with each other. The correlation coefficient of the SUS and the GER-MAUQ overall score was r = 0.854, P < 0.001 and the coefficients of the subscales and the SUS were r = 0.642, P < 0.001; r = 0.866, P < 0.001 and r = 0.643, P < 0.001.

Conclusions

We have developed a novel German version of the MAUQ and demonstrated it as a reliable and valid measurement tool for assessing the usability of standalone mHealth apps from the patients' perspective. The GER-MAUQ allows a new form of standardized assessment of usability of mHealth apps for patients with cardiovascular disease in Germany. Further research with a larger sample and other samples is recommended.

Refinement and Usability Analysis of an eHealth App for Ankylosing Spondylitis as a Complementary Treatment to Physical Therapy: Development and Usability Study

BACKGROUND

Mobile eHealth apps have been used as a complementary treatment to increase the quality of life of patients and provide new opportunities for the management of rheumatic diseases. Telemedicine, particularly in the areas of prevention, diagnostics, and therapy, has become an essential cornerstone in the care of patients with rheumatic diseases.

OBJECTIVE

This study aims to improve the design and technology of YogiTherapy and evaluate its usability and quality.

METHODS

We newly implemented the mobile eHealth app YogiTherapy with a modern design, the option to change language, and easy navigation to improve the app's usability and quality for patients. After refinement, we evaluated the app by conducting a study with 16 patients with AS (4 female and 12 male; mean age 48.1, SD 16.8 y). We assessed the usability of YogiTherapy with a task performance test (TPT) with a think-aloud protocol and the quality with the German version of the Mobile App Rating Scale (MARS).

RESULTS

In the TPT, the participants had to solve 6 tasks that should be performed on the app. The overall task completion rate in the TPT was high (84/96, 88% completed tasks). Filtering for videos and navigating to perform an assessment test caused the largest issues during the TPT, while registering in the app and watching a yoga video were highly intuitive. Additionally, 12 (75%) of the 16 participants completed the German version of MARS. The quality of YogiTherapy was rated with an average MARS score of 3.79 (SD 0.51) from a maximum score of 5. Furthermore, results from the MARS questionnaire demonstrated a positive evaluation regarding functionality and aesthetics.

CONCLUSIONS

The refined and tested YogiTherapy app showed promising results among most participants. In the future, the app could serve its function as a complementary treatment for patients with AS. For this purpose, surveys with a larger number of patients should still be conducted. As a substantial advancement, we made the app free and openly available on the iOS App and Google Play stores.

Assessment of healthcare application quality: Development of a standardized methods for healthcare professionals

The advancement of the mobile app market is reshaping healthcare, emphasizing the imperative for quality and efficacy in health applications. This methodology has been devised to assess mobile health applications, aiming to assist healthcare professionals in selecting apps for e-healthcare consumers. Key facets of this approach are: •A stringent selection process within mobile app stores•A standardized assessment using the Mobile App Rating Scale to achieve consistent and replicable evaluations, systematically organizing app evaluations•A comprehensive framework guiding healthcare practitioners in determining which apps to integrate into clinical practice and which to exclude Central to this method is the emphasis on distinguishing apps that enhance clinical practice from those that fall short in important areas such as the effectiveness of proposed health features, data accuracy, adherence to clinical guidelines, data security, and user privacy. With heightened attention to usability and accessibility, the methodology also addresses the common risks inherent in mHealth implementation, ensuring that selected apps not only meet technical criteria but also align with the broader healthcare ecosystem's needs and challenges.

German Version of the mHealth App Usability Questionnaire in a Cohort of Patients With Cancer: Translation and Validation Study

BACKGROUND

Good usability is important for the adoption and continued use of mobile health (mHealth) apps. In particular, high usability can support intuitive use by patients, which improves compliance and increases the app's effectiveness. However, many usability studies do not use adequate tools to measure perceived usability. The mHealth App Usability Questionnaire (MAUQ) was developed specifically for end users in a medical context. MAUQ is a relatively new but increasingly used questionnaire to evaluate mHealth apps, but it is not yet available in German.

OBJECTIVE

This study aims to translate MAUQ into German and determine its internal consistency, reliability, and construct validity.

METHODS

This validation study was conducted as part of a usability evaluation project for an mHealth app used as a therapy support tool during breast cancer chemotherapy. MAUQ was translated into German through a rigorous forward-backward translation process, ensuring semantic and conceptual equivalence. Patient responses to MAUQ and System Usability Scale (SUS) were analyzed for validation. Descriptive analysis was performed for the MAUQ subscales and SUS standard scores. Significance tests and correlation coefficients assessed the relationship between the SUS and MAUQ results, confirming construct validity. Internal consistency was assessed for item reliability and consistency in measuring the target construct. Free-text questions assessed translation comprehensibility, with responses analyzed descriptively and qualitatively using content analysis.

RESULTS

In this study, 133 participants responded to the questionnaire, and the validation analysis showed substantially positive correlations between the overall MAUQ score and its subscales: ease of use (r=0.56), interface and satisfaction (r=0.75), and usefulness (r=0.83). These findings support the construct validity of MAUQ and emphasize the importance of these subscales in assessing the usability of the Enable app. The correlation coefficients ranging from 0.39 to 0.68 for the items further validate the questionnaire by aligning with the overall score and capturing the intended concept. The high internal consistency reliability of MAUQ (Cronbach α=.81) and its subscales further enhances the instrument's robustness in accurately evaluating the usability of mHealth apps.

CONCLUSIONS

We successfully validated the German translation of the MAUQ for stand-alone apps using a standardized approach in a cohort of patients with breast cancer. In our validation study, MAUQ exhibited strong internal consistency reliability (Cronbach α=.81) across its subscales, indicating reliable and consistent measurement. Furthermore, a significant positive correlation (P<.001) was found between the subscales and the overall score, supporting their consistent measurement of the intended construct. Therefore, MAUQ can be considered a reliable instrument for assessing the usability of mHealth apps among German-speaking adults. The availability of the German version of MAUQ will help other researchers in conducting usability studies of mHealth apps in German-speaking cohorts and allow for international comparability of their results.

Improving mental well-being in psychocardiology-a feasibility trial for a non-blended web application as a brief metacognitive-based intervention in cardiovascular disease patients

Background

Many patients with cardiovascular disease also show a high comorbidity of mental disorders, especially such as anxiety and depression. This is, in turn, associated with a decrease in the quality of life. Psychocardiological treatment options are currently limited. Hence, there is a need for novel and accessible psychological help. Recently, we demonstrated that a brief face-to-face metacognitive therapy (MCT) based intervention is promising in treating anxiety and depression. Here, we aim to translate the face-to-face approach into digital application and explore the feasibility of this approach.

Methods

We translated a validated brief psychocardiological intervention into a novel non-blended web app. The data of 18 patients suffering from various cardiac conditions but without diagnosed mental illness were analyzed after using the web app over a two-week period in a feasibility trial. The aim was whether a non-blended web app based MCT approach is feasible in the group of cardiovascular patients with cardiovascular disease.

Results

Overall, patients were able to use the web app and rated it as satisfactory and beneficial. In addition, there was first indication that using the app improved the cardiac patients' subjectively perceived health and reduced their anxiety. Therefore, the approach seems feasible for a future randomized controlled trial.

Conclusion

Applying a metacognitive-based brief intervention via a non-blended web app seems to show good acceptance and feasibility in a small target group of patients with CVD. Future studies should further develop, improve and validate digital psychotherapy approaches, especially in patient groups with a lack of access to standard psychotherapeutic care.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

Investigating Relationships Among Self-Efficacy, Mood, and Anxiety Using Digital Technologies: Randomized Controlled Trial

BACKGROUND

Digital tools assessing momentary parameters and offering interventions in people's daily lives play an increasingly important role in mental health research and treatment. Ecological momentary assessment (EMA) makes it possible to assess transient mental health states and their parameters. Ecological momentary interventions (EMIs) offer mental health interventions that fit well into individuals' daily lives and routines. Self-efficacy is a transdiagnostic construct that is commonly associated with positive mental health outcomes.

OBJECTIVE

The aim of our study assessing mood, specific self-efficacy, and other parameters using EMA was 2-fold. First, we wanted to determine the effects of daily assessed moods and dissatisfaction with social contacts as well as the effects of baseline variables, such as depression, on specific self-efficacy in the training group (TG). Second, we aimed to explore which variables influenced both groups' positive and negative moods during the 7-day study period.

METHODS

In this randomized controlled trial, we applied digital self-efficacy training (EMI) to 93 university students with elevated self-reported stress levels and daily collected different parameters, such as mood, dissatisfaction with social contacts, and specific self-efficacy, using EMA. Participants were randomized to either the TG, where they completed the self-efficacy training combined with EMA, or the control group, where they completed EMA only.

RESULTS

In total, 93 university students participated in the trial. Positive momentary mood was associated with higher specific self-efficacy in the evening of the same day (b=0.15, SE 0.05, P=.005). Higher self-efficacy at baseline was associated with reduced negative mood during study participation (b=-0.61, SE 0.30, P=.04), while we could not determine an effect on positive mood. Baseline depression severity was significantly associated with lower specific self-efficacy over the week of the training (b=-0.92, SE 0.35, P=.004). Associations between higher baseline anxiety with higher mean negative mood (state anxiety: b=0.78, SE 0.38, P=.04; trait anxiety: b=0.73, SE 0.33, P=.03) and lower mean positive mood (b=-0.64, SE 0.28, P=.02) during study participation were found. Emotional flexibility was significantly enhanced in the TG. Additionally, dissatisfaction with social contacts was associated with both a decreased positive mood (b=-0.56, SE 0.15, P<.001) and an increased negative mood (b=0.45, SE 0.12, P<.001).

CONCLUSIONS

This study showed several significant associations between mood and self-efficacy as well as those between mood and anxiety in students with elevated stress levels, for example, suggesting that improving mood in people with low mood could enhance the effects of digital self-efficacy training. In addition, engaging in 1-week self-efficacy training was associated with increased emotional flexibility. Future work is needed to replicate and investigate the training's effects in other groups and settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05617248; https://clinicaltrials.gov/study/NCT05617248.

Conducting a systematic review and evaluation of commercially available mobile applications (apps) on a health-related topic: the TECH approach and a step-by-step methodological guide

OBJECTIVES

To provide an overview of the methodological considerations for conducting commercial smartphone health app reviews (mHealth reviews), with the aim of systematising the process and supporting high-quality evaluations of mHealth apps.

DESIGN

Synthesis of our research team's experiences of conducting and publishing various reviews of mHealth apps available on app stores and hand-searching the top medical informatics journals (eg, The Lancet Digital Health, npj Digital Medicine, Journal of Biomedical Informatics and the Journal of the American Medical Informatics Association) over the last five years (2018-2022) to identify other app reviews to contribute to the discussion of this method and supporting framework for developing a research (review) question and determining the eligibility criteria.

RESULTS

We present seven steps to support rigour in conducting reviews of health apps available on the app market: (1) writing a research question or aims, (2) conducting scoping searches and developing the protocol, (3) determining the eligibility criteria using the TECH framework, (4) conducting the final search and screening of health apps, (5) data extraction, (6) quality, functionality and other assessments and (7) analysis and synthesis of findings. We introduce the novel TECH approach to developing review questions and the eligibility criteria, which considers the Target user, Evaluation focus, Connectedness and the Health domain. Patient and public involvement and engagement opportunities are acknowledged, including co-developing the protocol and undertaking quality or usability assessments.

CONCLUSION

Commercial mHealth app reviews can provide important insights into the health app market, including the availability of apps and their quality and functionality. We have outlined seven key steps for conducting rigorous health app reviews in addition to the TECH acronym, which can support researchers in writing research questions and determining the eligibility criteria. Future work will include a collaborative effort to develop reporting guidelines and a quality appraisal tool to ensure transparency and quality in systematic app reviews.

Concept and study protocol of the process evaluation of a pragmatic randomized controlled trial to promote physical activity in outpatients with heterogeneous mental disorders-the ImPuls study

BACKGROUND

Evidence suggests that patients suffering from different mental disorders benefit from exercise programs combined with behavior change techniques. Based on this evidence, we have developed an exercise program (ImPuls) specifically designed to provide an additional treatment option in the outpatient mental health care system. The implementation of such complex programs into the outpatient context requires research that goes beyond the evaluation of effectiveness, and includes process evaluation. So far, process evaluation related to exercise interventions has rarely been conducted. As part of a current pragmatic randomized controlled trial evaluating ImPuls treatment effects, we are therefore carrying out comprehensive process evaluation according to the Medical Research Council (MRC) framework. The central aim of our process evaluation is to support the findings of the ongoing randomized controlled trial.

METHODS

The process evaluation follows a mixed-methods approach. We collect quantitative data via online-questionnaires from patients, exercise therapists, referring healthcare professionals and managers of outpatient rehabilitative and medical care facilities before, during, and after the intervention. In addition, documentation data as well as data from the ImPuls smartphone application are collected. Quantitative data is complemented by qualitative interviews with exercise therapists as well as a focus-group interview with managers. Treatment fidelity will be assessed through the rating of video-recorded sessions. Quantitative data analysis includes descriptive as well as mediation and moderation analyses. Qualitative data will be analyzed via qualitative content analysis.

DISCUSSION

The results of our process evaluation will complement the evaluation of effectiveness and cost-effectiveness and will, for example, provide important information about mechanisms of impact, structural prerequisites, or provider qualification that may support the decision-making process of health policy stakeholders. It might contribute to paving the way for exercise programs like ImPuls to be made successively available for patients with heterogeneous mental disorders in the German outpatient mental health care system.

TRIAL REGISTRATION

The parent clinical study was registered in the German Clinical Trials Register (ID: DRKS00024152, registered 05/02/2021, https://drks.de/search/en/trial/DRKS00024152 ).

Study protocol for a pilot trial analysing the usability, validity and safety of an interventional health app programme for the structured prehabilitation of patients before major surgical interventions: the PROTEGO MAXIMA trial

INTRODUCTION

Major surgery is associated with a high risk for postoperative complications, leading to an increase in mortality and morbidity, particularly in frail patients with a reduced cardiopulmonary reserve. Prehabilitation, including aerobic exercise training, aims to improve patients' physical fitness before major surgery and reduce postoperative complications, length of hospital stay and costs. The purpose of the study is to assess the usability, validity and safety of an app-based endurance exercise software in accordance with the Medical Device Regulation using wrist-worn wearables to measure heart rate (HR) and distance.

METHODS AND ANALYSIS

The PROTEGO MAXIMA trial is a prospective, interventional study with patients undergoing major elective surgery, comprising three tasks. Tasks I and II aim to assess the usability of the app, using evaluation questionnaires and usability scenarios. In Task IIIa, patients will undergo a structured risk assessment by the Patronus App, which will be correlated with the occurrence of postoperative complications after 90 days (non-interventional). In Task IIIb, healthy students and patients will perform a supervised 6 min walking test and a 37 min interval training on a treadmill based on HR reserve, wearing standard ECG limb leads and two smartwatches, which will be driven by the test software. The aim of this task is to assess the accuracy of HR measurement by the wearables and the safety, using specific alarm settings of the devices and lab testing of the participants (interventional).

ETHICS AND DISSEMINATION

Ethical approval was granted by the Institutional Review Board of the University Hospital of Frankfurt and by the Federal Institute for Pharmaceuticals and Medical Products (BfArM, reference number 94.1.04-5660-13655) on 7 February 2022. The results from this study will be submitted to peer-reviewed journals and reported at suitable national and international meetings.

TRIAL REGISTRATION NUMBERS

European Database on Medical Devices (CIV-21-07-037311) and German Clinical Trial Registry (DRKS00026985).

App-based oral health promotion interventions on modifiable risk factors associated with early childhood caries: A systematic review

Background

Early childhood caries (ECC) is a preventable chronic disease. Parents' knowledge and attitudes toward oral healthcare have been associated with higher caries experience in their children. Mobile apps within the context of mHealth interventions are a potential tool for raising awareness and informing parents about their children's oral health.

Objectives

The aim of this systematic review was to examine the effectiveness of mobile health apps, targeted at parents and caregivers, for the prevention of ECC.

Data sources

A systematic search was carried out in five scientific databases; Embase, CINAHL, MEDLINE, PsycINFO and Web of Science.

Study selection and data extraction

Original studies, delivering oral health interventions to parents of children <6 years via smartphones, were included. Both quantitative and qualitative findings from the included studies were extracted.

Synthesis

A convergent segregated approach was used to integrate the quantitative and qualitative evidence, followed by side-by-side display and narrative synthesis.

Results

Out of 5,953 retrieved articles, five met the inclusion criteria and were included in the review. Three articles reported quantitative findings, while two reported both quantitative and qualitative findings. Four studies reported that a mobile app can be an effective tool to improve the oral health knowledge of parents/caregivers, aiding them in incorporating good oral health habits into their children's daily routines.

Conclusion

This review demonstrated that oral health promotion programs delivered through mobile apps to parents could be effective in improving child oral health awareness among parents. There is a need for more high-quality studies with a large number of participants to find out which features of mHealth interventions with parents could effectively be employed to reduce the prevalence of ECC. Further studies and apps should be developed based on evidence-based behaviour change techniques and incorporate features such as gamification to increase the effectiveness and engagement of the target population.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/display_record.php?], identifier [CRD42021268331].

[Scientific evidence and user quality in mobile health applications for people with cognitive impairments and their caregivers]

INTRODUCTION

The range of health-related apps is large, but the scientific evidence for them is uncertain. The aim of this study is to evaluate the methodological quality of German-language mobile health apps for people with dementia and their caregivers.

METHODS

The app search was conducted according to the PRISMA-P guidelines in the application stores (Google Play Store and Apple App Store) using the terms "Demenz", "Alzheimer", "Kognition" and "Kognitive Beeinträchtigung". A systematic literature search with subsequent assessment of the scientific evidence was performed. The user quality assessment was conducted using "The German Version of the Mobile App Rating Scale" (MARS-G).

RESULTS

Scientific studies have been published for only 6 of the 20 apps identified. A total of 13 studies were included in the evaluation, whereby the app itself was the subject of investigation in only two publications. In addition, methodological weaknesses were often observed such as small group sizes, short study duration and / or insufficient comparative treatment. The overall quality of the apps can be rated as acceptable with a mean MARS rating of 3.38. Seven apps were able to achieve a score of over 4.0 and thus a good rating, but just as many apps fell below the acceptable limit of 3.0.

DISCUSSION

The contents of most apps have not been scientifically tested. This identified lack of evidence is consistent with the information in the literature in other indication areas. A systematic and transparent evaluation of health applications is necessary to protect end-users and better support their selection process.

Greek validation of the user version of the Mobile Application Rating Scale (uMARS)

OBJECTIVE

The original user version of the Mobile Application Rating Scale (uMARS) is an English-language questionnaire that was designed to allow non-expert app users to assess the quality of health apps. We aimed to translate into the Greek language and validate the uMARS.

METHODS

This was a qualitative prospective study. The World Health Organization translation process was followed and a readily available and free-of-charge app was used for the validation process. Internal consistency and reliability were tested twice within one month by 91 Greek medical students.

RESULTS

The total uMARS score showed excellent internal consistency (Cronbach's alpha = 0.86). The internal consistencies of its subscales were also very high (engagement alpha = 0.71; functionality alpha = 0.71; aesthetics alpha = 0.67; information alpha = 0.63), with the notable exception of the satisfaction alpha, which was 0.61. The uMARS total score demonstrated almost perfect agreement levels in most of the subscales according to the r_WG index from baseline to 1 month.

CONCLUSIONS

The Greek uMARS is a reliable and valid tool for assessing the quality of mobile apps.

Proposal of a New Rating Concept for Digital Health Applications in Orthopedics and Traumatology

BACKGROUND

Health-related mobile applications (apps) are rapidly increasing in number. There is an urgent need for assessment tools and algorithms that allow the usability and content criteria of these applications to be objectively assessed. The aim of this work was to establish and validate a concept for orthopedic societies to rate health apps to set a quality standard for their safe use.

METHODS

An objective rating concept was created, consisting of nine quality criteria. A self-declaration sheet for app manufacturers was designed. Manufacturers completed the self-declaration, and the app was examined by independent internal reviewers. The pilot validation and analysis were performed on two independent health applications. An algorithm for orthopedic societies was created based on the experiences in this study flow.

RESULTS

"Sprunggelenks-App" was approved by the reviewers with 45 (98%) fulfilled criteria and one (2%) unfulfilled criterion. "Therapie-App" was approved, with 28 (61%) met criteria, 6 (13%) unfulfilled criteria and 12 (26%) criteria that could not be assessed. The self-declaration completed by the app manufacturer is recommended, followed by a legal and technical rating performed by an external institution. When rated positive, the societies' internal review using independent raters can be performed. In case of a positive rating, a visual certification can be granted to the manufacturer for a certain time frame.

CONCLUSION

An objective rating algorithm is proposed for the assessment of digital health applications. This can help societies to improve the quality assessment, quality assurance and patient safety of those apps. The proposed concept must be further validated for inter-rater consistency and reliability.

Evaluating and rating HIV/AIDS mobile apps using the feature-based application rating method and mobile app rating scale

Background

The purpose of this study was to evaluate HIV/AIDS mobile applications using the Mobile App Rating Scale (MARS) and rate the features of these applications using the new tool called the Feature-based Application Rating Method (FARM).

Methods

In this study, all available HIV/AIDS apps in Iran from Cafe Bazaar and Google Play Store due to inclusion criteria were studied. The evaluation of the quality of applications was done using the MARS tool and the FARM tool. The FARM, which was developed in this study, was applied to rank the features of the applications.

Results

In this study, 79 applications were included. The mean score of all apps using both tools was 3.58 (SD = 0.95) out of 5. The overall mean quality score based on the MARS was 3.14 (SD = 0.84), and the mean score of features based on FARM was 3.81 (SD = 1.23). This study showed a higher than moderate correlation between the scores assigned to apps based on the MARS and FARM tools (r > 0.4).

Conclusions

The HIV/AIDS mobile applications available in Iran had the "acceptable" ranking. Also, our study results showed that to evaluate mobile apps, using a single tool may not provide good insight to evaluators about the assessed apps. However, using more than one tool may provide more details about the evaluated apps. To improve the quality of mobile health apps and help users select the most desirable app, we suggested using tools like FARM for ranking apps based on the features of each app in the app stores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02029-8.

Mobile Apps for the Management of Gastrointestinal Diseases: Systematic Search and Evaluation Within App Stores

Background

Gastrointestinal diseases are associated with substantial cost in health care. In times of the COVID-19 pandemic and further digitalization of gastrointestinal tract health care, mobile health apps could complement routine health care. Many gastrointestinal health care apps are already available in the app stores, but the quality, data protection, and reliability often remain unclear.

Objective

This systematic review aimed to evaluate the quality characteristics as well as the privacy and security measures of mobile health apps for the management of gastrointestinal diseases.

Methods

A web crawler systematically searched for mobile health apps with a focus on gastrointestinal diseases. The identified mobile health apps were evaluated using the Mobile Application Rating Scale (MARS). Furthermore, app characteristics, data protection, and security measures were collected. Classic user star rating was correlated with overall mobile health app quality.

Results

The overall quality of the mobile health apps (N=109) was moderate (mean 2.90, SD 0.52; on a scale ranging from 1 to 5). The quality of the subscales ranged from low (mean 1.89, SD 0.66) to good (mean 4.08, SD 0.57). The security of data transfer was ensured only by 11 (10.1%) mobile health apps. None of the mobile health apps had an evidence base. The user star rating did not correlate with the MARS overall score or with the individual subdimensions of the MARS (all P>.05).

Conclusions

Mobile health apps might have a positive impact on diagnosis, therapy, and patient guidance in gastroenterology in the future. We conclude that, to date, data security and proof of efficacy are not yet given in currently available mobile health apps.

Development and validation of the Turkish version of the Mobile App Rating Scale - MARS-TR

BACKGROUND

The number of mobile health apps (MHAs) is growing rapidly. MHAs have great potential to improve health and health care. However, the quality of available MHAs remains unknown due to the lack of quality assessment regulations and standards for MHAs. The Mobile Application Rating Scale (MARS) is the most widely used instrument to assess the quality of MHAs, and available in English, Italian, Spanish, German, French, Arabic and Japanese. However, the scale is currently not available in the Turkish language.

OBJECTIVE

This study aimed to cross-culturally adapt the MARS into Turkish and evaluate the validity and reliability of the scale.

METHODS

The MARS was translated and adapted into Turkish according to the international guidelines. A total of 52 pregnancy tracking apps were evaluated by two independent raters. Internal consistency (Cronbach's alpha), inter-rater reliability (Intraclass Correlation Coefficient [ICC]), convergent validity and concurrent validity were explored. Regarding convergent validity, MARS-TR scores were compared with the ENLIGHT scale.

RESULTS

The MARS-TR was highly aligned with the original MARS. The MARS-TR showed excellent internal consistency (Cronbach's alpha of 0.95 for both raters) and excellent inter-rater reliability (ICC = 0.94; SEM = 0.02), with a smallest detectable change (95 % confidence level) of 0.05 points for the total score. Cronbach's alphas for the subscales ranged from 0.76 to 0.94 for the two raters. Correlations between the MARS-TR and ENLIGHT demonstrated adequate convergent validity (P < 0.05). No ceiling or floor effects were observed.

CONCLUSION

The results provide evidence that the Turkish version of MARS is a valid and reliable tool for researchers and experts to assess the quality of MHAs in Turkey.

Feasibility of a Social Network-Based Physical Activity Intervention Targeting Vocational School Students: A Pilot Study

Globally, four out of five adolescents do not meet the recommendations for physical activity (PA). Moving large segments of young adults from inactivity to activity is essential to reach the global target of a 15% relative reduction in inactivity by 2030 worldwide. This study aimed to examine the feasibility of a social network-based PA intervention (WALK2gether) in vocational school students. Fourteen students from one vocational school in the city of Duesseldorf were instructed to walk ten thousand steps per day over six weeks. Applied behavior change techniques were self-monitoring of steps and social comparison via a pedometer app and a Facebook group. Indicators of feasibility were documented. The intervention was minimally resource intensive, with a total of 92 h spent by the research staff. The recruitment rate was 19.2% and loss-to-follow up 28.6%. Our data revealed no significant change in the target behavior PA from baseline to follow-up. The target population did not interact in the Facebook group, while a moderate use of the pedometer app was noted. Although the results ought to be interpreted with caution due to the small sample size, the findings suggest that the WALK2gether intervention was partially feasible, but not appropriate for the target group.

Development and validation of the Japanese version of the uMARS (user version of the mobile app rating system)

BACKGROUND

Although the global market of Mobile Health Apps (mHealth apps) continues to grow dramatically, most mHealth apps still not only lack evidence base but have even not been evaluated for the basic usability or functionality. The User Version of the Mobile App Rating Scale (uMARS) was developed to allow end users to assess mHealth apps objectively and subjectively. However, there is no Japanese version of uMARS to date.

OBJECTIVE

The purpose of this study is (1) to develop a validated Japanese version of uMARS and (2) to assess the translated version's reliability and validity in evaluating mHealth apps.

METHODS

The original uMARS was adapted for Japanese use by four specialists using universalist cross-cultural methods. Translation/back-translation was reviewed by the author of the original version of uMARS, and confirmed. Its reliability and validity were further evaluated as part of a prospective cohort study of postoperative patients using a new mHealth app.

RESULTS

Conceptual equivalence was analyzed and all items in all subcategories of the original uMARS were included in the Japanese version. Internal consistency was deemed acceptable for all subscales of objective and subjective quality with a Cronbach's alpha of 0.75-0.85. Test-retest reliability of all subscales was also acceptable with intraclass correlation coefficients (ICCs) of 0.57-0.88. Convergent/divergent validity and concurrent validity were also considered acceptable.

CONCLUSION

A Japanese version of uMARS was cross-culturally validated and found to be as reliable as the original uMARS. This Japanese version of uMARS is expected to become a standard tool in assessing the quality of mHealth apps in Japan.

A systematic quality rating of available mobile health apps for borderline personality disorder

BACKGROUND

Mobile health apps (MHAs) may offer a mean to overcome treatment barriers in Borderline Personality Disorder (BPD) mental health care. However, MHAs for BPD on the market lack transparency and quality assessment.

METHODS

European app stores were systematically searched, and two independent trained reviewers extracted relevant MHAs. Employed methods and privacy and security details documentation of included MHAs were extracted. MHAs were then assessed and rated using the German version of the standardized Mobile Application Rating Scale (MARS-G). Mean values and standard deviations of all subscales (engagement, functionality, aesthetics, information, and therapeutic gain) and correlations with user ratings were calculated.

RESULTS

Of 2977 identified MHAs, 16 were included, showing average quality across the four main subscales (M = 3.25, SD = 0.68). Shortcomings were observed with regard to engagement (M = 2.87, SD = 0.99), potential therapeutic gain (M = 2.67, SD = 0.83), existing evidence base (25.0% of included MHAs were tested empirically), and documented privacy and security details. No significant correlations were found between user ratings and the overall total score of the MARS-G or MARS-G main subscales.

CONCLUSIONS

Available MHAs for BPD vary in quality and evidence on their efficacy, effectiveness, and possible adverse events is scarce. More substantial efforts to ensure the quality of MHAs available for patients and a focus on transparency, particularly regarding privacy and security documentation, are necessary.

Eating for 2: A Systematic Review of Dutch App Stores for Apps Promoting a Healthy Diet during Pregnancy

A healthy diet during pregnancy has been associated with beneficial child and maternal health outcomes but is challenging to achieve. Recent technological advances offer new opportunities to support pregnant women in their food choices-for instance, via apps. This is already reflected by a wide availability of pregnancy-related apps, but health care professionals feel unsure about their potential. Therefore, the Dutch Google Play Store and Apple App Store were reviewed to identify existing apps on diet and pregnancy. App quality was assessed using the 1) Mobile App Rating Scale (MARS; i.e., assessing functionality, aesthetics, engagement, information quality), 2) Dutch dietary guidelines for pregnant women, and 3) App Behavior Change Scale (ABACUS). Fifty-seven unique apps were identified with an average star rating of 4.2 ±  0.6 and MARS quality score of 3.2 ±  0.3, indicating a moderate quality. Most apps scored best in terms of functionality and aesthetics (4.0 ±  0.4 and 3.3 ±  0.6), but lowest in terms of engagement (2.5 ±  0.6). Regarding nutrition information provision, most apps were incomplete or deviated from the Dutch guidelines. Folic acid supplementation (91%), hygiene (81%), caffeine (79%), and alcohol (77%) were the most commonly addressed nutrition aspects, whereas licorice (11%), iodine (19%), and soy (18%) were only addressed in a few apps. Moreover, a median of 2 out of 21 ABACUS behavior change items were identified per app, which were predominantly related to the category "knowledge and information." Thus, despite the abundance of apps supporting a healthy diet during pregnancy in the Dutch app stores, there is an urgent need for apps with complete and scientifically sound dietary information that is supported by effective behavior change techniques.

German Mobile Apps for Patients With Psoriasis: Systematic Search and Evaluation

Background

Psoriasis is a chronic inflammatory skin disease. The visibility of erythematous plaques on the skin as well as the pain and itchiness caused by the skin lesions frequently leads to psychological distress in patients. Smartphone apps are widespread and easily accessible. Earlier studies have shown that apps can effectively complement current management strategies for patients with psoriasis. However, no analysis of such apps has been published to date.

Objective

The aim of this study is to systematically identify and objectively assess the quality of current publicly available German apps for patients with psoriasis using the Mobile Application Rating Scale (MARS) and compile brief ready-to-use app descriptions.

Methods

We conducted a systematic search and assessment of German apps for patients with psoriasis available in the Google Play Store and Apple App Store. The identified apps were randomly assigned to 1 of 3 reviewers, who independently rated them using the German MARS (MARS-G). The MARS-G includes 15 items from 4 different sections (engagement, functionality, aesthetics, and information) to create an overall mean score for every app. Scores can range from 1 for the lowest-quality apps to 5 for the highest-quality apps. Apps were ranked according to their mean MARS-G rating, and the highest-ranked app was evaluated independently by 2 patients with psoriasis using the user version of the MARS-G (uMARS-G). Furthermore, app information, including origin, main function, and technical aspects, was compiled into a brief overview.

Results

In total, we were able to identify 95 unique apps for psoriasis, of which 15 were available in both app stores. Of these apps, 5 were not specifically intended for patients with psoriasis, 1 was designed for clinical trials only, and 1 was no longer available at the time the evaluation process began. Consequently, the remaining 8 apps were included in the final evaluation. The mean MARS-G scores ranged from 3.51 to 4.18. The app with the highest mean MARS-G score was Psoriasis Helferin (4.18/5.00). When rated by patients, however, the app was rated lower in all subcategories, resulting in a mean uMARS-G score of 3.48. Most apps had a commercial background and a focus on symptom tracking. However, only a fraction of the apps assessed used validated instruments to measure the user’s disease activity.

Conclusions

App quality was heterogeneous, and only a minority of the identified apps were available in both app stores. When evaluated by patients, app ratings were lower than when evaluated by health care professionals. This discrepancy highlights the importance of involving patients when developing and evaluating health-related apps as the factors that make an app appealing to users may differ between these 2 groups.

Trial Registration

Deutsches Register Klinischer Studien DRKS00020963; https://tinyurl.com/ye98an5b

Japanese Version of the Mobile App Rating Scale (MARS): Development and Validation

Background

The number of mobile health (mHealth) apps continues to rise each year. Widespread use of the Mobile App Rating Scale (MARS) has allowed objective and multidimensional evaluation of the quality of these apps. However, no Japanese version of MARS has been made available to date.

Objective

The purposes of this study were (1) to develop a Japanese version of MARS and (2) to assess the translated version’s reliability and validity in evaluating mHealth apps.

Methods

To develop the Japanese version of MARS, cross-cultural adaptation was used using a universalist approach. A total of 50 mental health apps were evaluated by 2 independent raters. Internal consistency and interrater reliability were then calculated. Convergent and divergent validity were assessed using multitrait scaling analysis and concurrent validity.

Results

After cross-cultural adaptation, all 23 items from the original MARS were included in the Japanese version. Following translation, back-translation, and review by the author of the original MARS, a Japanese version of MARS was finalized. Internal consistency was acceptable by all subscales of objective and subjective quality (Cronbach α=.78-.89). Interrater reliability was deemed acceptable, with the intraclass correlation coefficient (ICC) ranging from 0.61 to 0.79 for all subscales, except for “functionality,” which had an ICC of 0.40. Convergent/divergent validity and concurrent validity were also considered acceptable. The rate of missing responses was high in several items in the “information” subscale.

Conclusions

A Japanese version of MARS was developed and shown to be reliable and valid to a degree that was comparable to the original MARS. This Japanese version of MARS can be used as a standard to evaluate the quality and credibility of mHealth apps.

Health care effects and medical benefits of a smartphone-based diabetes self-management application: study protocol for a randomized controlled trial

Background

Diabetes self-management is a mainstay of diabetes care, but the implementation of self-management regimens into daily life is complex and often results in discouragement and distress. Modern approaches such as smartphone-based self-management applications are therefore needed to support people with diabetes. Since reimbursability would increase the availability of such digital applications to people with diabetes, we designed a study that meets all scientific and methodological requirements set by the German Digital Healthcare Act to allow reimbursement for a specific application (mySugr PRO). Here, we report the protocol of this study that aims at evaluating the efficacy of the digital self-management application with regard to patient-reported outcomes and medical benefits.

Methods/design

This multicenter, open-label, randomized, parallel-group, controlled trial will evaluate the health care effects and medical benefits of mySugr PRO. A total of 466 people with diabetes will be randomly allocated (2:1 randomization) to the interventional group (n = 311) that will use the digital self-management application during the 12-week study period or the control group (n = 155; no usage of the application). Baseline and follow-up examinations will assess diabetes distress as the primary endpoint as well as empowerment, HbA1c, blood glucose data, self-management, general well-being, and treatment satisfaction as secondary endpoints. Statistical analyses will use an intention-to-treat procedure (using multiple imputation for missing values) as well as a per-protocol approach for sensitivity analysis.

Discussion

To the best of our knowledge, this study will be one of the largest diabetes-specific evaluations of a digital health application supporting people with diabetes in their diabetes self-management that follow the requirements of the German Digital Healthcare Act.

Trial registration

German Clinical Trial Register DRKS00022923. Registered on 22 October 2020.

Standardized evaluation of the quality and persuasiveness of mobile health applications for diabetes management

This study evaluates diabetes self-management mobile health applications available from European app stores with respect to quality, concordance with recommended self-management tasks and implementation of persuasive system design principles. The European Play Store and Apple App Store were systematically searched and relevant apps were tested. Two raters independently assessed app quality using the Mobile Application Rating Scale and conducted a content analysis of provided persuasive system design principles and self-management tasks. A total of 2,269 mobile health applications were identified and 120 could be included in the evaluation. The overall quality was rated as moderate M = 3.20 (SD = 0.39, min = 2.31, max = 4.62), with shortcomings in the subcategories of engagement (M = 2.80, SD = 0.67) and information quality (M = 2.26, SD = 0.48). Scientific evidence is available for 8% of the apps. The reviewed apps implemented a median of three persuasive system design principles (range 0-15) and targeted a median of 4.5 (range 1-8) self-management tasks, however, with a lack of information about psychosocial coping strategies. Most available diabetes self-management apps lack a scientific evidence base. Persuasive system design features are underrepresented and may form a promising tool to improve app quality. Furthermore, the interaction of physical and behavioral health should be improved in existing diabetes self-management mobile health applications.

Piloting an Innovative Concept of e-Mental Health and mHealth Workshops With Medical Students Using a Participatory Co-design Approach and App Prototyping: Case Study

BACKGROUND

Medical students show low levels of e-mental health literacy. Moreover, there is a high prevalence of common mental illnesses among medical students. Mobile health (mHealth) apps can be used to maintain and promote medical students' well-being. To date, the potential of mHealth apps for promoting mental health among medical students is largely untapped because they seem to lack familiarity with mHealth. In addition, little is known about medical students' preferences regarding mHealth apps for mental health promotion. There is a need for guidance on how to promote competence-based learning on mHealth apps in medical education.

OBJECTIVE

The aim of this case study is to pilot an innovative concept for an educative workshop following a participatory co-design approach and to explore medical students' preferences and ideas for mHealth apps through the design of a hypothetical prototype.

METHODS

We conducted a face-to-face co-design workshop within an elective subject with 26 participants enrolled at a medical school in Germany on 5 consecutive days in early March 2020. The aim of the workshop was to apply the knowledge acquired from the lessons on e-mental health and mHealth app development. Activities during the workshop included group work, plenary discussions, storyboarding, developing personas (prototypical users), and designing prototypes of mHealth apps. The workshop was documented in written and digitalized form with the students' permission.

RESULTS

The participants' feedback suggests that the co-design workshop was well-received. The medical students presented a variety of ideas for the design of mHealth apps. Among the common themes that all groups highlighted in their prototypes were personalization, data security, and the importance of scientific evaluation.

CONCLUSIONS

Overall, this case study indicates the feasibility and acceptance of a participatory design workshop for medical students. The students made suggestions for improvements at future workshops (eg, use of free prototype software, shift to e-learning, and more time for group work). Our results can be (and have already been) used as a starting point for future co-design workshops to promote competence-based collaborative learning on digital health topics in medical education.

Validation of a Korean version of mobile app rating scale (MARS) for apps targeting disease management

The mobile app rating scale (MARS) is a widely used instrument for evaluating smartphone app quality. We aimed to examine the reliability and validity of the Korean version of MARS (MARS-K). Two independent raters performed the assessment using the translated 23-item questionnaire. We applied intraclass correlation coefficient analysis (ICC) to examine inter-rater reliability, Omega, and item-total correlation for internal consistency, and Pearson's r for test-retest reliability and correlation between subscales and the total score of MARS-K. Most items showed moderate to good ICC (0.447-1.000). The MARS-K showed excellent internal consistency and all subscales exceeded the acceptable level of omega. Results indicated MARS-K to be a valid and reliable instrument for evaluating disease management apps offered in the Korean app store. However, upgrades are recommended to further improve MARS-K's rating accuracy and reliability.

Effects of a Novel, Transdiagnostic, Hybrid Ecological Momentary Intervention for Improving Resilience in Youth (EMIcompass): Protocol for an Exploratory Randomized Controlled Trial

BACKGROUND

Most mental disorders first emerge in youth and, in their early stages, surface as subthreshold expressions of symptoms comprising a transdiagnostic phenotype of psychosis, mania, depression, and anxiety. Elevated stress reactivity is one of the most widely studied mechanisms underlying psychotic and affective mental health problems. Thus, targeting stress reactivity in youth is a promising indicated and translational preventive strategy for adverse mental health outcomes that could develop later in life and for improving resilience. Compassion-focused interventions offer a wide range of innovative therapeutic techniques that are particularly amenable to being implemented as ecological momentary interventions (EMIs), a specific type of mobile health intervention, to enable youth to access interventions in a given moment and context in daily life. This approach may bridge the current gap in youth mental health care.

OBJECTIVE

This study aims to investigate the clinical feasibility, candidate underlying mechanisms, and initial signals of the efficacy of a novel, transdiagnostic, hybrid EMI for improving resilience to stress in youth-EMIcompass.

METHODS

In an exploratory randomized controlled trial, youth aged between 14 and 25 years with current distress, a broad Clinical High At-Risk Mental State, or the first episode of a severe mental disorder will be randomly allocated to the EMIcompass intervention (ie, EMI plus face-to-face training sessions) in addition to treatment as usual or a control condition of treatment as usual only. Primary (stress reactivity) and secondary candidate mechanisms (resilience, interpersonal sensitivity, threat anticipation, negative affective appraisals, and momentary physiological markers of stress reactivity), as well as primary (psychological distress) and secondary outcomes (primary psychiatric symptoms and general psychopathology), will be assessed at baseline, postintervention, and at the 4-week follow-up.

RESULTS

The first enrollment was in August 2019, and as of May 2021, enrollment and randomization was completed (N=92). We expect data collection to be completed by August 2021.

CONCLUSIONS

This study is the first to establish feasibility, evidence on underlying mechanisms, and preliminary signals of the efficacy of a compassion-focused EMI in youth. If successful, a confirmatory randomized controlled trial will be warranted. Overall, our approach has the potential to significantly advance preventive interventions in youth mental health provision.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27462.

Spanish adaptation and validation of the User Version of the Mobile Application Rating Scale (uMARS)

OBJECTIVE

While the professional version of the Mobile App Rating Scale (MARS) has already been translated, and validated into the Spanish language, its user-centered counterpart has not yet been adapted. Furthermore, no other similar tools exist in the Spanish language. The aim of this paper is to adapt and validate User Version of the MARS (uMARS) into the Spanish language.

MATERIALS AND METHODS

Cross-cultural adaptation, translation, and metric evaluation. The internal consistency and test-retest reliability of the Spanish version of the uMARS were evaluated using the RadarCovid app. Two hundred and sixteen participants rated the app using the translated scale. The app was then rated again 2 weeks later by 21 of these participants to measure test-retest reliability.

RESULTS

No major differences were observed between the uMARS original and the Spanish version. Discrimination indices (item-scale correlation) obtained appropriate results for both raters. The Spanish uMARS presented with excellent internal consistency, α = .89 and .67 for objective and subjective quality, respectively, and temporal stability (r > 0.82 for all items and subscales).

DISCUSSION

The Spanish uMARS is a useful tool for health professionals to recommend high-quality mobile apps to their patients based on the user's perspective and for researchers and app developers to use end-user feedback and evaluation, to help them identify highly appraised and valued components, as well as areas for further development, to continue ensuring the increasing quality and prominence of the area of mHealth.

CONCLUSION

uMARS Spanish version is an instrument with adequate metric properties to assess the quality of health apps from the user perspective.

Digitalisierung in der Rehabilitation von rheumatischen Erkrankungen: Was ist sinnvoll, was ist bewiesen, welche Perspektiven gibt es?

In Deutschland besteht ein deutlicher Mangel an internistischen Rheumatologen. Um diese Versorgungslücke zu reduzieren, können verschiedene technische Anwendungen genutzt werden. Dies reicht von der Hilfe bei der Früherkennung und Diagnostik für Hausärzte, über Konsilsysteme mit Telemedizin, bis hin zur Videosprechstunde mit den Patienten nach Koordination in einem entsprechenden Netzwerk, das stufenförmig aufgebaut ist, um die vorhandenen Spezialisten möglichst effektiv einzusetzen. Auch Apps für die Nutzung am Smartphone oder Tablet können sowohl Ärzte in Diagnostik und Therapie unterstützen, aber auch vielfältig Patienten bei den jeweiligen Krankheitsbewältigungen helfen. Eine Sonderform sind dabei „Digitale Gesundheitsanwendungen“ (DiGAs), die geprüft wurden und als Medizinprodukte zugelassen und verordnungsfähig sind. Für die Unterstützung von Bewegungsübungen, wie sie bei rheumatischen Erkrankungen so wichtig sind, kommen auch Telemedizinische Assistenzsysteme in Betracht, bei denen über 3D-Kamera und Computeranalyse zu Hause ein individuelles Übungsprogramm angeleitet und kontrolliert wird. Studien zu Anwendungen und Bewertungsoptionen für Apps liegen bereits einige vor, hier besteht aber noch hoher Nachholbedarf.

"Help in a Heartbeat?": A Systematic Evaluation of Mobile Health Applications (Apps) for Coronary Heart Disease

For patients with coronary heart disease (CHD) lifestyle changes and disease management are key aspects of treatment that could be facilitated by mobile health applications (MHA). However, the quality and functions of MHA for CHD are largely unknown, since reviews are missing. Therefore, this study assessed the general characteristics, quality, and functions of MHA for CHD. Hereby, the Google Play and Apple App stores were systematically searched using a web crawler. The general characteristics and quality of MHA were rated with the Mobile Application Rating Scale (MARS) by two independent raters. From 3078 identified MHA, 38 met the pre-defined criteria and were included in the assessment. Most MHA were affiliated with commercial companies (52.63%) and lacked an evidence-base. An overall average quality of MHA (M = 3.38, SD = 0.36) was found with deficiencies in information quality and engagement. The most common functions were provision of information and CHD risk score calculators. Further functions included reminders (e.g., for medication or exercises), feedback, and health management support. Most MHA (81.58%) had one or two functions and MHA with more features had mostly higher MARS ratings. In summary, this review demonstrated that a number of potentially helpful MHA for patients with CHD are commercially available. However, there is a lack of scientific evidence documenting their usability and clinical potential. Since it is difficult for patients and healthcare providers to find suitable and high-quality MHA, databases with professionally reviewed MHA are required.

Mobile-based interventions for common mental disorders in youth: a systematic evaluation of pediatric health apps

BACKGROUND

The access to empirically-supported treatments for common mental disorders in children and adolescents is often limited. Mental health apps might extend service supplies, as they are deemed to be cost-efficient, scalable and appealing for youth. However, little is known about the quality of available apps. Therefore, we aimed to systematically evaluate current mobile-based interventions for pediatric anxiety, depression and posttraumatic stress disorder (PTSD).

METHODS

Systematic searches were conducted in Google Play Store and Apple App Store to identify relevant apps. To be eligible for inclusion, apps needed to be: (1) designed to target either anxiety, depression or PTSD in youth (0-18 years); (2) developed for children, adolescents or caregivers; (3) provided in English or German; (4) operative after download. The quality of eligible apps was assessed with two standardized rating systems (i.e., Mobile App Rating Scale (MARS) and ENLIGHT) independently by two reviewers.

RESULTS

Overall, the searches revealed 3806 apps, with 15 mental health apps (0.39%) fulfilling our inclusion criteria. The mean overall scores suggested a moderate app quality (MARS: M = 3.59, SD = 0.50; ENLIGHT: M = 3.22, SD = 0.73). Moreover, only one app was evaluated in an RCT. The correlation of both rating scales was high (r = .936; p < .001), whereas no significant correlations were found between rating scales and user ratings (p > .05).

CONCLUSIONS

Our results point to a rather poor overall app quality, and indicate an absence of scientific-driven development and lack of methodologically sound evaluation of apps. Thus, future high-quality research is required, both in terms of theoretically informed intervention development and assessment of mental health apps in RCTs. Furthermore, institutionalized best-practices that provide central information on different aspects of apps (e.g., effectiveness, safety, and data security) for patients, caregivers, stakeholders and mental health professionals are urgently needed.

Promoting Health via mHealth Applications Using a French Version of the Mobile App Rating Scale: Adaptation and Validation Study

Background

In the recent decades, the number of apps promoting health behaviors and health-related strategies and interventions has increased alongside the number of smartphone users. Nevertheless, the validity process for measuring and reporting app quality remains unsatisfactory for health professionals and end users and represents a public health concern. The Mobile Application Rating Scale (MARS) is a tool validated and widely used in the scientific literature to evaluate and compare mHealth app functionalities. However, MARS is not adapted to the French culture nor to the language.

Objective

This study aims to translate, adapt, and validate the equivalent French version of MARS (ie, MARS-F).

Methods

The original MARS was first translated to French by two independent bilingual scientists, and their common version was blind back-translated twice by two native English speakers, culminating in a final well-established MARS-F. Its comprehensibility was then evaluated by 6 individuals (3 researchers and 3 nonacademics), and the final MARS-F version was created. Two bilingual raters independently completed the evaluation of 63 apps using MARS and MARS-F. Interrater reliability was assessed using intraclass correlation coefficients. In addition, internal consistency and validity of both scales were assessed. Mokken scale analysis was used to investigate the scalability of both MARS and MARS-F.

Results

MARS-F had a good alignment with the original MARS, with properties comparable between the two scales. The correlation coefficients (r) between the corresponding dimensions of MARS and MARS-F ranged from 0.97 to 0.99. The internal consistencies of the MARS-F dimensions engagement (ω=0.79), functionality (ω=0.79), esthetics (ω=0.78), and information quality (ω=0.61) were acceptable and that for the overall MARS score (ω=0.86) was good. Mokken scale analysis revealed a strong scalability for MARS (Loevinger H=0.37) and a good scalability for MARS-F (H=0.35).

Conclusions

MARS-F is a valid tool, and it would serve as a crucial aid for researchers, health care professionals, public health authorities, and interested third parties, to assess the quality of mHealth apps in French-speaking countries.

What do people want in a smoking cessation app? An analysis of user reviews and app quality

INTRODUCTION

Mobile smoking cessation (mCessation) apps have the potential to complement and enhance existing interventions, but many are of low quality. Exploring app reviews can provide a broader understanding of user experiences and engagement, to enhance the quality, acceptability and effectiveness of future developments.

METHODS

Publicly available user reviews and ratings of smoking cessation apps were mined from Google Play TM and the App Store ® via a targeted two-stage search strategy. English language smoking cessation apps with at least 20 consumer reviews between 2011 and 2020 were included. User reviews were thematically analysed using Braun & Clarke's framework. Apps were independently scored using the Mobile Apps Rating Scale (MARS) and compared to average user star ratings.

RESULTS

Forty-eight versions of 42 apps, encompassing 1,414 associated reviews, met eligibility criteria. Inductive coding of reviews produced 1,084 coding references including reviews coded across multiple nodes. Themes generated included: (1) supportive characteristics/tools; (2) useability; (3) influence on smoking behaviour; (4) benefits of quitting; and (5) role as a supplementary tool for quitting. The mean MARS score of 36 free and accessible apps was 3.10 (SD 0.71) with mean scores ranging from 2.00 to 4.47. An inverse relationship between MARS scores and average user star ratings was observed .

CONCLUSIONS

App personalisation, relationality, functionality and credibility were important to users, and should be considered as key design components for future apps. Differences between user star ratings and MARS scores may illustrate competing priorities of consumers and researchers, and the importance of a co-design development method.

IMPLICATIONS

This is the first study to use unsolicited user reviews from a large population to understand the general mCessation user experience in relation to making a quit attempt. Our findings highlight specific features favoured and disliked by users, including their influence on engagement, and supports previous findings that mCessation applications need to be highly tailorable, functional, credible and supportive. We recommend a consumer-driven, co-design approach for future mCessation app developments to optimise user acceptability and engagement.

A Systematic Evaluation of Mobile Health Applications for the Prevention of Suicidal Behavior or Non-suicidal Self-injury

People with suicidal ideation and non-suicidal self-injury (NSSI) behavior face numerous barriers to help-seeking, which worsened during the COVID-19 pandemic. Mobile health applications (MHA) are discussed as one solution to improve healthcare. However, the commercial app markets are growing unregulated and rapidly, leading to an inscrutable market. This study evaluates the quality, features, functions, and prevention strategies of MHA for people with suicidal ideation and NSSI. An automatic search engine identified MHA for suicidal behavior and NSSI in the European commercial app stores. MHA quality and general characteristics were assessed using the Mobile Application Rating Scale (MARS). MHA of high quality (top 25%) were examined in detail and checked for consistency with established suicide prevention strategies. Of 10,274 identified apps, 179 MHA met the predefined inclusion criteria. Average MHA quality was moderate (M = 3.56, SD = 0.40). Most MHA provided emergency contact, but lacked security features. High-quality MHA were broadly consistent with the best-practice guidelines. The search revealed apps containing potentially harmful and triggering content, and no randomized controlled trial of any included MHA was found. Despite a large heterogeneity in the quality of MHA, high-quality MHA for suicidal behavior and NSSI are available in European commercial app stores. However, a lack of a scientific evidence base poses potential threats to users.

Quality of a Supporting Mobile App for Rheumatic Patients: Patient-Based Assessment Using the User Version of the Mobile Application Scale (uMARS)

Introduction: Mobile applications promise to improve current health care. However, current mobile app quality ratings are mostly physician-based. The aim of this study was (1) to assess the quality of the self-management app Rheuma Auszeit using the validated uMARS (User Version of the Mobile App Rating Scale) app quality assessment tool and (2) to evaluate the association between uMARS scores and patients' characteristics.

Materials and Methods: Consecutive patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis were seen at the rheumatology clinic at university hospital Erlangen, Germany. They were asked to test Rheuma Auszeit, evaluate its quality using uMARS and complete a paper-based survey evaluating the individual preferences, attitudes and ehealth literacy. The association between uMARS scores and patients' characteristics was further explored.

Results: Between December 2018 and January 2019, a total of 126 patients evaluated Rheuma Auszeit using uMARS and filled out the paper-based survey. The median uMARS score was 3.9, IQR 0.7. Functionality was the domain with the highest rating (median 4.8, IQR 0.8), followed by aesthetics (median 4.0, IQR 0.7), information (median 3.5, IQR 0.8), and engagement (median 3.2, IQR 1.0). Subjective quality was average (median 3.0, IQR 1.0). The lowest scoring individual item was customization with a median of 2.5/5. Lower functionality scores were reported among older female rheumatic patients (P < 0.004). Older male rheumatic patients reported a higher subjective quality score (P < 0.024). Perceived disease activity and disease duration did not significantly correlate with any uMARS subdomain scores. eHealth literacy significantly correlated with functionality uMARS subdomain ratings (Rho = 0.18; P < 0.042). Preferred time of app usage significantly correlated with engagement (Rho = 0.20; P < 0.024), functionality (Rho = 0.19; P < 0.029), total uMARS score (Rho = 0.21; P < 0.017) and subjective quality score (Rho = 0.21; P < 0.017). The vast majority of rheumatic patients would consider recommending Rheuma Auszeit to other patients (117/126; 92.9%).

Conclusion: Rheuma Auszeit was well-accepted by German patients suffering from rheumatoid arthritis, psoriatic arthritis and ankylosing spondyloarthritis. Lacking customization could lead to low app compliance and should be improved. Lower functionality scores among older female rheumatic patients highlight the need for patient education. The study underlines the potential and feasibility of therapeutic complementary digital solutions in rheumatology.

Quality of Physical Activity Apps: Systematic Search in App Stores and Content Analysis

Background

Physical inactivity is a major contributor to the development and persistence of chronic diseases. Mobile health apps that foster physical activity have the potential to assist in behavior change. However, the quality of the mobile health apps available in app stores is hard to assess for making informed decisions by end users and health care providers.

Objective

This study aimed at systematically reviewing and analyzing the content and quality of physical activity apps available in the 2 major app stores (Google Play and App Store) by using the German version of the Mobile App Rating Scale (MARS-G). Moreover, the privacy and security measures were assessed.

Methods

A web crawler was used to systematically search for apps promoting physical activity in the Google Play store and App Store. Two independent raters used the MARS-G to assess app quality. Further, app characteristics, content and functions, and privacy and security measures were assessed. The correlation between user star ratings and MARS was calculated. Exploratory regression analysis was conducted to determine relevant predictors for the overall quality of physical activity apps.

Results

Of the 2231 identified apps, 312 met the inclusion criteria. The results indicated that the overall quality was moderate (mean 3.60 [SD 0.59], range 1-4.75). The scores of the subscales, that is, information (mean 3.24 [SD 0.56], range 1.17-4.4), engagement (mean 3.19 [SD 0.82], range 1.2-5), aesthetics (mean 3.65 [SD 0.79], range 1-5), and functionality (mean 4.35 [SD 0.58], range 1.88-5) were obtained. An efficacy study could not be identified for any of the included apps. The features of data security and privacy were mainly not applied. Average user ratings showed significant small correlations with the MARS ratings (r=0.22, 95% CI 0.08-0.35; P<.001). The amount of content and number of functions were predictive of the overall quality of these physical activity apps, whereas app store and price were not.

Conclusions

Apps for physical activity showed a broad range of quality ratings, with moderate overall quality ratings. Given the present privacy, security, and evidence concerns inherent to most rated apps, their medical use is questionable. There is a need for open-source databases of expert quality ratings to foster informed health care decisions by users and health care providers.

Quality and Adoption of COVID-19 Tracing Apps and Recommendations for Development: Systematic Interdisciplinary Review of European Apps

BACKGROUND

Simulation study results suggest that COVID-19 contact tracing apps have the potential to achieve pandemic control. Concordantly, high app adoption rates were a stipulated prerequisite for success. Early studies on potential adoption were encouraging. Several factors predicting adoption rates were investigated, especially pertaining to user characteristics. Since then, several countries have released COVID-19 contact tracing apps.

OBJECTIVE

This study's primary aim is to investigate the quality characteristics of national European COVID-19 contact tracing apps, thereby shifting attention from user to app characteristics. The secondary aim is to investigate associations between app quality and adoption. Finally, app features contributing to higher app quality were identified.

METHODS

Eligible COVID-19 contact tracing apps were those released by national health authorities of European Union member states, former member states, and countries of the European Free Trade Association, all countries with comparable legal standards concerning personal data protection and app use voluntariness. The Mobile App Rating Scale was used to assess app quality. An interdisciplinary team, consisting of two health and two human-computer interaction scientists, independently conducted Mobile App Rating Scale ratings. To investigate associations between app quality and adoption rates and infection rates, Bayesian linear regression analyses were conducted.

RESULTS

We discovered 21 national COVID-19 contact tracing apps, all demonstrating high quality overall and high-level functionality, aesthetics, and information quality. However, the average app adoption rate of 22.9% (SD 12.5%) was below the level recommended by simulation studies. Lower levels of engagement-oriented app design were detected, with substantial variations between apps. By regression analyses, the best-case adoption rate was calculated by assuming apps achieve the highest ratings. The mean best-case adoption rates for engagement and overall app quality were 39.5% and 43.6%, respectively. Higher adoption rates were associated with lower cumulative infection rates. Overall, we identified 5 feature categories (symptom assessment and monitoring, regularly updated information, individualization, tracing, and communication) and 14 individual features that contributed to higher app quality. These 14 features were a symptom checker, a symptom diary, statistics on COVID-19, app use, public health instructions and restrictions, information of burden on health care system, assigning personal data, regional updates, control over tracing activity, contact diary, venue check-in, chats, helplines, and app-sharing capacity.

CONCLUSIONS

European national health authorities have generally released high quality COVID-19 contact tracing apps, with regard to functionality, aesthetics, and information quality. However, the app's engagement-oriented design generally was of lower quality, even though regression analyses results identify engagement as a promising optimization target to increase adoption rates. Associations between higher app adoption and lower infection rates are consistent with simulation study results, albeit acknowledging that app use might be part of a broader set of protective attitudes and behaviors for self and others. Various features were identified that could guide further engagement-enhancing app development.

Effective German and English Language mHealth Apps for Self-management of Bronchial Asthma in Children and Adolescents: Comparison Study

Background

Mobile health (mHealth) apps hold great potential for asthma self-management. Data on the suitability of asthma apps intended for children are insufficient, and the availability of German language apps is still inadequate compared with English language apps.

Objective

This study aims to identify functional asthma apps for children in German and to compare them with English language apps. In line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the Google Play Store and Apple App Store are systematically searched to preselect the most efficient apps, which are then compared according to a self-compiled criteria catalog.

Methods

Both app stores were screened for the term asthma. Following a PRISMA preselection process, the apps that met the inclusion criteria (ie, available free of charge, German or English language, and suitable for children) were rated by 3 independent persons following a criteria catalog consisting of 9 categories, some conceived for this purpose (availability, child-friendly, learning factor, and range of functions) and some adopted from existing validated catalogs (functionality and design, ease of use, potential for improving asthma self-management, fun factor and incentives, and information management and medical accuracy). The highest rated apps in German and English were compared.

Results

A total of 403 apps were identified on the Google Play Store and the Apple App Store. Finally, 24 apps that met the inclusion criteria were analyzed. In the first step of the quality assessment, only 4 available German language asthma apps were compared with 20 English language asthma apps. The 4 German language apps were then compared with the 4 highest rated English language apps. All selected apps, independent of the language, were comparable in the following categories: availability, functionality and design, ease of use, and information management and medical accuracy. The English language apps scored significantly higher in the following categories: potential for improving self-management, child-friendly, fun factor, learning factor, and range of function. English language apps (mean total points 34.164, SD 1.09) performed significantly better than German language asthma apps (mean total points 22.91, SD 2.898; P=.003). The best rated English language app was Kiss my asthma (36/42 points), whereas the best rated German language app Kata achieved only 27.33 points.

Conclusions

The recommended English language apps are Kiss my asthma, AsthmaXcel, AsthmaAustralia, and Ask Me, AsthMe!, whereas the only recommended German language app is Kata. The use of apps plays an increasingly important role in patients’ lives and in the medical field, making mHealth a staple in the future of asthma treatment plans. Although validated recommendations on rating mHealth apps have been published, it remains a challenging task for physicians and patients to choose a suitable app for each case, especially in non–English-speaking countries.

Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders

Introduction: Internet- and mobile-based interventions (IMIs) and their integration into routine psychotherapy (i.e., blended therapy) can offer a means of complementing psychotherapy in a flexible and resource optimized way. Objective: The present study will evaluate the non-inferiority, cost-effectiveness, and safety of two versions of integrated blended psychotherapy for depression and anxiety compared to standard cognitive behavioral therapy (CBT). Methods: A three-armed multicenter cluster-randomized controlled non-inferiority trial will be conducted comparing two implementations of blended psychotherapy (PSYCHOnlineTHERAPYfix/flex) compared to CBT. Seventy-five outpatient psychotherapists with a CBT-license will be randomized in a 1:1:1 ratio. Each of them is asked to include 12 patients on average with depressive or anxiety disorders resulting in a total sample size of N = 900. All patients receive up to a maximum of 16 psychotherapy sessions, either as routine CBT or alternating with Online self-help sessions (fix: 8/8; flex: 0-16). Assessments will be conducted at patient study inclusion (pre-treatment) and 6, 12, 18, and 24 weeks and 12 months post-inclusion. The primary outcome is depression and anxiety severity at 18 weeks post-inclusion (post-treatment) using the Patient Health Questionnaire Anxiety and Depression Scale. Secondary outcomes are depression and anxiety remission, treatment response, health-related quality of life, patient satisfaction, working alliance, psychotherapy adherence, and patient safety. Additionally, several potential moderators and mediators including patient characteristics and attitudes toward the interventions will be examined, complemented by ecological day-to-day digital behavior variables via passive smartphone sensing as part of an integrated smart-sensing sub-study. Data-analysis will be performed on an intention-to-treat basis with additional per-protocol analyses. In addition, cost-effectiveness and cost-utility analyses will be conducted from a societal and a public health care perspective. Additionally, qualitative interviews on acceptance, feasibility, and optimization potential will be conducted and analyzed. Discussion: PSYCHOnlineTHERAPY will provide evidence on blended psychotherapy in one of the largest ever conducted psychotherapy trials. If shown to be non-inferior and cost-effective, PSYCHOnlineTHERAPY has the potential to innovate psychotherapy in the near future by extending the ways of conducting psychotherapy. The rigorous health care services approach will facilitate a timely implementation of blended psychotherapy into standard care. Trial Registration: The trial is registered in the German Clinical Trials Register (DRKS00023973; date of registration: December 28th 2020).