Effectiveness of Mobile App-Assisted Self-Care Interventions for Improving Patient Outcomes in Type 2 Diabetes and/or Hypertension: Systematic Review and Meta-Analysis of Randomized Controlled Trials

The effects of multifactorial pharmacist-led intervention protocol on medication optimisation and adherence among patients with type 2 diabetes: A randomised control trial

Background

Patient-related factors and limited medication adherence in patients with chronic diseases, are associated with poor clinical outcomes, long-term complications, and increased overall disease costs. Many methods have been tested with mixed results, and innovative approaches are needed to encourage patients to adhere to their prescribed drug regimens.

Methods

This randomised controlled trial examined a new multifactorial pharmacist-led intervention protocol (MPIP), including a medication therapy management (MTM) program with face-to-face counselling, patient-specific medication booklets, and a mobile application, from July 2021 to September 2022 in the Oud Al Touba diagnostic and screening ambulatory centre in 192 patients with type 2 diabetes in the United Arab Emirates. Medication adherence was assessed using the fixed medication possession ratio of medication refills and the medication adherence questionnaire.

Results

At 12 months follow-up, participants in the MPIP showed significant improvement in overall medication adherence with total (composite) medication possession ratio (MPRt) of mean (±SD) 0.95 (±0.09) compared to 0.92 (± 0.09) in the control group with mean difference of 0.03 (95%, CI 0.01-0.06), P =0.02. In addition, improvement trend was evident in the MPIP group for all medication regimens with P value <0.01. Comparable results were noticeable in adherence questionnaire scores at the end of the study, with 66 participants in the intervention group scored zero on the questionnaire, suggesting high adherence to medication compared to the control group (48 participants only). The MTM program performed 41 clinical interventions on drug-related problems, compared to six interventions in the control group, and the use of mobile application and medication booklet have increased to 45.7% compared to 21.4% before study exit.

Conclusions

The pharmacy intervention protocol effectively improved medication adherence and optimised medication regimens in diabetic patients with chronic medication regimens in an ambulatory healthcare centre.

Assessment of Eye Care Apps for Children and Adolescents Based on the Mobile App Rating Scale: Content Analysis and Quality Assessment

BACKGROUND

In China, the current situation of myopia among children and adolescents is very serious. Prevention and control of myopia are inhibited by the lack of medical resources and the low awareness about eye care. Nevertheless, mobile apps provide an effective means to solve these problems. Since the health app market in China is still immature, it has become particularly important to conduct a study to assess the quality of eye-care apps to facilitate the development of better eye-care service strategies.

OBJECTIVE

This study aimed to evaluate the quality, functionality, medical evidence, and professional background of eye-care apps targeting children and adolescents in the Chinese app stores.

METHODS

A systematic search on iOS and Android app stores was performed to identify eye-care apps for children and adolescents. The general characteristics, development context, and functional features of the apps were described. Quality assessment of the apps was completed by 2 independent researchers using the Mobile App Rating Scale.

RESULTS

This study included 29 apps, of which 17 (59%) were developed by commercial organizations and 12 (41%) had a design with relevant scientific basis. The main built-in functions of these apps include self-testing (18/29, 62%), eye exercises (16/29, 55%), and eye-care education (16/29, 55%). The mean overall quality of eye-care apps was 3.49 (SD 0.33), with a score ranging from 2.89 to 4.39. The overall Mobile App Rating Scale score exhibited a significant positive correlation with the subscale scores (r=0.81-0.91; P<.001). In addition, although most apps provided basic eye-care features, there are some deficiencies. For example, only a few apps were developed with the participation of medical organizations or professional ophthalmologists, and most of the apps were updated infrequently, failing to provide the latest eye-care information and technology in a timely manner.

CONCLUSIONS

In general, the quality of eye-care apps for children and teenagers in Chinese app stores is good. These apps fulfill users' needs for eye-care services to a certain extent, but they still suffer from insufficient medical background, low user engagement, and untimely updates. In order to further improve the effectiveness of eye-care apps, cooperation with medical institutions and professional ophthalmologists should be strengthened to enhance the scientific and authoritative nature of the apps. At the same time, interactive features and regular updates should be added to enhance user participation and the continuity of the apps. This study provides a reference for future development or improvement of eye-care apps, which can help promote myopia prevention and control.

Identification of challenges and leveraging mHealth technology, with need-based solutions to empower self-management in type 2 diabetes: a qualitative study

INTRODUCTION

Effective diabetes management relies mainly on an individual's ability to perform self-care tasks. However, this process is influenced by a complex interplay of factors. This study explores the multifaceted influences on Diabetes Self-Management (DSM), examining both factors influencing and affecting DSM. Understanding these influences is crucial for developing targeted Digital Health Interventions that empower individuals with diabetes to achieve successful self-management.

OBJECTIVES

To identify problems faced by Type 2 Diabetes Mellitus (T2DM) individuals in self-managing diabetes and leveraging mHealth technology, with need-based solutions to Empower Self-Management in T2DM.

METHODOLOGY

In-depth semi-structured interviews were conducted among ten patients with T2DM visiting the outpatient department of a tertiary care hospital in coastal Karnataka. Additionally, six healthcare professionals (HCPs) working closely with T2DM patients were interviewed to understand their perspectives on using mHealth to manage T2DM effectively. The themes for the solutions described were analyzed using ATLAS-TI software.

RESULTS

Our research examined certain factors that might have influenced effective diabetes self-management and investigated patient perspectives on using digital health solutions in diabetes self-management. This study found that technology skills, duration of diabetes, knowledge, and personal beliefs were all significant factors affecting self-management in participants with T2DM. Additionally, socioeconomic factors were also seen to influence effective diabetes self-management. The Google search engine was used by 50% of the participants interviewed to learn about T2DM. Diet management through Google searches was used by a minority (30%) of the patients. None of the participants had previously used any mobile health applications (mHealth apps) to manage T2DM. 20% of the participants expressed limited knowledge about using smartphones or wearables to track health parameters. The study also identified potential non-technological barriers to mHealth adoption. To address these concerns, researchers used an empathy map to develop solutions that promote mHealth use.

CONCLUSION

Several challenges and need-based mHealth solutions were identified to empower diabetes self-management education among T2DM patients. Implementing need-based mHealth solutions such as data tracking, personalized feedback, and access to educational resources can lead to better disease control and a higher quality of life for those with T2DM. Further research and development in mHealth interventions, and collaborative efforts among healthcare providers, patients, and technology developers, hold a promising future for the healthcare sector in providing efficient, effective, and accessible care.

Empowering WHISE women: usability testing of a mobile application to enhance blood pressure control

Background

High blood pressure (hypertension) disproportionately affects African American/Black (Black) women. Previous research suggests that self-managing hypertension may be challenging, yet mobile applications (apps) can help to empower patients and increase medication adherence. We developed questions to test the usability of evaluating the WHISE (Wellness, Hypertension, Information Sharing, Self-Management, Education) mobile app for Black women with hypertension.

Methods

Fifteen participants completed usability testing; five were potential app users (Black women with hypertension); each invited two of their peers to participate. Each testing session (n=5) included a brief overview of the app, time for participants to complete surveys and have an active discussion about the app (concurrent and retrospective think-aloud, concurrent and retrospective probing, per usability.gov), and observation of participants' body language during the session. Testing sessions were designed to familiarize participants with the app's features and examine their navigating ability.

Results

The app received overwhelmingly positive feedback, with 80% of participants finding it to be a valuable tool in hypertension management. Participants praised the app's user-friendliness and educational value, with one stating, 'It is a good educational piece for helping people manage hypertension, at least to understand its basics.' Another participant highlighted the potential for community support, saying, 'Having a community, having some people to be accountable, to check in with and see how things are going, could encourage and motivate people to be more diligent about managing their hypertension.' Some participants also provided constructive feedback, suggesting font size adjustments (73%) and color scheme changes (60%) for certain screens.

Conclusions

Based on the feedback we received, we were able to mitigate the participants' concerns about font size and color and create tutorial videos to guide future users in using the app. We completed these changes prior to deploying the app in our randomized clinical controlled trial.

Effectiveness of mHealth Interventions to Improve Pain Intensity and Functional Disability in Individuals With Hip or Knee Osteoarthritis: A Systematic Review and Meta-analysis

OBJECTIVE

This review aimed to investigate the effectiveness of mHealth-supported active exercise interventions to reduce pain intensity and disability level in persons with hip or knee osteoarthritis (OA).

DATA SOURCES

Three databases (PubMed, Cochrane Library, and Web of Science) were systematically searched for randomized controlled trials (RCTs) published between January 1, 2012 and July 31, 2023. PROSPERO registration number of this review was CRD42023394119.

STUDY SELECTION

We included only RCTs that were identified and screened by 2 independent reviewers (J.M. and G.N.). In addition, the reference lists of the identified studies were manually checked for further inclusion. Included studies had to provide mHealth-supported active exercises for persons with hip or knee OA, and evaluate pain intensity and disability using both questionnaires and performance tests.

DATA EXTRACTION

From the included studies, the 2 independent authors extracted data using a predetermined Excel form. Characteristics of the interventions were described and a meta-analysis was performed.

DATA SYNTHESIS

Twelve RCTs were included, representing 1541 patients with a mean age of 58.7±5 years, and a body mass index of 28.8±3.1 kg/m2; women being more predominant than men with a total female to male ratio of 2.2. The methodological quality of the included studies was moderate in 75% of the studies. There was no statistically significant difference between mHealth-supported active exercises compared with the interventions without mHealth in terms of pain reduction (standard mean differences [SMD]=-0.42; 95% CI, -0.91 to 0.07; P=.08) and disability mitigation (SMD=-0.36; 95% CI, -0.81 to 0.09; P=.10). However, a statistically significant difference was found between patient education combined with mHealth-supported active exercises compared with patient education alone in terms of pain (SMD= -0.42; 95% CI, -0.61 to -0.22; P<.01) and disability (SMD=-0.27; 95% CI, -0.46 to -0.08; P<.01) reduction.

CONCLUSIONS

mHealth-supported exercises were found to be effective, especially when combined with patient education, in reducing pain and mitigating disability in patients with hip or knee OA.

An mHealth application for chronic vascular access: A multi-method evaluation

BACKGROUND

Healthcare consumers require diverse resources to assist their navigation of complex healthcare interactions, however, these resources need to be fit for purpose.

AIM

In this study, we evaluated the utility, usability and feasibility of children, families and adults requiring long-term intravenous therapy using a recently developed mobile health application (App), intravenous (IV) Passport.

DESIGN

Multi-site, parallel, multi-method, prospective cohort study.

METHODS

A multi-site, multi-method study was carried out in 2020-2021, with 46 participants (20 adults, 26 children/family) reporting on their experiences surrounding the use of the IV Passport for up to 6 months.

RESULTS

Overall, utility rates were acceptable, with 78.3% (N = 36) using the IV Passport over the follow-up period, with high rates of planned future use for those still active in the project (N = 21; 73%), especially in the child/family cohort (N = 13; 100%). Acceptability rates were high (9/10; IQR 6.5-10), with the IV Passport primarily used for documenting new devices and complications. Thematic analysis revealed three main themes (and multiple subthemes) in the qualitative data: Advocacy for healthcare needs, Complexity of healthcare and App design and functionality.

CONCLUSION

Several recommendations were made to improve the end-user experience including 'how to' instructions; and scheduling functionality for routine care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The IV Passport can be safely and appropriately integrated into healthcare, to support consumers.

IMPACT

Patient-/parent-reported feedback suggests the Intravenous Passport is a useful tool for record-keeping, and positive communication between patients/parents, and clinicians.

REPORTING METHOD

Not applicable.

PATIENT CONTRIBUTION

Consumers reported their experiences surrounding the use of the IV Passport for up to 6 months.

Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme: a feasibility pilot study in Singapore

BACKGROUND

Considering time-consuming, cost-related limitations of laboratory-based HbA1c testing and follow-up clinic visits for diabetes management, it is important to explore alternative care models which incorporate point-of-care testing for HbA1c to monitor glycaemic control and related management.

METHODS

Therefore, we adopted an implementation perspective to conduct one group pre- and post-intervention feasibility pilot assessing feasibility, acceptability and satisfaction with conducting home HbA1c test by patients with type 2 diabetes coupled with telemonitoring and teleconsultations (i.e., the Primary Technology Enhanced Care (PTEC) Home HbA1c Testing (HAT) Programme) in Singaporean primary care setting. The secondary objective was to compare the HbA1c, blood pressure and primary care visits at the end or during intervention, vs. 6 months before. Adult patients with type 2 diabetes with HbA1c ≤ 8% without any diabetes complications and having phone compatibility were recruited. Data was collected via patient self-reports and electronic medical records extraction. While summary statistics and paired t-test were computed for quantitative data, open-ended feedback was analysed using content analysis.

RESULTS

A total of 33 participants completed the intervention out of 37 (33/37 = 89%) recruited from 73 eligible (37/73 = 51%). Most were either 51 to 60 years old (46.9%) or more than 60 years (37.5%), with more males (53.1%) and majority Chinese (93.8%). Majority (81.3%) felt that home HbA1c testing was beneficial with most commonly reported benefit of not having a clinic visit. A key finding was the average of diabetes-related visits being significantly lower post-intervention with comparable HbA1c values pre- and post-intervention. The most commonly reported challenge was using Bluetooth to transmit the reading (43.7%), followed by having too many steps to remember (28.1%). While participants reported being overall satisfied with the intervention, only 22% were willing to pay for it.

CONCLUSION

Our findings support home HbA1c testing by patients coupled with telemonitoring and teleconsultations. Following are practical recommendations for the implementation scaling phase: offering PTEC HAT Programme to suitable patients who are self-motivated and have adequate digital literacy, provision of adequate educational and training support, sending reminders and exploring enabling manual submission of HbA1c readings considering Bluetooth-related challenges.

Lifestyle Intervention With Smartphone App and isCGM for People at High Risk of Type 2 Diabetes: Randomized Trial

AIMS

Although conventional interventions for people at high risk of developing type 2 diabetes are usually conducted face-to-face, such interventions are burdensome for health care providers. We developed a lifestyle intervention program combining lifestyle coaching via a smartphone application augmented by intermittently scanned continuous glucose monitoring without burdening health care providers. Its effectiveness for glycemic control and body weight reduction in people at risk of type 2 diabetes was investigated.

MATERIALS AND METHODS

For this 12-week randomized unblinded trial with offline recruitment, participants with a hemoglobin A1c level of 5.6% to 6.4% or a fasting blood glucose of 110 to 125 mg/dL and body mass index (BMI) >23 kg/m2 but <40 kg/m2 were randomly assigned to the intervention group (App) and control group (C). The primary endpoint was the difference in time in range of blood glucose between 70 and 140 mg/dL (3.9-7.8 mmol/L) before and after the study period between the 2 groups.

RESULTS

Among 168 patients (mean age, 48.1 years; mean BMI, 26.6 kg/m2; and male, 80.4%), 82 and 86 were assigned to the App group and C group, respectively. After 12 weeks, time in range of blood glucose at 70 to 140 mg/dL significantly improved in the App group compared with the C group (-2.6 minutes/day vs +31.5 minutes/day, P = .03). Changes in time above range did not differ, whereas time below range (blood glucose <70 mg/dL; +23.5 minutes/day vs -8.9 minutes/day, P = .02) improved in the App group. BMI (-0.26 vs -0.59, P = .017) was reduced in the App group compared with the C group.

CONCLUSION

Intervention with a smartphone app and intermittently scanned continuous glucose monitoring increased glycemic control accompanied by decreased carbohydrate intake and weight loss. Further trials are needed to confirm whether these interventions can reduce incident type 2 diabetes.

Empowering patients with comorbid diabetes and hypertension through a multi-component intervention of mobile app, health coaching and shared decision-making: Protocol for an effectiveness-implementation of randomised controlled trial

INTRODUCTION

Diabetes and hypertension are prevalent and costly to the health system. We have developed a mobile app (EMPOWER app) which enables remote monitoring and education through personalised nudges. We aim to study the effectiveness of a multi-component intervention comprising the EMPOWER mobile app with health coaching and shared decision-making for diabetes and hypertension.

METHODS

We will conduct a two-arm, open-label, pragmatic randomised controlled trial (RCT). Participants with comorbid diabetes and hypertension enrolled from public primary care clinics will be randomised to either intervention or control in a 1:1 ratio. The intervention group participants will have access to health coaching with shared decision-making interventions in addition to the EMPOWER app and their usual primary care. The control group participants will continue to receive usual primary care and will neither receive the EMPOWER app nor health coaching and shared decision-making interventions. Our primary outcome is change in HbA1c level over 9 months. Secondary outcomes include change in systolic blood pressure, quality of life, patient activation, medication adherence, physical activity level, diet, and healthcare cost (direct and indirect) over 9 months.

DISCUSSION

Our trial will provide key insights into clinical- and cost-effectiveness of a multi-component intervention comprising EMPOWER mobile app, health coaching and shared decision-making in diabetes and hypertension management. This trial will also offer evidence on cost-effective and sustainable methods for promoting behavioural changes among patients with comorbid diabetes and hypertension.

TRIAL REGISTRATION

This study was registered on clintrials.gov on August 3, 2022, with the trial registration number: NCT05486390.

Advancing Virtual at-Home Care for Community Health Center Patients Using Patient Self-Care Tools, Technology, and Education

Introduction

Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers.

Objective

This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures.

Methods

A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared.

Results

A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p<0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p<0.001).

Conclusion

Health centers applying the Value Transformation Framework's organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.

Effect of emerging digital technologies and methodologies combined with incentives on HbA1c in patients with type 2 diabetes mellitus: study protocol for a parallel, open randomized controlled trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a common metabolic disease that requires long-term management and treatment. Digital intervention, as an emerging medical model, has been widely used in the treatment of T2DM patients. Behavioral economics theory provides a favorable perspective for studying the effect of digital intervention because it can reveal the decision-making mechanisms behind human behavior and provide more effective interventions for digital intervention. The purpose of this trial is to evaluate the impact of behaviorally based digital intervention on T2DM patients' HbA1c, self-monitoring of blood glucose (SMBG) testing rate, diabetes self-efficacy, and other indicators compared to conventional treatment.

METHODS

This trial is a prospective randomized controlled trial conducted at the First People's Hospital of Kunshan City from April 1, 2023, to December 31, 2024, with a follow-up period of 3 months. The specific randomization method was established and implemented through the EDC clinical trial center's randomization system. We will measure and collect baseline data from three groups, including Group A: digital intervention + virtual incentives + conventional treatment, Group B: digital intervention + physical incentives + conventional treatment, and Group C: conventional treatment. HbA1c, weight, SMBG testing rate, diabetes self-efficacy, and diabetes-related medical expenses will be recorded at baseline, 1 month, 2 months, and 3 months for all three groups. The Shapiro-Wilk test will be used to test for normality, and Pearson correlation analysis will be used for correlation analysis. Dropouts will be analyzed separately. Analysis of variance or exact probability calculation will be used to compare demographic data and other baseline indicators.

DISCUSSION

This study is a novel clinical trial that integrates multiple disciplines (economics and medicine) and uses digital technology to deliver the intervention. Most published studies were offline interventions based on behavioral economics theory, but very few were on online interventions for T2DM patients. This study has both novelty and social value.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300070753. Registered on 2023/04/22.

Effectiveness of mobile application interventions for stroke survivors: systematic review and meta-analysis

BACKGROUND

Although smartphone usage is ubiquitous, and a vast amount of mobile applications have been developed for chronic diseases, mobile applications amongst stroke survivors remain unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to determine the effectiveness of mobile applications on medication adherence, functional outcomes, cardiovascular risk factors, quality of life and knowledge on stroke in stroke survivors.

METHODS

A review of the literature was conducted using key search terms in PubMed, EMBASE, Cochrane and Web of Science databases until 16 March 2023 to identify eligible randomized controlled trials (RCTs) or controlled clinical trial (CCTs) of mobile application interventions among stroke survivors. Two reviewers independently screened the literature in accordance with the eligibility criteria and collected data from the articles included. Outcomes included medication adherence,functional outcomes,cardiovascular risk factors, quality of life,and knowledge of stroke.

RESULTS

Twenty-three studies involving 2983 participants across nine countries were included in this review. Sixteen trials involved health care professionals in app use, and seven trials reported measures to ensure app-based intervention adherence. Mobile applications targeting stroke survivors primarily encompassed three areas: rehabilitation, education and self-care. The participants in the studies primarily included young and middle-aged stroke survivors. Meta-analysis results demonstrated that mobile application intervention significantly improved trunk control ability (mean differences [MD] 3.00, 95% CI [1.80 to 4.20]; P < 0.00001), Fugl-Meyer assessment of upper extremity (MD 9.81, 95% CI [8.72 to 10.90]; P < 0.00001), low-density lipoprotein cholesterol (MD - 0.33, 95% CI [- 0.54 to - 0.11]; P = 0.003) and glycosylated haemoglobin A1c (HbA1c)<7 levels (MD 1.95, 95% CI [1.17 to 3.25]; P = 0.01). However, the mobile application intervention did not differ significantly in medication adherence, 10-min walk test (10 MWT), Barthel index, systolic blood pressure, diastolic blood pressure, high-density lipoprotein cholesterol, body mass index, smoking, health-related quality of life and knowledge of stroke.

CONCLUSION

Our study suggested that mobile application interventions may have a potential benefit to stroke survivors, but clinical effectiveness should be established. More studies using rigorous designs are warranted to understand their usefulness. Future research should also involve more older adult stroke survivors.

The role of adherence in patients with chronic diseases

In the long-term management of chronic diseases, adherence and persistence to prescribed medications are continuous challenges in order to obtain all the potential benefits of drug therapies. Suboptimal drug adherence and discontinuations of therapies remain the most frequent reasons why several diseases are poorly controlled in the population. One the main issue is that physicians are relatively limited in time and tools to detect patients with a poor adherence. The present review discusses present and future strategies that are now available or are being developed to detect and to support adherence in patients with chronic diseases and provides some simple clues to identify patients at high risk of discontinuation in the clinic.

Willingness to pay for health apps, its sociodemographic correlates, and reasons for being unwilling to pay

Background

Knowledge about whether, how much, and why individuals are willing to pay for health apps is limited.

Objectives

This study aimed to examine (1) the proportion of individuals willing to pay for health apps, (2) their willingness to pay (WTP; i.e. the maximum price the individual is willing to pay) for health apps, (3) the sociodemographic correlates determining whether individuals are willing to pay for these apps, (4) the sociodemographic correlates of their WTP, and (5) reasons for being unwilling to pay.

Methods

Six hundred adults were invited to participate in a questionnaire survey examining their sociodemographic characteristics, WTP for health apps, and reasons for being unwilling to pay. Sociodemographic characteristics and WTP for health apps were analyzed using descriptive statistics. Logistic regression was applied to examine the sociodemographic variables correlated with whether individuals were willing to pay for health apps. Among those who were willing to pay, log-linear regression was conducted to examine the sociodemographic correlates of their WTP. The reasons for unwillingness to pay were descriptively analyzed.

Results

A total of 577 individuals completed the questionnaire. Of them, 58.9% were willing to pay for health apps. Their median WTP was HK$50 (HK$1 ≈ US$0.13). Participants with a bachelor's degree or higher and those who had previously installed health apps were more inclined to pay for health apps. WTP was positively associated with the maximum price previously paid for a health app. The most frequently cited reasons for being unwilling to pay were the belief that the government should provide free health apps, distrust in health apps, and a lack of awareness of health apps and their benefits.

Conclusions

This study provides insights that can inform strategies to enhance the marketability, affordability, and accessibility of health apps.

An umbrella review of effectiveness and efficacy trials for app-based health interventions

Health interventions based on mobile phone or tablet applications (apps) are promising tools to help patients manage their conditions more effectively. Evidence from randomized controlled trials (RCTs) on efficacy and effectiveness of such interventions is increasingly available. This umbrella review aimed at mapping and narratively summarizing published systematic reviews on efficacy and effectiveness of mobile app-based health interventions within patient populations. We followed a pre-specified publicly available protocol. Systematic reviews were searched in two databases from inception until August 28, 2023. Reviews that included RCTs evaluating integrated or stand-alone health app interventions in patient populations with regard to efficacy/effectiveness were considered eligible. Information on indications, outcomes, app characteristics, efficacy/effectiveness results and authors' conclusions was extracted. Methodological quality was assessed using the AMSTAR2 tool. We identified 48 systematic reviews published between 2013 and 2023 (35 with meta-analyses) that met our inclusion criteria. Eleven reviews included a broad spectrum of conditions, thirteen focused on diabetes, five on anxiety and/or depression, and others on various other indications. Reported outcomes ranged from medication adherence to laboratory, anthropometric and functional parameters, symptom scores and quality of life. Fourty-one reviews concluded that health apps may be effective in improving health outcomes. We rated one review as moderate quality. Here we report that the synthesized evidence on health app effectiveness varies largely between indications. Future RCTs should consider reporting behavioral (process) outcomes and measures of healthcare resource utilization to provide deeper insights on mechanisms that make health apps effective, and further elucidate their impact on healthcare systems.

Design, development and evaluation of a mobile-based self-care application for patients with COVID-19 not requiring hospitalization; a study of Northwest of Iran

BACKGROUND

Given the effective role of a mobile applications in disease management, disease monitoring, and self-care in patients with COVID-19 disease, we aimed to design, development and evaluation of a self-care Mobile app for COVID-19 patients not requiring hospitalization.

METHODS

The design, development and evaluation the usability of the self-care and education mobile app for patients with COVID-19 disease were conducted in two main phases at 2021 in Northwest of IRAN; (1) Determine the features and capabilities and (2) Design, development and evaluation of self-care mobile App. JAVA programming languages and Android Operating System were used and selected to design and development of a mobile app. There were 25 participants who conducted evaluations of the mobile app's usability and impact using the mobile health app usability a Questionnaire of User Interface Satisfaction was administered to assess the usability of the developed application. The results were analyzed via Excel 2013.

RESULTS

The model of developing a mobile app as an Information System was the Waterfall model. The smartphone application based on a set of capabilities and features was designed and consists of two main parts: the login screen for user registration, and the main home menu. The user interface includes three main pages or activities; (a) Main Menu for quick access to all of the pages, (b) Symptom management and monitoring to monitor the signs and symptoms during the illness, and (c) Set Reminders and Alarms to notify patients. The users' mean score of the application usability was calculated as 7.91 out of 9 indicating a good level of satisfaction.

CONCLUSION

This app can be a guideline and a useful tools for managing and monitoring symptoms, reminding medications, and implementing self-care instructions in outpatients. The authors suggest evaluating the efficacy and functionality test of mobile-based applications for COVID-19 in clinical trial studies.

The Effect of Mobile eHealth Education to Improve Knowledge, Skills, Self-Care, and Mobile eHealth Literacies Among Patients With Diabetes: Development and Evaluation Study

BACKGROUND

The promotion of mobile health (mHealth) and eHealth technologies as tools for managing chronic diseases, particularly diabetes mellitus, is on the rise. Nevertheless, individuals with diabetes frequently face a literacy gap that hinders their ability to fully leverage the benefits offered by these resources. Enhancing technology literacy to facilitate the adoption of mobile eHealth services poses a significant challenge in numerous countries.

OBJECTIVE

This study aims to develop an educational mobile eHealth literacy (eHL) program for patients with diabetes and to evaluate its effect on patients' outcomes.

METHODS

This study designed a mobile eHL education program comprising 2 modules specifically tailored for individuals with type 2 diabetes (T2D). These modules focused on guiding participants through the process of effectively navigating reliable health websites and utilizing diabetes-related apps. Using a pre- and posttest experimental design, the study featured an intervention group and a control group. Participants were recruited from 3 outpatient departments in hospitals, and assessments were conducted both before and after the intervention, along with a follow-up measure at the 3-month mark. The evaluation encompassed sociodemographic characteristics, computer and internet proficiency, mobile app usage, mobile eHL, and patient outcomes such as self-care behaviors and glycated hemoglobin (HbA1c) levels.

RESULTS

The analysis included a total of 132 eligible participants. Significant differences were observed in the mean scores of knowledge (P<.001) and skills (P<.001) related to computers, the web, and mobile devices at the initiation of the study and after the intervention. During the 3-month follow-up, the findings indicated a significant improvement in mobile eHL (t114=3.391, P=.001) and mHealth literacy (mHL, a subconcept of mobile eHL; t114=3.801, P<.001) within the intervention group, whereas no such improvement was observed in the control group. The chi-square values from the McNemar test underscored that individuals with uncontrolled diabetes (HbA1c≥7%) in the intervention group exhibited more improvement compared with the control group. The generalized estimating equations model unveiled a significant difference in the change of general mHL in the intervention group (β=1.91, P=.047) and self-care behavior in the control group from T0 to T2 (β=-8.21, P=.015). Despite being small, the effect sizes for mobile eHL (d=0.49) and HbA1c (d=0.33) in the intervention group were greater than those in the control group (d=0.14 and d=0.16, respectively).

CONCLUSIONS

The implementation of a mobile eHL education intervention demonstrates a positive influence on the familiarity of patients with T2D regarding health technology, leading to favorable glycemic outcomes. While additional studies are warranted for a more comprehensive understanding, this program emerges as a promising solution for enhancing patients' uptake of digital health technology.

Efficacy of a WeChat-Based Multimodal Digital Transformation Management Model in New-Onset Mild to Moderate Hypertension: Randomized Clinical Trial

BACKGROUND

The advantages of multimodal digitally transformed mobile health management for patients diagnosed with mild to moderate hypertension are not yet established.

OBJECTIVE

We aim to evaluate the therapeutic benefits of a novel WeChat-based multimodal digital transforming management model in mobile health blood pressure (BP) management.

METHODS

This randomized controlled clinical trial included 175 individuals with new-onset mild to moderate hypertension who were admitted to our center between September and October 2022. The patients were randomly assigned to either the multimodal intervention group (n=88) or the usual care group (n=87). The primary composite outcome was home and office BP differences after 6 months. The major secondary outcomes were 6-month quality-of-life scores, including the self-rating anxiety scale, self-rating depression scale, and Pittsburgh Sleep Quality Index.

RESULTS

The mean home BP decreased from 151.74 (SD 8.02)/94.22 (SD 9.32) to 126.19 (SD 8.45)/82.28 (SD 9.26) mm Hg in the multimodal intervention group and from 150.78 (SD 7.87)/91.53 (SD 9.78) to 133.48 (SD 10.86)/84.45 (SD 9.19) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -8.25 mm Hg (95% CI -11.71 to -4.78 mm Hg; P<.001) and -4.85 mm Hg (95% CI -8.41 to -1.30 mm Hg; P=.008), respectively. The mean office BP decreased from 153.64 (SD 8.39)/93.56 (SD 8.45) to 127.81 (SD 8.04)/ 82.16 (SD 8.06) mm Hg in the multimodal intervention group and from 151.48 (SD 7.14)/(91.31 (SD 9.61) to 134.92 (SD 10.11)/85.09 (SD 8.26) mm Hg in the usual care group, with a mean difference in systolic blood pressure and diastolic blood pressure of -9.27 mm Hg (95% CI -12.62 to -5.91 mm Hg; P<.001) and -5.18 mm Hg (95% CI -8.47 to -1.89 mm Hg; P=.002), respectively. From baseline to 6 months, home BP control <140/90 mm Hg was achieved in 64 (72.7%) patients in the multimodal intervention group and 46 (52.9%) patients in the usual care group (P=.007). Meanwhile, home BP control <130/80 mm Hg was achieved in 32 (36.4%) patients in the multimodal intervention group and 16 (18.4%) patients in the usual care group (P=.008). After 6 months, there were significant differences in the quality-of-life total and graded scores, including self-rating anxiety scale scores (P=.04), self-rating depression scale scores (P=.03), and Pittsburgh Sleep Quality Index scores (P<.001), in the multimodal intervention group compared with the usual care group.

CONCLUSIONS

The WeChat-based multimodal intervention model improved the BP control rates and lowered the BP levels more than the usual care approach. The multimodal digital transforming management model for hypertension represents an emerging medical practice that utilizes the individual's various risk factor profiles for primary care and personalized therapy decision-making in patients with hypertension.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200063550; https://www.chictr.org.cn/showproj.html?proj=175816.

The effect of personalized intelligent digital systems for self-care training on type II diabetes: a systematic review and meta-analysis of clinical trials

AIMS

Type 2 diabetes (T2D) is rising worldwide. Self-care prevents diabetic complications. Lack of knowledge is one reason patients fail at self-care. Intelligent digital health (IDH) solutions have a promising role in training self-care behaviors based on patients' needs. This study reviews the effects of RCTs offering individualized self-care training systems for T2D patients.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library, and Science Direct databases were searched. The included RCTs provided data-driven, individualized self-care training advice for T2D patients. Due to the repeated studies measurements, an all-time-points meta-analysis was conducted to analyze the trends over time. The revised Cochrane risk-of-bias tool (RoB 2.0) was used for quality assessment.

RESULTS

In total, 22 trials met the inclusion criteria, and 19 studies with 3071 participants were included in the meta-analysis. IDH interventions led to a significant reduction of HbA1c level in the intervention group at short-term (in the third month: SMD = - 0.224 with 95% CI - 0.319 to - 0.129, p value < 0.0; in the sixth month: SMD = - 0.548 with 95% CI - 0.860 to - 0.237, p value < 0.05). The difference in HbA1c reduction between groups varied based on patients' age and technological forms of IDH services delivery. The descriptive results confirmed the impact of M-Health technologies in improving HbA1c levels.

CONCLUSIONS

IDH systems had significant and small effects on HbA1c reduction in T2D patients. IDH interventions' impact needs long-term RCTs. This review will help diabetic clinicians, self-care training system developers, and researchers interested in using IDH solutions to empower T2D patients.

Review and content analysis of mobile apps for inflammatory bowel disease management using the mobile application rating scale (MARS): Systematic search in app stores

BACKGROUND

People with inflammatory bowel disease (IBD) need tools for self-management of their disease with the ultimate goal of improving medication adherence and health outcomes. Mobile apps represent a novel opportunity to provide self-management for patients with IBD. Many mobile apps have been developed for IBD self-management, but more evidence is needed about the quality of these mobile apps.

OBJECTIVE

This study evaluated mobile apps developed for the IBD community and rated the quality of these apps to provide a roadmap for future development.

MATERIALS AND METHODS

The Apple App Store and Google Play Store were systematically searched to identify IBD mobile apps for patients and physicians based on the IBD-related keywords. We included mobile apps that focus on IBD, are in the English language, and are free. The related app quality was evaluated independently by two reviewers using the Mobile Application Rating Scale (MARS).

RESULTS

We identified 401 mobile apps. After removing duplicates and unrelated apps, 44 apps were included in the review. Overall, the mean MARS scores were 3.5 (SD = 0.5) on a scale from 1.00 to 5.00, which was the acceptable range.; 12 apps got scores ≥ 4.00. The highest mean domain score belonged to the functionality dimension (mean = 3.9, SD = 0.6) and the lowest belonged to the engagement dimension (mean = 3.2, SD = 0.8).

CONCLUSION

The MARS ratings showed that the IBD mobile apps quality meet acceptable criteria. However, more attention must be paid to design features that improve user interest and engagement, especially among children and adolescents. Healthcare professional involvement is crucial for designing mobile health apps.

Remote monitoring for long-term physical health conditions: an evidence and gap map

Background

Remote monitoring involves the measurement of an aspect of a patient's health without that person being seen face to face. It could benefit the individual and aid the efficient provision of health services. However, remote monitoring can be used to monitor different aspects of health in different ways. This evidence map allows users to find evidence on different forms of remote monitoring for different conditions easily to support the commissioning and implementation of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent systematic reviews on the effectiveness, acceptability and implementation of remote monitoring for adults with long-term physical health conditions.

Data sources

We searched MEDLINE, nine further databases and Epistemonikos for systematic reviews published between 2018 and March 2022, PROSPERO for continuing reviews, and completed citation chasing on included studies.

Review methods

(Study selection and Study appraisal): Included systematic reviews focused on adult populations with a long-term physical health condition and reported on the effectiveness, acceptability or implementation of remote monitoring. All forms of remote monitoring where data were passed to a healthcare professional as part of the intervention were included. Data were extracted on the characteristics of the remote monitoring intervention and outcomes assessed in the review. AMSTAR 2 was used to assess quality. Results were presented in an interactive evidence and gap map and summarised narratively. Stakeholder and public and patient involvement groups provided feedback throughout the project.

Results

We included 72 systematic reviews. Of these, 61 focus on the effectiveness of remote monitoring and 24 on its acceptability and/or implementation, with some reviews reporting on both. The majority contained studies from North America and Europe (38 included studies from the United Kingdom). Patients with cardiovascular disease, diabetes and respiratory conditions were the most studied populations. Data were collected predominantly using common devices such as blood pressure monitors and transmitted via applications, websites, e-mail or patient portals, feedback provided via telephone call and by nurses. In terms of outcomes, most reviews focused on physical health, mental health and well-being, health service use, acceptability or implementation. Few reviews reported on less common conditions or on the views of carers or healthcare professionals. Most reviews were of low or critically low quality.

Limitations

Many terms are used to describe remote monitoring; we searched as widely as possible but may have missed some relevant reviews. Poor reporting of remote monitoring interventions may mean some included reviews contain interventions that do not meet our definition, while relevant reviews might have been excluded. This also made the interpretation of results difficult.

Conclusions and future work

The map provides an interactive, visual representation of evidence on the effectiveness of remote monitoring and its acceptability and successful implementation. This evidence could support the commissioning and delivery of remote monitoring interventions, while the limitations and gaps could inform further research and technological development. Future reviews should follow the guidelines for conducting and reporting systematic reviews and investigate the application of remote monitoring in less common conditions.

Review registration

A protocol was registered on the OSF registry (https://doi.org/10.17605/OSF.IO/6Q7P4).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR award ref: NIHR135450) as part of a series of evidence syntheses under award NIHR130538. For more information, visit https://fundingawards.nihr.ac.uk/award/NIHR135450 and https://fundingawards.nihr.ac.uk/award/NIHR130538. The report is published in full in Health and Social Care Delivery Research; Vol. 11, No. 22. See the NIHR Funding and Awards website for further project information.

Pilot Investigation of Blood Pressure Control Using a Mobile App (Cardi.Health): Retrospective Chart Review Study

BACKGROUND

The high prevalence of hypertension necessitates effective, scalable interventions for blood pressure (BP) control. Self-monitoring has shown improved adherence to medication and better BP management. Mobile apps offer a promising approach with their increasing popularity and potential for large-scale implementation. Studies have demonstrated associations between mobile app interventions and lowered BP, yet real-world data on app effectiveness and engagement remain limited.

OBJECTIVE

In this study, we analyzed real-world user data from the Cardi.Health mobile app, which is aimed at helping its users monitor and control their BP. Our goal was to find out whether there is an association between the use of the mobile app and a decrease in BP. Additionally, the study explored how engagement with the app may influence this outcome.

METHODS

This was a retrospective chart review study. The initial study population comprised 4407 Cardi.Health users who began using the app between January 2022 and April 2022. After applying inclusion criteria, the final study cohort comprised 339 users with elevated BP at the baseline. The sample consisted of 108 (31.9%) men and 231 (68.1%) women (P=.04). This retrospective chart review study obtained permission from the Biomedical Research Alliance of New York Institutional Review Board (June 2022, registration ID 22-08-503-939).

RESULTS

The study's main findings were that there is a possible relationship between use of the Cardi.Health mobile app and a decrease in systolic BP. Additionally, there was a significant association between active use of the app and systolic BP decrease (χ21=5.311; P=.02). Finally, active users had an almost 2 times greater chance of reducing systolic BP by 5 mm Hg or more over 4 weeks (odds ratio 1.932, 95% CI 1.074-3.528; P=.03).

CONCLUSIONS

This study shows a possible relationship between Cardi.Health mobile app use and decreased BP. Additionally, engagement with the app may be related to better results-active use was associated with an almost 2-fold increase in the odds of reducing BP by 5 or more mm Hg.

Heuristic smartphone usability evaluations of the mobile application NANDA, nursing interventions classification, and nursing outcomes classification customized for nursing home registered nurses

PURPOSE

We aimed to evaluate the usability of a smartphone application consisting of standardized nursing language (SNL) using NANDA, Nursing Intervention Classification, and Nursing Outcome Classification for nursing home nurses.

DATA SOURCES

Applying convenience sampling, a total of 14 experts and 15 real users were invited to test and evaluate the smartphone application independently. For the usability evaluation of the developed application, the Korean version of the Mobile Application Rating Scale for experts and Mobile Application Rating Scale: User Version developed by Stoyanov et al. were used.

DATA SYNTHESIS

Both groups determined that the SNL application was quite informative about SNL and efficient function; however, the engagement was quite lower than other categories.

CONCLUSIONS

Although SNLs were scientifically developed for several decades, the widely available technological application for registered nurses in different languages is urgently needed to improve quality of nursing care.

IMPLICATIONS FOR NURSING PRACTICE

The identified problems and recommendations by users and experts using heuristic evaluation will be reflected in the application's final version to be used for research.

Effective Behavior Change Techniques in Digital Health Interventions for the Prevention or Management of Noncommunicable Diseases: An Umbrella Review

BACKGROUND

Despite an abundance of digital health interventions (DHIs) targeting the prevention and management of noncommunicable diseases (NCDs), it is unclear what specific components make a DHI effective.

PURPOSE

This narrative umbrella review aimed to identify the most effective behavior change techniques (BCTs) in DHIs that address the prevention or management of NCDs.

METHODS

Five electronic databases were searched for articles published in English between January 2007 and December 2022. Studies were included if they were systematic reviews or meta-analyses of DHIs targeting the modification of one or more NCD-related risk factors in adults. BCTs were coded using the Behavior Change Technique Taxonomy v1. Study quality was assessed using AMSTAR 2.

RESULTS

Eighty-five articles, spanning 12 health domains and comprising over 865,000 individual participants, were included in the review. We found evidence that DHIs are effective in improving health outcomes for patients with cardiovascular disease, cancer, type 2 diabetes, and asthma, and health-related behaviors including physical activity, sedentary behavior, diet, weight management, medication adherence, and abstinence from substance use. There was strong evidence to suggest that credible source, social support, prompts and cues, graded tasks, goals and planning, feedback and monitoring, human coaching and personalization components increase the effectiveness of DHIs targeting the prevention and management of NCDs.

CONCLUSIONS

This review identifies the most common and effective BCTs used in DHIs, which warrant prioritization for integration into future interventions. These findings are critical for the future development and upscaling of DHIs and should inform best practice guidelines.

Consumers' Preferences for Purchasing mHealth Apps: Discrete Choice Experiment

Background

There is growing interest in mobile health apps; however, not all of them have been successful. The most common issue has been users' nonadoption or abandonment of health apps because the app designs do not meet their preferences. Therefore, to facilitate design-preference fit, understanding consumers' preferences for health apps is necessary, which can be accomplished by using a discrete choice experiment.

Objective

This study aims to examine consumer preferences for health apps and how these preferences differ across individuals with different sociodemographic characteristics and health app usage and purchase experiences.

Methods

A cross-sectional discrete choice experiment questionnaire survey was conducted with 593 adults living in Hong Kong. A total of 7 health app attributes that might affect consumers' preferences for health apps were examined, including usefulness, ease of use, security and privacy, health care professionals' attitudes, smartphone storage consumption, mobile data consumption, and cost. Mixed-effect logit regressions were used to examine how these attributes affected consumer preferences for health apps. Fixed effects (coefficient β) of the attributes and random effects of individual differences were modeled. Subgroup analyses of consumer preferences by sex, age, household income, education level, and health app usage and purchase experiences were conducted.

Results

Cost was the attribute that had the greatest effect on consumers' choice of health apps (compared to HK $10 [US $1.27]-HK $50 [US $6.37]: β=-1.064; P<.001; HK $100 [US $12.75]: β=-2.053; P<.001), followed by security and privacy (compared to no security insurance-some security policies: β=.782; P<.001; complete security system: β=1.164; P<.001) and usefulness (compared to slightly useful-moderately useful: β=.234; P<.001; very useful: β=.979; P=.007), mobile data consumption (compared to data-consuming-a bit data-consuming: β=.647; P<.001; data-saving: β=.815; P<.001), smartphone storage consumption (compared to >100 MB-around 38 MB: β=.334; P<.001; <10 MB: β=.511; P<.001), and attitudes of health care professionals (compared to neutral-moderately supportive: β=.301; P<.001; very supportive: β=.324; P<.001). In terms of ease of use, consumers preferred health apps that were moderately easy to use (compared to not easy to use-moderately easy to use: β=.761; P<.001; very easy to use: β=.690; P<.001). Our results also showed that consumers with different sociodemographic characteristics and different usage and purchase experiences with health apps differed in their preferences for health apps.

Conclusions

It is recommended that future health apps keep their mobile data and phone storage consumption low, include a complete security system to protect personal health information, provide useful content and features, adopt user-friendly interfaces, and involve health care professionals. In addition, health app developers should identify the characteristics of their intended users and design and develop health apps to fit the preferences of the intended users.

Evaluating a WeChat-Based Health Behavioral Digital Intervention for Patients With Hypertension: Protocol for a Randomized Controlled Trial

BACKGROUND

Hypertension is the most prevalent chronic condition and a significant risk factor for cardiovascular and kidney diseases. The efficacy of health behavioral interventions in blood pressure (BP) control has been demonstrated by a large and expanding body of literature, with "adherence" playing a crucial role. WeChat is the most common social communication mobile app in China, and it has been shown to be an acceptable delivery platform for delivering health interventions. The WeChat-based health behavioral digital intervention program (WHBDIP) showed high feasibility and efficacy. However, the results regarding BP improvement between the WHBDIP and control groups were inconsistent.

OBJECTIVE

The objective of this study is to develop a WHBDIP and assess its efficacy in controlling BP and improving adherence among patients with hypertension.

METHODS

A 2-arm, parallel-group, and randomized trial design was used. Patients older than 60 years and with hypertension were randomly assigned to either the control group or the experimental group, which received a 12-week intervention. The program, primarily developed based on the Behavior Change Wheel (BCW) theory, offers health education on exercise, diet, BP monitoring, and medicine adherence (MA). It also includes other behavior interventions guided by an intervention manual, incorporating behavior change techniques (BCTs). The primary outcomes encompass BP and adherence indicators, while the secondary outcomes encompass cardiovascular function indicators, body composition indicators, learning performance, satisfaction, and acceptability. The exercise and blood pressure monitoring adherence (BPMA) indicators for the WHBDIP group were assessed weekly via WeChat during the initial 3 months, while other outcome data for both groups will be collected at the baseline assessment phase, 3 months after the intervention, and 1 year after the program.

RESULTS

The trial will assess the efficacy of WHBDIP for patients with hypertension (N=68). The WHBDIP seeks to enhance participants' knowledge of healthy behaviors and assist patients in developing positive health behaviors to improve their health outcomes. Patient recruitment for individuals with hypertension commenced on September 5, 2022, and concluded on September 19, 2022. The 3-month intervention and phased data collection were finalized in January 2023. Data analysis will commence in August 2023, and the final 1-year health outcome results will be collected in September 2023.

CONCLUSIONS

A successful WHBDIP will establish the management mode as a feasible approach for hypertension management in the community. Additionally, it will pave the way for the development of related mobile health programs.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://tinyurl.com/mwyv67wk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46883.

Development and usability of a Mobile Interactive Application (VCPW) for Vascular Crisis Prewarning after Skin Flap Transplantation

Background

In microsurgical tissue transfer, skin flap transplantation is frequently used to heal the surface of a wound. Effective microcirculation surveillance of the skin flap is crucial. However, with traditional monitoring methods-that is, clinical observation-vascular crisis can still occur, thereby impairing postoperative recovery. A smartphone application is required to assist health care professionals in the standardized collection of flap perfusion parameters for flap management.

Methods

The Vascular Crisis Prewarning Application was created using a design science research methodology that prioritizes users and problems. The system usability scale was used to assess the application's usability among medical practitioners. The application was used at the clinic from December 2020 to September 2022. The unplanned return to the operating room, time to diagnose vascular crisis, and flap survival rate were compared with and without the application.

Results

The application consisted of 5 modules: patient addition and basic information entry, flap labeling, flap observation, crisis warning, and case archiving. The average rating for the application's usability among medical practitioners was 97.95 score (SD 2.36). With the application, the time to detect vascular crisis reduced from 26.71 to 16.26 h (P < 0.001), the unplanned return to the operation room increased from 8.18% to 10.24% (P = 0.587), and the flap survival rate went from 94.55% to 99.21% (P = 0.083).

Conclusions

An easy-to-use flap perfusion monitoring and prewarning application for medical practitioners was produced using a user-centered development method. The application provided a more standardized and accurate platform for data collection in flap management and reduced the time to detect vascular crisis. Larger cohort studies are required in the future to better assess the full potential of the application.

Association of Generation and Group Size With the Usage of a Mobile Health App in Thailand: Secondary Analysis of the ThaiSook Cohort Study

BACKGROUND

In Thailand, The National Science and Technology Development Agency developed ThaiSook, a behavior-tracking app, to promote healthy lifestyles. The Faculty of Medicine, Prince of Songkla University (MED PSU)×ThaiSook Healthier Challenge encouraged employees to use the app over a 28-day period (from July 11 to August 7, 2022). Until recently, no previous studies have examined the association of generations and group sizes with mobile health (mHealth) app use. Understanding these relationships can inform the design of effective mHealth interventions and facilitate targeted interventions.

OBJECTIVE

This study aimed to (1) compare the overall app usage and logging function across different generations and group sizes and (2) describe the demographic characteristics of the participants of the MED PSU×ThaiSook Healthier Challenge.

METHODS

We conducted a secondary data analysis of the data from the ThaiSook prospective cohort study. Data were collected through the app and comprised demographic characteristics (ie, age, sex, weight, height, and group size) and behaviors (ie, water consumption, fruit and vegetable consumption, sleep hours, and exercise). The outcomes consisted of users who used the app for at least 80% of the participation period (≥23 days). Bivariate tests (Pearson chi-square test for categorical variables and Mann-Whitney U and Kruskal-Wallis tests for continuous variables) were conducted over sex, generations, initial BMI, and group size. Finally, multiple logistic regression models were used to examine the relationship between the independent variables used by the ThaiSook app and consistent users who had used the app for at least 80% of the participation period.

RESULTS

Of the 827 participants, most were female (734/827, 88.8%), belonged to a medium-sized group of 6-10 members (479/827, 57.9%), and belonged to generation Y (377/761, 49.5%). Multivariate analysis revealed that the overall app usage was 2.09 times higher in women than in men (adjusted odds ratio [AOR] 2.09, 95% CI 1.27-3.44). The older generations used all logging functions more frequently than did generation Y (baby boomers AOR 2.54, 95% CI 1.31-4.92; generation X AOR 1.96, 95% CI 1.42-2.72). The use of all logging functions was higher among participants belonging to larger groups than among those belonging to smaller groups (large groups AOR 2.85, 95% CI 1.58-5.16; medium groups AOR 2.06, 95% CI 1.47-2.88). Water logging was most used (806/827, 97.5% participants), followed by food, sleep, and workout logging.

CONCLUSIONS

The MED PSU×ThaiSook Healthier Challenge participants were mostly females from generation Y and medium-sized groups. Water logging was most frequently used, followed by fruit and vegetable logging. The results indicate that generation and group size were significantly associated with consistent and daily usage (P<.05). Older generations and larger groups engaged with the app more consistently than younger generations and smaller groups and individuals.

Development and evaluation of DiabeText, a personalized mHealth intervention to support medication adherence and lifestyle change behaviour in patients with type 2 diabetes in Spain: A mixed-methods phase II pragmatic randomized controlled clinical trial

BACKGROUND

Despite the increasing interest in text-messaging interventions to support healthcare delivery, the available evidence about their effectiveness is still limited.

OBJECTIVES

1) to develop DiabeText, an intervention delivering automated, tailored brief text messages to support diabetes self-management; 2) to explore the potential impact of DiabeText on self-management behavior and glycaemic control, and; 3) to examine the feasibility of conducting a future phase III randomized clinical trial to evaluate the effectiveness of DiabeText.

METHODS

3-month, two-arm, randomized feasibility trial (ClinicalTrials.gov: NCT04738591) with patients with type 2 diabetes (HbA1c > 8%). Participants were allocated to the control (usual care) or DiabeText group (usual care + five text messages per week). Outcomes were: recruitment rate; follow-up rate, missing data; medication adherence; adherence to Mediterranean diet; physical activity; and HbA1c. In addition, after delivering the intervention, we conducted a qualitative study involving 14 semi-structured interviews with participants allocated to the DiabeText group, to understand their views about the intervention.

RESULTS

From 444 screened people, we recruited 207 participants (recruitment rate = 47%), of which 179 completed the post-intervention interview (follow-up rate = 86%). We sent 7,355 SMS during the intervention period, of which 99% successfully reached the participants. At post-intervention, DiabeText was associated with non-statistically significant (p > 0.05) improvements in adherence to medication (OR = 2.0; 95%CI 1.0 to 4.2), Mediterranean diet (1.7; 0.9 to 3.2), and physical activity (1.7; 0.9 to 3.1). No between-group differences were observed in mean HbA1c (p = 0.670). The qualitative study indicated that participants perceived DiabeText as a helpful resource because it increased their awareness about the importance of adequate self-management and the sense of being cared for.

CONCLUSIONS

DiabeText is the first system in Spain to integrate patient-generated and routinely collected clinical data to deliver tailored text messages to support diabetes self-management. More robust trials are needed to determine its effectiveness and cost-efficacy.

Overcoming the struggle of living with type 2 diabetes - diabetes specialist nurses' and patients' perspectives on digital interventions

BACKGROUND

Diabetes self-management education and support (DSMES) is a cornerstone in the treatment of type 2 diabetes mellitus (T2DM). It is unclear whether delivering DSMES as a digital health intervention (DHI) might meet the needs experienced by patients with T2DM and diabetes specialist nurses (DSN) of the primary health care system in Sweden.

METHODS

Fourteen patients with T2DM and four DSN participated in three separate focus groups: two groups comprised patients and one group comprised DSN. The patients discussed the questions: "What needs did you experience after your T2DM diagnosis?" and "How might these needs be met with a DHI?" The DSN discussed the questions: "What needs do you experience when treating a patient with newly diagnosed T2DM?" and "How might these needs be met with a DHI?". Furthermore, data were collected in the form of field notes from group discussions at a meeting including 18 DSNs working with T2DM in PHCCs. The discussions from focus groups were transcribed verbatim and analyzed together with the field notes from the meeting using inductive content analysis.

RESULTS

The analysis yielded the overall theme: "Overcoming the struggle of living with T2DM", which was summarized in two categories: "learning and being prepared" and "giving and receiving support". Important findings were that, for success, a DHI for DSMES must be integrated into routine care, provide structured, high-quality information, suggest tasks to stimulate behavioral changes, and provide feedback from the DSN to the patient.

CONCLUSION

This study highlighted several important aspects, from the perspectives of both the patient with T2DM and the DSN, which should be taken into consideration for the successful development and use of a DHI for DSMES.

Design and development of a smartphone app for hypertension management: An intervention mapping approach

Background

Several research studies have demonstrated the potential of mobile health apps in supporting health management. However, the design and development process of these apps are rarely presented.

Objective

We present the design and development of a smartphone-based lifestyle app integrating a wearable device for hypertension management.

Methods

We used an intervention mapping approach for the development of theory- and evidence-based intervention in hypertension management. This consisted of six fundamental steps: needs assessment, matrices, theoretical methods and practical strategies, program design, adoption and implementation plan, and evaluation plan. To design the contents of the intervention, we performed a literature review to determine the preferences of people with hypertension (Step 1) and necessary objectives toward the promotion of self-management behaviors (Step 2). Based on these findings, we implemented theoretical and practical strategies in consultation with stakeholders and researchers (Steps 3), which was used to identify the functionality and develop an mHealth app (Step 4). The adoption (Step 5) and evaluation (Step 6) of the mHealth app will be conducted in a future study.

Results

Through the needs analysis, we identified that people with hypertension preferred having education, medication or treatment adherence, lifestyle modification, alcohol and smoking cessation and blood pressure monitoring support. We utilized MoSCoW analysis to consider four key elements, i.e., education, medication or treatment adherence, lifestyle modification and blood pressure support based on past experiences, and its potential benefits in hypertension management. Theoretical models such as (i) the information, motivation, and behavior skills model, and (ii) the patient health engagement model was implemented in the intervention development to ensure positive engagement and health behavior. Our app provides health education to people with hypertension related to their condition, while utilizing wearable devices to promote lifestyle modification and blood pressure management. The app also contains a clinician portal with rules and medication lists titrated by the clinician to ensure treatment adherence, with regular push notifications to prompt behavioral change. In addition, the app data can be reviewed by patients and clinicians as needed.

Conclusions

This is the first study describing the design and development of an app that integrates a wearable blood pressure device and provides lifestyle support and hypertension management. Our theory-driven intervention for hypertension management is founded on the critical needs of people with hypertension to ensure treatment adherence and supports medication review and titration by clinicians. The intervention will be clinically evaluated in future studies to determine its effectiveness and usability.

The role of trust and habit in the adoption of mHealth by older adults in Hong Kong: a healthcare technology service acceptance (HTSA) model

BACKGROUND

Evidence from the literature suggests that mobile health (mHealth) services can potentially improve healthcare outcomes among older adults. Hence, the government of Hong Kong has recently taken several community and information technology (IT) services initiatives to train older adults on how to enhance their abilities and interest in using mHealth technology. Although mHealth services have been widely implemented globally, their adoption and use by older adults are very low, including those in Hong Kong. This study aims to understand key factors influencing mHealth use intention among the older Chinese population in Hong Kong.

METHODS

We extended the Unified Theory of Acceptance and Use of Technology (UTAUT2) as the basis of our conceptual framework. We applied Partial Least Squares path modeling method to conduct the Structural Equation Model (SEM) technique that allows measuring the theoretical validity of any conceptual framework. Convenience and snowball sampling methods were used to recruit participants aged 65 or above. In total, 201 valid responses were used for testing the theoretical validity of the proposed conceptual framework.

RESULTS

The primary finding shows that the widely used UTAUT2 model falls short in explaining mHealth service acceptance behavior in the Chinese older population in Hong Kong. We further propose a simplified model, the Healthcare Technology Service Acceptance (HTSA) model, to understand the formation of mHealth service acceptance behavior. The findings show that trust is an important component of technology service acceptance intention behavior that was missing in the UTAUT2 model. The results also show that several antecedent factors (i.e., social influence, government policy, and service quality) are critical in forming technology trust beliefs.

CONCLUSIONS

The study shows that the HTSA model can better explain mHealth acceptance behavior than the UTAUT2 model. This study advances knowledge in the mHealth technology adoption domain by proposing a simplified new version of the UTAUT2 model for understanding healthcare technology service acceptance and use intention among older adults. The findings of the study provide valuable information to the Hong Kong government and healthcare organizations for wider adoption of mHealth services, especially in older adults.

Comparing the effects of self- care education by lecture and smartphone application on self-efficacy of patients with thalassemia

BACKGROUND

Patients with the thalassemia have a basic requirement for self-efficacy regarding their treatment procedure. The present study aimed to compare the effect of self-care education via a smartphone application and lectures on the self-efficacy of patients with thalassemia.

METHODS

In the present quasi-experimental study, 99 patients with thalassemia at Shahid Beheshti Hospital in Yasuj, Iran, in 2019 who were eligible to enter the study, were selected. The block randomization was done with the block sizes of 3, 6, and 9, and participants were randomly assigned to 3 groups: smartphone application (A), lecture intervention (B), and control (c). Smartphone application and lecture interventions were performed for intervention groups A and B, respectively, during 8 weeks. Scherer's self-efficacy measure was used to collect the data at baseline and eight weeks after the intervention. Data were analyzed by SPSS-version 25 software using Paired t-test, Wilcoxon and Kruskal-Wallis tests.

RESULTS

Ninety-nine patients with thalassemia with a mean (SD) age of 25 (6) and 58 females (58.59%) participated in the present study. The results indicated a significant difference in self-efficacy among 3 groups after intervention (P = 0.001). However, self-care education with smartphone application revealed a significant increase in the mean (SD) of self-efficacy of the patients with thalassemia 68.36(8.45) compared to the lecture method 62.55 (7.3) (P = 0.003) and control 62.09 (6.7) (P = 0.001). There were no significant differences among the self-efficacy scores of the patients in lecture intervention and control groups.

CONCLUSIONS

The results revealed that smartphone application was a suitable educational software to promote self-efficacy in patients with thalassemia. It is recommended to use smartphone application methods to improve the self-efficacy levels of patients with thalassemia.

User Engagement and Weight Loss Facilitated by a Mobile App: Retrospective Review of Medical Records

BACKGROUND

Intermittent fasting (IF) has gained popularity in recent years for its effect on weight loss and supposed additional health benefits, such as a positive effect on body composition and metabolic markers. Mobile apps can act as platforms that help deliver dietary interventions by improving adherence and motivation. Although the effect of IF on weight loss has been demonstrated in earlier trials, there is not much research about the engagement and weight loss results with IF apps.

OBJECTIVE

Our main objective was to compare how a nudging platform (including smart scales) influences engagement (the extent to which users interact with the app measured by the number of active days) with the app among users who had obesity at the beginning of use. The secondary objectives were to evaluate the body weight changes among active and nonactive users and, finally, to evaluate the body composition changes of users possessing smart scales during app usage. Through this study, we hope to provide (1) more insight into how nudging (using smart scales as a nudging platform) is associated with engagement with the mobile app, (2) how engagement with the mobile app is associated with weight loss, and (3) how IF is associated with body composition.

METHODS

We performed a retrospective analysis of data from 665 users with obesity (BMI≥30) who started using the IF app DoFasting. Of them, 244 used body composition scales that estimated body fat and body muscle values. Users were stratified into engagement groups in accordance with their activity ratio (number of active days divided by the total time of use). Baseline and final users' weight (in kg), body fat (in %), and body muscle (in %) were compared.

RESULTS

Our findings suggest an association between the nudging platform (smart scales) and better engagement with the app. Smart scale users had a significantly higher activity ratio than regular users. Additionally, active DoFasting users lost significantly more weight. Further, body composition analysis showed that app usage might be related to body fat loss and an increase in muscle mass.

CONCLUSIONS

We found a possible association between the nudging and gamified elements and higher app engagement. Additionally, increased app engagement is associated with increased weight loss. Thus, nudging and gamified elements of mobile health apps, such as interactive tools, goals, challenges, and progress tracking, are suggested to affect engagement positively and should be investigated further in future research. Finally, the IF regime delivered through the DoFasting app might be related to the body muscle mass gain and reduced fat mass.

Heart Failure-Smart Life: a randomized controlled trial of a mobile app for self-management in patients with heart failure

BACKGROUND

It is an important strategy for healthcare providers to support heart failure patients with comprehensive aspects of self-management. A practical alternative to a comprehensive and user-friendly self-management program for heart failure patients is needed. This study aimed to develop a mobile self-management app program for patients with heart failure and to identify the impact of the program.

METHODS

We developed a mobile app, called Heart Failure-Smart Life. The app was to provide educational materials using a daily health check-up diary, Q & A, and 1:1 chat, considering individual users' convenience. An experimental study was employed using a randomized controlled trial to evaluate the effects of the program in patients with heart failure from July 2018 to June 2019. The experimental group (n = 36) participated in using the mobile app that provided feedback on their self-management and allowed monitoring of their daily health status by cardiac nurses for 3 months, and the control group (n = 38) continued to undergo their usual care. The differences in the physical, psychosocial, and behavioral factors between the two groups over time were analyzed using the analysis of covariance.

RESULTS

After 3 months of intervention, significant differences between experimental and control groups were shown in the New York Heart Association functional class (p = 0.003) and cardiac diastolic function (p = 0.024). The improvements over time in the experimental group tended to be higher than those in the control group in considered variables. However, no changes in psychosocial and behavioral variables were observed between the groups over time.

CONCLUSIONS

This study provides evidence that the mobile app program may provide benefits to its users, specifically improvements of symptom and cardiac diastolic function in patients with heart failure. Healthcare providers can effectively and practically guide and support patients with heart failure using comprehensive and convenient self-management tools such as smartphone apps.

Assessing the technical feasibility of a flexible, integrated Internet-of-things connected for asthma (C4A) system to support self-management: a mixed method study exploring patients and healthcare professionals perspectives

Background

A connected system with smart devices could transform patient care and empower patients control of their asthma.

Objective

To explore how a connected-for-asthma system (C4A) with smart devices from multiple companies (smart-inhaler; smart-watch; smart-peak-flow meter, manual digital thermometer during the Coronavirus disease (COVID)-pandemic) could support asthma self-management.

Methods

In a proof-of-concept mixed-methods study (Winter 2021/2022), we collected data from devices linked via the C4A app enabling patients to self-monitor and share a monitoring summary (in PDF format) with their clinician. Ten patients (range of age/gender, asthma experience, Apple/Android user) via social media, used C4A for a month. We conducted pre/post-interviews with patients, and a single post-interview with an asthma nurse and 3 general practitioners. Thematic analysis, informed by the Unified Theory of Acceptance and Use of Technology was triangulated with descriptive analysis of usage data.

Results

The system was perceived as "easy" to use. During the study, 7517 data points were collected from 10 patients; monitoring reduced over the month. Patients used devices if they trusted their "accuracy," and adopted the system to monitor new medication or assess troublesome symptoms. One patient lost contact (because of COVID), 8 wanted to keep using C4A to manage their asthma, though were selective about the most useful devices. Clinicians wanted the report to provide an asthma score/status and reliever usage.

Conclusion

A connected system could enable flexible digital care by linking data from several devices to support self-management. To promote adoption/adherence, setup has to be simple, and patients need to trust that the devices accurately reflect their condition.

Psychosocial Determinants of Recommended Lifestyle Behaviors among Hypertensive Patients: An Integrative Literature Review

Healthy lifestyle levels are low among adults with hypertension (HTN). Unfortunately, psychosocial factors contributing to patients' inability to meet healthy lifestyle recommendations are not well-understood. This integrative review examined the relationships of three psychosocial factors (self-efficacy, outcome expectancy, and social support) with dietary adherence (DA) and physical activity (PA) among adults with HTN. In total, 24 peer-reviewed studies were assessed. Results showed self-efficacy had small-to-large relationships with PA (r = 0.02-0.46) and DA (r = 0.06-0.79), with the strength of the associations varying by the assessed domain and country of origin. However, few studies reported a small relationship between the remaining factors (outcome expectancy and social support) and PA and DA. Thus, more efforts are needed to delineate the contributions of social support and outcome expectancies on DA or PA. When designing an intervention that focuses on improving PA or DA among adults with HTN, these psychosocial factors should be targeted.

Fasting and weight loss: mobile application-based approach

BACKGROUND

The purpose of this study was to investigate the efficacy of intermittent fasting (IF) guidance, delivered through a smartphone application, in terms of engagement and weight loss.

METHODS

We performed a retrospective chart-review study of all consecutive users with overweight or obesity of the DoFasting mobile application, which integrates IF solutions for people looking to lose weight. Users with overweight and obesity at the beginning of application use, who met the inclusion criteria (entered their gender, height, and starting weight; had more than one weight entry; used the app for at least a month; had at least one active day per week with valid app-related activities) and used the application for weight loss were included in the study.

RESULTS

The final study cohort comprised 22,022 consecutive users. The short-term cohort comprised 17,221 users (8585 females and 8636 males), while 4801 users (2983 females and 1818 males) were in the long-term cohort. Long-term active users of the application lost a statistically significant amount of weight over the study period and lost more than inactive users did (2.2 [3.5] vs 1.4 [3.2], p < 0.0001; the results are shown in kilograms as medians with the interquartile range in brackets). Active and long-term users were also more likely to reduce their BMI class (p < 0.05) in comparison to non-active short-term users. A multiple regression model showed that the total length of use and active days were the most significant predictors of weight loss. In-app activities such as total fasting hours, weight logging, completing challenges, and providing feedback were also statistically significant predictors of weight loss with varying contributions.

CONCLUSION

We found that the DoFasting mobile application that implements IF is an effective tool for weight loss if used actively and sufficiently.

TRIAL REGISTRATION

This retrospective chart review study was approved by BRANY IRB in January 2022 (study ID.: 22-08-034-939).

Effect of a Multicomponent Intervention Delivered on a Web-Based Platform on Hypertension Control: A Cluster Randomized Clinical Trial

IMPORTANCE

The prevalence of hypertension is high and still increasing across the world, while the control rate remains low in many countries. Emerging technology, such as telemedicine, may offer additional support to change the unsatisfactory situation.

OBJECTIVE

To establish a multicomponent intervention delivered on a web-based telemedicine platform and oriented with the Chinese hypertension management guidelines and to evaluate the effect of the intervention on blood pressure (BP) control for patients with hypertension.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial of a hypertension management program was conducted at 66 community health centers in China from October 1, 2018, to May 31, 2020, with a 12-month follow-up. Patients with hypertension were blinded to randomization and were randomized to either the intervention group or control group. Hypertension was diagnosed at mean systolic BP (SBP) and diastolic BP (DBP) readings higher than 140 and 90 mm Hg or with use of antihypertensive medication. Evaluation of the intervention effect was based on the principle of modified intention to treat.

INTERVENTIONS

Multicomponent intervention was delivered on a web-based platform and consisted of a primary prevention program for cardiovascular disease and standardized management for hypertension.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in BP control rate (SBP and DBP levels <140 and 90 mm Hg, or <130 and 80 mm Hg for patients with diabetes) from baseline to the 12-month follow-up among patients with hypertension in the intervention and control groups.

RESULTS

A total of 4118 patients (mean [SD] age, 61.6 [9.4] years; 2265 women [55.0%]) were included in the analysis, with 2985 in the intervention group and 1133 in the control group. The BP control rate at baseline was 22.8% in the intervention group and 22.5% in the control group. After 12 months of the intervention, the BP control rate for the intervention group compared with the control group was significantly higher (47.4% vs 30.2%; odds ratio, 1.18; 95% CI, 1.13-1.24; P < .001). The intervention effect on SBP level was -10.1 mm Hg (95% CI, -11.7 to -8.5 mm Hg; P < .001) and on DBP level was -1.8 mm Hg (95% CI, -2.8 to -0.8 mm Hg; P < .001).

CONCLUSIONS AND RELEVANCE

Results of this trial showed that a multicomponent intervention delivered on a web-based platform improved BP control rate and lowered BP level more than usual care alone. Such a telemedicine program may provide a new, effective way to treat patients with hypertension in the community and may generate public health benefits across diverse populations.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017791.

Personal Goals, Barriers to Self-Management and Desired mHealth Application Features to Improve Self-Care in Multi-Ethnic Asian Patients with Type 2 Diabetes: A Qualitative Study

(1) Introduction: The ubiquity of mobile phones suggests the potential of mobile health applications to reach patients with type 2 diabetes and engage them to improve self-care. This study aimed to explore personal goals, barriers to self-management and desired mobile health application features to improve self-care among multi-ethnic Asian patients with type 2 diabetes. (2) Methods: We conducted semi-structured interviews with patients with type 2 diabetes (n = 29). Patients were recruited from a multi-disciplinary center for diabetes and metabolism in Singapore, using a purposive sampling strategy. Various visual materials, collated from existing mobile health application features, were used to facilitate the discussion. Interviews were transcribed verbatim and thematically analyzed. (3) Results: A total of 29 patients participated in 11 focus group discussions or one-on-one interviews. Personal goals for self-management were centered around short-term outcome expectancy, such as better glucose control and a reduced number of medications. Self-management was hampered by competing priorities and limited healthy food options when at work, while a lack of tailored advice from healthcare providers further diminished competence. The desired mobile health app features to improve self-care behaviors included quantifiable goal-setting, personalized nudges based on tracked data, built-in resources from credible sources, in-app social support through virtual interaction with peers and healthcare providers, technology-driven novel data logging and user-defined nudges. (4) Conclusions: We identified a set of app features that may foster motivation to engage in lifestyle modification for patients with T2DM. The findings serve to inform the design of artificial intelligence-enabled mobile health application intervention aimed at improving diabetes self-care.

Digital health applications and the fast-track pathway to public health coverage in Germany: challenges and opportunities based on first results

OBJECTIVES

Evidence-based decision-making is the sine qua non for safe and effective patient care and the long-term functioning of health systems. Since 2020 Digital Health Applications (DiHA) in Germany have been undergoing a systematic pathway to be reimbursed by statutory health insurance (SHI) which is attracting attention in other European countries. We therefore investigate coverage decisions on DiHA and the underlying evidence on health care effects, which legally include both medical outcomes and patient-centred structural and procedural outcomes.

METHODS

Based on publicly available data of the Institute for Medicines and Medical Devices searched between 08/2021 and 02/2022, all DiHA listed in the corresponding registry and thus reimbursable by the SHI were systematically investigated and presented descriptively on the basis of predefined criteria, such as clinical condition, and costs. The clinical trials on DiHA permanently included in the registry were reviewed with regard to their study design, endpoints investigated, the survey instruments used, and whether an intention-to-treat analysis was performed. Risk of bias was assessed using the ROB II tool.

RESULTS

By February 2022, 30 DiHA had been included in the DiHA registry, one third of them permanently and two thirds conditionally. Most DiHA were therapeutic applications for mental illness based on cognitive behavioural therapy. For all permanently included DiHA, randomised controlled trials were conducted to demonstrate the impact on health care effects. While medical outcomes were investigated for all of these DiHA, patient-centred structural and procedural outcomes were rarely investigated. The majority of clinical trials showed a high risk of bias, mainly due to insufficient reporting quality. Overall, the prices for DiHA covered by SHI are on average around € 150 per month (min. € 40; max. € 248).

CONCLUSIONS

Evidence-based decision-making on coverage of DiHA leaves room for improvements both in terms of reporting-quality and the use of patient-centred structural and procedural outcomes in addition to medical outcomes. With appropriate evidence, DiHA can offer an opportunity as an adjunct to existing therapy while currently the high risk of bias of the trials raises doubts about the justification of its high costs.

Development of a behavior change intervention to improve physical activity adherence in individuals with metabolic syndrome using the behavior change wheel

Background

Adherence to physical activity is inadequate in adults with metabolic syndrome. Adherence to physical activity recommendations is crucial and can result in improved health outcomes and reduced medical burdens. A comprehensive behavior change intervention, including identifying determinants of adherence to physical activity recommendations, intervention options, intervention content and implementation options, was imperative for enhancing physical activity adherence. The aim of the study is to develop an intervention to increase physical activity adherence among individuals with metabolic syndrome.

Methods

The study followed the eight steps of the Behavior Change Wheel guide, including defining the problem in behavioral terms (Step 1), selecting target behavior (Step 2), specifying target behavior (Step 3), identifying what needs to change (Step 4), identifying intervention functions (Step 5), identifying policy categories (Step 6), identifying behavior change techniques (Step 7), and determining model of delivery (Step 8). The semi-structured, in-depth interviews were employed to identify the determinants of adherence to physical activity among twenty-eight individuals with metabolic syndrome based on capability, opportunity, motivation and behavior model. Next, the intervention functions and policy categories were chosen to address these determinants. Finally, behavior change techniques were selected to assist in the delivery of the intervention functions and be translated into intervention content.

Results

Our study identified eighteen facilitators and fifteen barriers to physical activity adherence. It resulted in the selection of seven intervention functions and nineteen behavior change techniques for the intervention program. Then, the current study identified an app as the delivery mode. Finally, a behavioral change intervention was generated for individuals with metabolic syndrome to increase physical activity recommendation adherence.

Conclusions

The Behavior Change Wheel provided a systematic approach to designing a behavior change intervention, which helped improve the health outcomes and reduce medical burdens and economic burdens among individuals with metabolic syndrome. The findings suggested that potential intervention should pay special attention to increasing knowledge in metabolic syndrome, imparting skills of physical activity, offering a supportive environment, and providing suggestions on regular physical activity using the appropriate behavior change techniques. A feasibility study will be undertaken to assess the acceptability and effectiveness of the intervention program in the future.

Consumers’ Willingness to Pay for eHealth and Its Influencing Factors: Systematic Review and Meta-analysis

Background

Despite the great potential of eHealth, substantial costs are involved in its implementation, and it is essential to know whether these costs can be justified by its benefits. Such needs have led to an increased interest in measuring the benefits of eHealth, especially using the willingness to pay (WTP) metric as an accurate proxy for consumers’ perceived benefits of eHealth. This offered us an opportunity to systematically review and synthesize evidence from the literature to better understand WTP for eHealth and its influencing factors.

Objective

This study aimed to provide a systematic review of WTP for eHealth and its influencing factors.

Methods

This study was performed and reported as per the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, CINAHL Plus, Cochrane Library, EconLit, and PsycINFO databases were searched from their inception to April 19, 2022. We conducted random-effects meta-analyses to calculate WTP values for eHealth (at 2021 US dollar rates) and meta-regression analyses to examine the factors affecting WTP.

Results

A total of 30 articles representing 35 studies were included in the review. We found that WTP for eHealth varied across studies; when expressed as a 1-time payment, it ranged from US $0.88 to US $191.84, and when expressed as a monthly payment, it ranged from US $5.25 to US $45.64. Meta-regression analyses showed that WTP for eHealth was negatively associated with the percentages of women (β=−.76; P<.001) and positively associated with the percentages of college-educated respondents (β=.63; P<.001) and a country’s gross domestic product per capita (multiples of US $1000; β=.03; P<.001). Compared with eHealth provided through websites, people reported a lower WTP for eHealth provided through asynchronous communication (β=−1.43; P<.001) and a higher WTP for eHealth provided through medical devices (β=.66; P<.001), health apps (β=.25; P=.01), and synchronous communication (β=.58; P<.001). As for the methods used to measure WTP, single-bounded dichotomous choice (β=2.13; P<.001), double-bounded dichotomous choice (β=2.20; P<.001), and payment scale (β=1.11; P<.001) were shown to obtain higher WTP values than the open-ended format. Compared with ex ante evaluations, ex post evaluations were shown to obtain lower WTP values (β=−.37; P<.001).

Conclusions

WTP for eHealth varied significantly depending on the study population, modality used to provide eHealth, and methods used to measure it. WTP for eHealth was lower among certain population segments, suggesting that these segments may be at a disadvantage in terms of accessing and benefiting from eHealth. We also identified the modalities of eHealth that were highly valued by consumers and offered suggestions for the design of eHealth interventions. In addition, we found that different methods of measuring WTP led to significantly different WTP estimates, highlighting the need to undertake further methodological explorations of approaches to elicit WTP values.

A “No-Code” App Design Platform for Mobile Health Research: Development and Usability Study

Background

A challenge facing researchers conducting mobile health (mHealth) research is the amount of resources required to develop mobile apps. This can be a barrier to generating relevant knowledge in a timely manner. The recent rise of “no-code” software development platforms may overcome this challenge and enable researchers to decrease the cost and time required to develop mHealth research apps.

Objective

We aimed to describe the development process and the lessons learned to build Pathverse, a no-code mHealth app design platform.

Methods

The study took place between November 2019 and December 2021. We used a participatory research framework to develop the mHealth app design platform. In phase 1, we worked with researchers to gather key platform feature requirements and conducted an exploratory literature search to determine needs related to this platform. In phase 2, we used an agile software framework (Scrum) to develop the platform. Each development sprint cycle was 4 weeks in length. We created a minimum viable product at the end of 7 sprint cycles. In phase 3, we used a convenience sample of adults (n=5) to gather user feedback through usability and acceptability testing. In phase 4, we further developed the platform based on user feedback, following the V-model software development process.

Results

Our team consulted end users (ie, researchers) and utilized behavior change technique taxonomy and behavior change models (ie, the multi-process action control framework) to guide the development of features. The first version of the Pathverse platform included features that allowed researchers to (1) design customized multimedia app content (eg, interactive lessons), (2) set content delivery logic (eg, only show new lessons when completing the previous lesson), (3) implement customized participant surveys, (4) provide self-monitoring tools, (5) set personalized goals, and (6) customize app notifications. Usability and acceptability testing revealed that researchers found the platform easy to navigate and that the features were intuitive to use. Potential improvements include the ability to deliver adaptive interventions and add features such as community group chat.

Conclusions

To our knowledge, Pathverse is the first no-code mHealth app design platform for developing mHealth interventions for behavior. We successfully used behavior change models and the behavior change technique taxonomy to inform the feature requirements of Pathverse. Overall, the use of a participatory framework, combined with the agile and hybrid-agile software development process, enabled our team to successfully develop the Pathverse platform.

Experience of using a smartphone WeChat applet for dental anxiety assessment and preoperative evaluation: A nationwide multicenter study

Introduction

Dental anxiety is a multivariate phenomenon that regularly occurs during a dental procedure. Although it may lead to patients' safety concerns and adverse events in routine treatment, it is often ignored. The purpose of this research is to develop a novel WeChat Applet for dental anxiety (WADA) with the following features and aims: (1) to help patients with dental anxiety management; (2) provide patient with a physical status self-evaluation; and(3) provide a platform for online assessment and tele-consultancy by dentists. We aimed to test and verify whether such an applet could play a beneficial role before and after a dental procedure and facilitate management of high-risk patients during the COVID-19 pandemic.

Materials and methods

During the 12-month survey period (August 2020 to July 2021), a total of 180 patients aged 3–74 years from eight different cities (n = 180 at the end of treatment, n = 25 for the System Usability Scale (SUS) and follow-up interview) and 20 medical staff from eight different cities (n =20 for follow-up interview) were evaluated by WADA. At the end of the survey period, the results of the interviews were analyzed thematically.

Results

WADA assessment results from 180 patients and follow-up interview results from 45 participants were analyzed. In this study with a male to female ratio of 2:3, 75% were found to be suffering from dental anxiety, 86% were found with postoperative complications, and 11 cases were found to have contraindications to surgery. The total SUS score for WADA is 72.25 above the mean score, proving that WADA is a relevant and useful tool before and after dental treatment. Based on the results of the interviews, the following themes were identified: patient satisfaction; dentists' effectiveness; multi-center data integration; and increase its frequency of usage.

Conclusions

The WADA was developed for dental procedures and is effective for reducing treatment risks, improving patients' satisfaction and dentists' convenience, especially in terms of facilitating management of high-risk patient during the COVID-19 pandemic.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review

BACKGROUND

A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature.

METHODS

We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias.

RESULTS

The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C.

CONCLUSIONS

Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

Review and Analysis of German Mobile Apps for Inflammatory Bowel Disease Management Using the Mobile Application Rating Scale: Systematic Search in App Stores and Content Analysis

Background

Patients suffering from inflammatory bowel disease (IBD) frequently need long-term medical treatment. Mobile apps promise to complement and improve IBD management, but so far there has been no scientific analysis of their quality.

Objective

This study evaluated the quality of German mobile apps targeting IBD patients and physicians treating IBD patients using the Mobile Application Rating Scale (MARS).

Methods

The German Apple App Store and Google Play Store were systematically searched to identify German IBD mobile apps for patient and physician use. MARS was used by 6 physicians (3 using Android smartphones and 3 using iPhones) to independently assess app quality. Apps were randomly assigned so that the 4 apps with the most downloads were rated by all raters and the remaining apps were rated by 1 Android and 1 iOS user.

Results

In total, we identified 1764 apps in the Apple App Store and Google Play Store. After removing apps that were not related to IBD (n=1386) or not available in German (n=317), 61 apps remained. After removing duplicates (n=3) and apps for congresses (n=7), journals (n=4), and clinical studies (n=6), as well as excluding apps that were available in only 1 of the 2 app stores (n=20) and apps that could only be used with an additional device (n=7), we included a total of 14 apps. The app “CED Dokumentation und Tipps” had the highest overall median MARS score at 4.11/5. On the whole, the median MARS scores of the 14 apps ranged between 2.38/5 and 4.11/5. As there was no significant difference between iPhone and Android raters, we used the Wilcoxon comparison test to calculate P values.

Conclusions

The MARS ratings showed that the quality of German IBD apps varied. We also discovered a discrepancy between app store ratings and MARS ratings, highlighting the difficulty of assessing perceived app quality. Despite promising results from international studies, there is little evidence for the clinical benefits of German IBD apps. Clinical studies and patient inclusion in the app development process are needed to effectively implement mobile apps in routine care.

KetoCycle mobile app for ketogenic diet: a retrospective study of weight loss and engagement

BACKGROUND

The ketogenic diet is one of the oldest diets that has been used for more than a centennial in the clinical setting, and it is gaining popularity as a measure to fight obesity, which is a major predisposing factor for many diseases to manifest, including diabetes mellitus, chronic heart disease, cancer, and others. Thus, we designed this retrospective investigation to determine if users of the mobile application KetoCycle achieved statistically significant weight loss outcomes.

METHODS

The initial study cohort comprised 12,965 consecutive users who started using KetoCycle between January 2020 and December 2020. The final cohort comprised 10,269 users. The main parameters obtained from the database containing all self-reported data were gender, number of active days (AD), total time of use (TT), height, initial weight, and last recorded weight. The primary outcome of the study was weight loss. Statistical analyses were performed using IBM SPSS Statistics, version 26 (IBM Corp., Armonk, NY, USA). In addition, a standard multiple regression model was created to predict weight loss from significant actions.

RESULTS

A retrospective analysis of KetoCycle user data showed that 87.3% of KetoCycle users lost some of their initial weight. Of those, 1645 users (18.3%) lost more than 10% of their initial body weight, 3528 (39.3%) users lost between 5 and 10% of their initial body weight, and 3796 (42.3%) users lost less than 5% of their body weight. When user activity was taken into account, it was found that active users lost statistically significantly more weight than non-active users (p < 0.05). App engagement was also associated with losing > 5% of initial weight. Using water tracking, weight tracking, and creation of a meals list within KetoCycle statistically significantly predicted weight loss in a multiple regression model.

CONCLUSIONS

We concluded that KetoCycle appeared as a promising mobile application suited for weight loss and weight control.

TRIAL REGISTRATION

This retrospective chart review study was approved by BRANY IRB in January 2022 (registration ID.: 21-08-564-939).