Taking mHealth Forward: Examining the Core Characteristics

Usability Assessment Methods for Mobile Apps for Physical Rehabilitation: Umbrella Review

BACKGROUND

Usability has been touted as one determiner of success of mobile health (mHealth) interventions. Multiple systematic reviews of usability assessment approaches for different mHealth solutions for physical rehabilitation are available. However, there is a lack of synthesis in this portion of the literature, which results in clinicians and developers devoting a significant amount of time and effort in analyzing and summarizing a large body of systematic reviews.

OBJECTIVE

This study aims to summarize systematic reviews examining usability assessment instruments, or measurements tools, in mHealth interventions including physical rehabilitation.

METHODS

An umbrella review was conducted according to a published registered protocol. A topic-based search of PubMed, Cochrane, IEEE Xplore, Epistemonikos, Web of Science, and CINAHL Complete was conducted from January 2015 to April 2023 for systematic reviews investigating usability assessment instruments in mHealth interventions including physical exercise rehabilitation. Eligibility screening included date, language, participant, and article type. Data extraction and assessment of the methodological quality (AMSTAR 2 [A Measurement Tool to Assess Systematic Reviews 2]) was completed and tabulated for synthesis.

RESULTS

A total of 12 systematic reviews were included, of which 3 (25%) did not refer to any theoretical usability framework and the remaining (n=9, 75%) most commonly referenced the ISO framework. The sample referenced a total of 32 usability assessment instruments and 66 custom-made, as well as hybrid, instruments. Information on psychometric properties was included for 9 (28%) instruments with satisfactory internal consistency and structural validity. A lack of reliability, responsiveness, and cross-cultural validity data was found. The methodological quality of the systematic reviews was limited, with 8 (67%) studies displaying 2 or more critical weaknesses.

CONCLUSIONS

There is significant diversity in the usability assessment of mHealth for rehabilitation, and a link to theoretical models is often lacking. There is widespread use of custom-made instruments, and preexisting instruments often do not display sufficient psychometric strength. As a result, existing mHealth usability evaluations are difficult to compare. It is proposed that multimethod usability assessment is used and that, in the selection of usability assessment instruments, there is a focus on explicit reference to their theoretical underpinning and acceptable psychometric properties. This could be facilitated by a closer collaboration between researchers, developers, and clinicians throughout the phases of mHealth tool development.

TRIAL REGISTRATION

PROSPERO CRD42022338785; https://www.crd.york.ac.uk/prospero/#recordDetails.

Policy Guidance for Direct-to-Consumer Genetic Testing Services: Framework Development Study

BACKGROUND

The online offer of commercial genetic tests, also called direct-to-consumer genetic tests (DTC-GTs), enables citizens to gain insight into their health and disease risk based on their genetic profiles. DTC-GT offers often consist of a combination of services or aspects, including advertisements, information, DNA analysis, and medical or lifestyle advice. The risks and benefits of DTC-GT services have been debated and studied extensively, but instruments that assess DTC-GT services and aid policy are lacking. This leads to uncertainty among policy makers, law enforcers, and regulators on how to ensure and balance both public safety and autonomy and about the responsibilities these 3 parties have toward the public.

OBJECTIVE

This study aimed to develop a framework that outlines aspects of DTC-GTs that lead to policy issues and to help provide policy guidance regarding DTC-GT services.

METHODS

We performed 3 steps: (1) an integrative literature review to identify risks and benefits of DTC-GT services for consumers and society in Embase and Medline (January 2014-June 2022), (2) structuring benefits and risks in different steps of the consumer journey, and (3) development of a checklist for policy guidance.

RESULTS

Potential risks and benefits of DTC-GT services were mapped from 134 papers and structured into 6 phases. In summary, these phases were called the consumer journey: (1) exposure, (2) pretest information, (3) DNA analysis, (4) data management, (5) posttest information, and (6) individual and societal impact. The checklist for evaluation of DTC-GT services consisted of 8 themes, covering 38 items that may raise policy issues in DTC-GT services. The themes included the following aspects: general service content, validity and quality assurance, potential data and privacy risks, scientific evidence and robustness, and quality of the provided information.

CONCLUSIONS

Both the consumer journey and the checklist break the DTC-GT offer down into key aspects that may impact and compromise individual and public health, safety, and autonomy. This framework helps policy makers, regulators, and law enforcers develop methods to interpret, assess, and act in the DTC-GT service market.

The efficacy of online physical activity interventions with added mobile elements within adults aged 50 years and over: Randomized controlled trial

Electronic health (eHealth) and mobile health (mHealth) could stimulate physical activity (PA) in a time-efficient and cost-effective way. This randomized controlled trial aims to investigate effects on moderate-to-vigorous PA (MVPA) of different combined computer- and mobile-based PA interventions targeted at adults aged 50 years and over. Participants (N = 954) were randomly allocated to a basic existing computer-based intervention (Active Plus [AP] or I Move [IM]) supplemented with one of three mobile elements being (1) activity tracker (AT), (2) ecological momentary intervention (EMI), or (3) chatbot (CB) or a control group (CG). MVPA was assessed via the SQUASH at baseline (T0), 3 months (T1), and 6 months (T2) and via accelerometers at T0 and T2. No intervention effects were found on objective (p = .502) and subjective (p = .368) MVPA for main research groups (AP/IM + AT, AP/IM + EMI, AP/IM + CB). Preliminary MVPA findings for subgroups (AP + AT, AP + EMI, AP + CB, IM + AT, IM + EMI, IM + CB) combined with drop-out data showed potential for the computer-based intervention AP with an integrated AT. Based on these preliminary findings, eHealth developers can be recommended to integrate ATs with existing computer-based PA interventions. However, further research is recommended to confirm the findings as a result of the exploratory nature of the subgroup analyses.

Effectiveness of a diabetes program based on digital health on capacity building and quality of care in type 2 diabetes: a pragmatic quasi-experimental study

Health systems in Latin America face many challenges in controlling the increasing burden of diabetes. Digital health interventions are a promise for the provision of care, especially in developing countries where mobile technology has a high penetration. This study evaluated the effectiveness of the implementation of a Diabetes Program (DP) that included digital health interventions to improve the quality of care of persons with type 2 Diabetes (T2DM) in a vulnerable population attending the public primary care network.

MATERIALS AND METHODS

A quasi-experimental pre-post uncontrolled study was conducted in 19 primary care centers and hospitals in the province of Corrientes, Argentina. We included persons with T2DM, age >  = 18 years with access to a mobile phone. The multicomponent intervention included a mobile app with a diabetes registry, a clinical decision support tool for providers and a text messaging intervention for patients.

RESULTS AND DISCUSSION

One thousand sixty-five participants were included, 72.8% had less than 12 years of formal education and 53.5% lacked health coverage. Comorbidities were hypertension (60.8%) and overweight/obesity (88.2%). During follow-up there was a significant increase in the proportion of participants who underwent laboratory check-ups (HbA1c 20.3%-64.4%; p < 0.01) and foot exams (62.1%-87.2%; p < 0.01). No changes were observed at 12 and 24 months in the proportion of participants with poor metabolic control. The proportion of participants with uncontrolled blood pressure (≥ 140/90 mmHg) decreased from 47.2% at baseline to 30.8% at 24 months in those with a follow-up visit.

CONCLUSION

The DP was innovative by integrating digital health interventions in the public primary care level. The study showed improvements in quality indicators related with diabetes care processes and in blood pressure control.

The positive impact of gamification in imparting nutritional knowledge and combating childhood obesity: A systematic review on the recent solutions

Objective

This paper reviews the recent gamified interventions that focus on the dietary factor to explore the effectiveness of using gaming elements in combating the prevalence of childhood obesity.

Methods

Two electronic databases were searched (PubMed and ProQuest); to identify the relevant papers published between 2018 and 2021. The keywords that use to search the entire selected databases were gamification and obesity. There were no restrictions regarding the language. Two independent reviewers screened the titles, abstracts, and keywords for relevance.

Results

407 papers were identified initially, while only 18 articles met the inclusion criteria. Most of the included articles indicated the positive impact of gamification on changing children eating behaviors. This systematic review summarizes the theories followed in developing such interventions and suggests some other theories to use and follow. Moreover, we synthesized the main findings into six recommendations that would assist in combating the global concern regarding childhood obesity if IS/IT researchers and other implement them during the development of any IT intervention.

Conclusions

Using gamification and gaming elements in imparting nutritional knowledge to children and improving their eating habits and behaviors is considered effective generally. It provides them with the needed knowledge and promotes the acquisition of better habits within enjoyable environment.

Exploring the Black Box of an mHealth Intervention (LIFE4YOUth): A Qualitative Process and Outcome Evaluation of End-User Engagement

The effectiveness of mHealth interventions rely on whether the content successfully activate mechanisms necessary for behavior change. These mechanisms may be affected by end-users' experience of the intervention content. The aim of this study was to explore how the content of a novel mHealth intervention (LIFE4YOUth) was understood, interpreted, and applied by high school students, and the consequences of engaging with the content. Qualitative content analysis was used inductively and deductively to analyze interview data (n = 16) based on think-aloud techniques with Swedish high school students aged 16-19 years. Theoretical constructs from social cognitive theory framed the deductive analysis. The analysis resulted in four categories which describe central activities of intervention engagement among end-users: defining, considering, centralizing, and personalizing. End-users engaged in these activities to different degrees as illustrated by four typologies: Literal, Vague, Rigid, and Creative engagement. Most informants knew about the risks and benefits of health behaviors, but engagement with intervention content generally increased informants' awareness. In conclusion, this study provides in-depth knowledge on the cognitive process when engaging with mHealth content and suggests that deliberate and flexible engagement most likely deepens end-users' understanding of why and how health behavior change can be managed.

Evaluating the impact of a sleep health education and a personalised smartphone application on sleep, productivity and healthcare utilisation among employees: results of a randomised clinical trial

OBJECTIVES

We evaluated an online Sleep Health and Wellness (SHAW) programme paired with dayzz, a personalised sleep training programme deployed via smartphone application (dayzz app) that promotes healthy sleep and treatment for sleep disorders, among employees at a large healthcare organisation.

DESIGN

Open-label, randomised, parallel-group controlled trial.

SETTING

A healthcare employer in the USA.

PARTICIPANTS

1355 daytime workers.

INTERVENTION

Participants were randomised to intervention (n=794) or control (n=561) on consent. Intervention participants received the SHAW educational programme at baseline plus access to the personalised dayzz app for up to 9 months. The control condition received the intervention at month 10.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measures were sleep-related behavioural changes (eg, consistent sleep schedule); sleep behaviour tracked on an electronic sleep diary and sleep quality. Our secondary outcome measures included employee absenteeism, performance and productivity; stress, mood, alertness and energy; and adverse health and safety outcomes (eg, accidents).

RESULTS

At follow-up, employees in the intervention condition were more likely to report increased sleep duration on work (7.20 vs 6.99, p=0.01) and on free (8.26 vs 8.04, p=0.03) nights. At follow-up, the prevalence of poor sleep quality was lower in the intervention (n=160 of 321, 50%) compared with control (n=184 of 327, 56%) (p=0.04). The mean total dollars lost per person per month due to reduced workplace performance (presenteeism) was less in the intervention condition (US$1090 vs US$1321, p=0.001). Employees in the intervention reported fewer mental health visits (RR 0.72, 95% CI 0.56 to 0.94, p=0.01) and lower healthcare utilisation over the study interval (RR 0.81, 95% CI 0.67 to 0.98, p=0.03). We did not observe differences in stress (4.7 (95% CI 4.6 to 4.8) vs 4.7 (95% CI 4.6 to 4.8)), mood (4.5 (95% CI 4.4 to 4.6) vs 4.6 (95% CI 4.5 to 4.7)), alertness (4.9 (95% CI 4.8 to 5.0) vs 5.0 (95% CI 4.9 to 5.1)) or adverse health and safety outcomes (motor vehicle crashes: OR 0.82 (95% CI 0.34 to 1.9); near-miss crashes: OR=0.89 (95% CI 0.5 to 1.5) and injuries: 0.9 (95% CI 0.6 to 1.3)); energy was higher at follow-up in the intervention group (4.3 vs 4.5; p=0.03).

CONCLUSIONS

Results from this trial demonstrate that a SHAW programme followed by access to the digital dayzz app can be beneficial to both the employee and employer.

TRIAL REGISTRATION NUMBER

NCT04224285.

What are Digital Public Health Interventions? First Steps Toward a Definition and an Intervention Classification Framework

Digital public health is an emerging field in population-based research and practice. The fast development of digital technologies provides a fundamentally new understanding of improving public health by using digitalization, especially in prevention and health promotion. The first step toward a better understanding of digital public health is to conceptualize the subject of the assessment by defining what digital public health interventions are. This is important, as one cannot evaluate tools if one does not know what precisely an intervention in this field can be. Therefore, this study aims to provide the first definition of digital public health interventions. We will merge leading models for public health functions by the World Health Organization, a framework for digital health technologies by the National Institute for Health and Care Excellence, and a user-centered approach to intervention development. Together, they provide an overview of the functions and areas of use for digital public health interventions. Nevertheless, one must keep in mind that public health functions can differ among different health care systems, limiting our new framework’s universal validity. We conclude that a digital public health intervention should address essential public health functions through digital means. Furthermore, it should include members of the target group in the development process to improve social acceptance and achieve a population health impact.

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

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

A clinical trial to evaluate the dayzz smartphone app on employee sleep, health, and productivity at a large US employer

Sleep deficiency is a hidden cost of our 24-7 society, with 70% of adults in the US admitting that they routinely obtain insufficient sleep. Further, it is estimated that 50-70 million adults in the US have a sleep disorder. Undiagnosed and untreated sleep disorders are associated with diminished health for the individual and increased costs for the employer. Research has shown that adverse impacts on employees and employers can be mitigated through sleep health education and sleep disorder screening and treatment programs. Smartphone applications (app) are increasingly commonplace and represent promising, scalable modalities for such programs. The dayzz app is a personalized sleep training program that incorporates assessment of sleep disorders and offers a personalized comprehensive sleep improvement solution. Using a sample of day workers affiliated with a large institution of higher education, we will conduct a single-site, parallel-group, randomized, waitlist control trial. Participants will be randomly assigned to either use the dayzz app throughout the study or receive the dayzz app at the end of the study. We will collect data on feasibility and acceptability of the dayzz app; employee sleep, including sleep behavioral changes, sleep duration, regularity, and quality; employee presenteeism, absenteeism, and performance; employee mood; adverse and safety outcomes; and healthcare utilization on a monthly basis throughout the study, as well as collect more granular daily data from the employee during pre-specified intervals. Our results will illuminate whether a personalized smartphone app is a viable approach for improving employee sleep, health, and productivity. Trial registration: ClinicalTrials.gov Identifier: NCT04224285.

The Interplay Between Technology Performativity and Health Care Professionals in Hospital Settings: Service Design Approach

BACKGROUND

The unexpected outbreak of the COVID-19 pandemic and the preventive measures of physical distancing have further necessitated the application of information and communication technologies (ICTs) to enhance the efficiency of work activities in health care. Although the interplay between human agency and technology performativity is critical to the success or failure of ICTs use in routine practice, it is rarely explored when designing health ICTs for hospital settings within the sub-Saharan Africa context.

OBJECTIVE

The objective of this study is to explore how the service delivery quality is being influenced by the technology-enabled activities of health care professionals at points of care using a service design strategy.

METHODS

An interpretivist stance was assumed to understand the socially constructed realities of health care professionals at points of care in a hospital setting. A service design strategy was identified as suitable for engaging health care professionals in co-design sessions to collect data. A purposive sampling technique was used to identify the participants. Open-ended questions were administered to gain insights into the work activities of physicians and nurses at points of care. Qualitative (textual) data were analyzed using thematic analysis. Ethical concerns about the safety and privacy of participants' data were addressed as per the university ethics review committee and provincial department of health.

RESULTS

The findings show that the attributes of human agency and technology features that drive technology performativity result in an interplay between social concepts and technical features that influence the transformation of human-machine interactions. In addition, the interplay of the double dance of agency model can be divided into 2 successive phases: intermediate and advanced. Intermediate interplay results in the perceived suitability or discomfort of health ICTs as experienced by health care professionals at initial interactions during the execution of work activities. Subsequently, the advanced interplay determines the usefulness and effectiveness of health ICTs in aiding task performance, which ultimately leads to either the satisfaction or dissatisfaction of health care professionals in the completion of their work activities at points of care.

CONCLUSIONS

The adopted service design strategy revealed that the interaction moments of the tasks performed by health care professionals during the execution of their work activities at point of care determine the features of health ICTs relevant to work activities. Consequently, the ensuing experience of health care professionals at the completion of their work activities influences the use or discontinuation of health ICTs. Health care professionals consider the value-added benefits from the automation of their work activities to ultimately influence the quality of service delivery. The major knowledge contribution of this study is the awareness drawn to both the intermediate and advanced interplay of human-machine interaction when designing health ICTs.

A Mobile App With Multimodality Prehabilitation Programs for Patients Awaiting Elective Surgery: Development and Usability Study

Background

Complying with a prehabilitation program is difficult for patients who will undergo surgery, owing to transportation challenges and a limited intervention time window. Mobile health (mHealth) using smartphone apps has the potential to remove barriers and improve the effectiveness of prehabilitation.

Objective

This study aimed to develop a mobile app as a tool for facilitating a multidisciplinary prehabilitation protocol involving blood flow restriction training and sport nutrition supplementation.

Methods

The app was developed using “Appy Pie,” a noncoding app development platform. The development process included three stages: (1) determination of principles and requirements of the app through prehabilitation research team meetings; (2) app prototype design using the Appy Pie platform; and (3) app evaluation by clinicians and exercise and fitness specialists, technical professionals from Appy Pie, and non–team-member users.

Results

We developed a prototype of the app with the core focus on a multidisciplinary prehabilitation program with accessory features to improve engagement and adherence to the mHealth intervention as well as research-focused features to evaluate the effects of the program on frailty status, health-related quality of life, and anxiety level among patients awaiting elective surgery. Evaluations by research members and random users (n=8) were consistently positive.

Conclusions

This mobile app has great potential for improving and evaluating the effectiveness of the multidisciplinary prehabilitation intervention in the format of mHealth in future.

Development of a Mobile App for Ecological Momentary Assessment of Circadian Data: Design Considerations and Usability Testing

BACKGROUND

Collecting data on daily habits across a population of individuals is challenging. Mobile-based circadian ecological momentary assessment (cEMA) is a powerful frame for observing the impact of daily living on long-term health.

OBJECTIVE

In this paper, we (1) describe the design, testing, and rationale for specifications of a mobile-based cEMA app to collect timing of eating and sleeping data and (2) compare cEMA and survey data collected as part of a 6-month observational cohort study. The ultimate goal of this paper is to summarize our experience and lessons learned with the Daily24 mobile app and to highlight the pros and cons of this data collection modality.

METHODS

Design specifications for the Daily24 app were drafted by the study team based on the research questions and target audience for the cohort study. The associated backend was optimized to provide real-time data to the study team for participant monitoring and engagement. An external 8-member advisory board was consulted throughout the development process, and additional test users recruited as part of a qualitative study provided feedback through in-depth interviews.

RESULTS

After ≥4 days of at-home use, 37 qualitative study participants provided feedback on the app. The app generally received positive feedback from test users for being fast and easy to use. Test users identified several bugs and areas where modifications were necessary to in-app text and instructions and also provided feedback on the engagement strategy. Data collected through the mobile app captured more variability in eating windows than data collected through a one-time survey, though at a significant cost.

CONCLUSIONS

Researchers should consider the potential uses of a mobile app beyond the initial data collection when deciding whether the time and monetary expenditure are advisable for their situation and goals.

Development of an Instrument for Assessing the Maturity of Citizens for Consumer Health Informatics in Developing Countries: The Case of Chile, Ghana, and Kosovo

OBJECTIVE

 We aimed to develop a survey instrument to assess the maturity level of consumer health informatics (ConsHI) in low-middle income countries (LMIC).

METHODS

 We deduced items from unified theory of acceptance and use of technology (UTAUT), UTAUT2, patient activation measure (PAM), and ConsHI levels to constitute a pilot instrument. We proposed a total of 78 questions consisting of 14 demographic and 64 related maturity variables using an iterative process. We used a multistage convenient sampling approach to select 351 respondents from all three countries.

RESULTS

 Our results supported the earlier assertion that mobile devices and technology are standard today than ever, thus confirming that mobile devices have become an essential part of human activities. We used the Wilcoxon Signed-Rank Test (WSRT) and item response theory (IRT) to reduce the ConsHI-related items from 64 to 43. The questionnaire consisted of 10 demographic questions and 43 ConsHI relevant questions on the maturity of citizens for ConsHI in LMIC. Also, the results supported some moderators such as age and gender. Additionally, more demographic items such as marital status, educational level, and location of respondents were validated using IRT and WSRT.

CONCLUSION

 We contend that this is the first composite instrument for assessing the maturity of citizens for ConsHI in LMIC. Specifically, it aggregates multiple theoretical models from information systems (UTAUT and UTAUT2) and health (PAM) and the ConsHI level.

COVID-19 Pathophysiology Predicts That Ischemic Stroke Occurrence Is an Expectation, Not an Exception-A Systematic Review

Clinical reports of neurological manifestations associated with severe coronavirus disease 2019 (COVID-19), such as acute ischemic stroke (AIS), encephalopathy, seizures, headaches, acute necrotizing encephalitis, cerebral microbleeds, posterior reversible leukoencephalopathy syndrome, hemophagocytic lymphohistiocytosis, peripheral neuropathy, cranial nerve palsies, transverse myelitis, and demyelinating disorders, are increasing rapidly. However, there are comparatively few studies investigating the potential impact of immunological responses secondary to hypoxia, oxidative stress, and excessive platelet-induced aggregation on the brain. This scoping review has focused on the pathophysiological mechanisms associated with peripheral and consequential neural (central) inflammation leading to COVID-19-related ischemic strokes. It also highlights the common biological processes shared between AIS and COVID-19 infection and the importance of the recognition that severe respiratory dysfunction and neurological impairments associated with COVID and chronic inflammation [post-COVID-19 neurological syndrome (PCNS)] may significantly impact recovery and ability to benefit from neurorehabilitation. This study provides a comprehensive review of the pathobiology of COVID-19 and ischemic stroke. It also affirms that the immunological contribution to the pathophysiology of COVID-19 is predictive of the neurological sequelae particularly ischemic stroke, which makes it the expectation rather than the exception. This work is of fundamental significance to the neurorehabilitation community given the increasing number of COVID-related ischemic strokes, the current limited knowledge regarding the risk of reinfection, and recent reports of a PCNS. It further highlights the need for global collaboration and research into new pathobiology-based neurorehabilitation treatment strategies and more integrated evidence-based care.

Sexual health interventions delivered to participants by mobile technology: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The use of mobile technologies to prevent STIs is recognised as a promising approach worldwide; however, evidence has been inconclusive, and the field has developed rapidly. With about 1 million new STIs a day globally, up-to-date evidence is urgently needed.

OBJECTIVE

To assess the effectiveness of mobile health interventions delivered to participants for preventing STIs and promoting preventive behaviour.

METHODS

We searched seven databases and reference lists of 49 related reviews (January 1990-February 2020) and contacted experts in the field. We included randomised controlled trials of mobile interventions delivered to adolescents and adults to prevent sexual transmission of STIs. We conducted meta-analyses and assessed risk of bias and certainty of evidence following Cochrane guidance.

RESULTS

After double screening 6683 records, we included 22 trials into the systematic review and 20 into meta-analyses; 18 trials used text messages, 3 used smartphone applications and 1 used Facebook messages as delivery modes. The certainty of evidence regarding intervention effects on STI/HIV occurrence and adverse events was low or very low. There was moderate certainty of evidence that in the short/medium-term text messaging interventions had little or no effect on condom use (standardised mean differences (SMD) 0.02, 95% CI -0.09 to 0.14, nine trials), but increased STI/HIV testing (OR 1.83, 95% CI 1.41 to 2.36, seven trials), although not if the standard-of-care control already contained an active text messaging component (OR 1.00, 95% CI 0.68 to 1.47, two trials). Smartphone application messages also increased STI/HIV testing (risk ratio 1.40, 95% CI 1.22 to 1.60, subgroup analysis, two trials). The effects on other outcomes or of social media or blended interventions is uncertain due to low or very low certainty evidence.

CONCLUSIONS

Text messaging interventions probably increase STI/HIV testing but not condom use in the short/medium term. Ongoing trials will report the effects on biological and other outcomes.

Interest in Communication Technology by Rural Caregivers of Adolescents with Mental Health Issues in South Africa: The Mmogo-Method®

Caregivers determine the level of care adolescents with mental issues receive; however, caregivers' own needs are often unmet. Communication technology can be tailored to address these challenges, especially in a rural environment. This study aimed to explore caregivers' interest in using communication technology to provide support to address challenges. This study involved a visual-based narrative inquiry that gathered data through the Mmogo-method^®. Three (n = 3) groups were held with rural caregivers (n = 17) of adolescents with mental health issues in a rural area in the Free State province of South Africa during 2017. Three themes captured challenges confronting caregivers, namely, psychosocial, social resources, and informational challenges. Interest in communication technology was captured in a fourth theme. The findings indicate that communication technology can address caregivers' challenges by providing support and information to caregivers in rural areas. Communication technology, including mobile phones, electronic devices, and the Internet, has transformed healthcare services and proved to be valuable in resource constraint environments.

Smartphone use by health professionals: A review

Introduction

On the world stage unlimited internet access by smartphones have made in social, cultural and economic relations, has transformed the world to be faster and more efficient. In this context, health care requires more attention. Health professionals must be concerned about the majority of the patient’s care on the use of smartphone’s in this process. Smartphones can be cause distractions and cause poor patient care. Behavioral and psychological changes related to abusive and uncontrolled use in this population may create severe impacts not only on the user’s life but also on the community health care.

Method

A careful research was performed through PubMed, Web of Science and Psycho Info databases using the terms: “Smartphone addiction”, “Smartphone dependence”, “Smartphone abuse”, “physicians”, “nurses” and ‘‘health professionals”. The search covered the past 5 years up to August 2019. Articles that examine abusive use on smartphones in health professionals were included. We analyzed how this concept evolved over the last five years and hope to contribute to the better understanding of the issue and its impacts on this population and on the health care.

Results

There is a lack of specific trial instruments on screening of smartphone addiction or abusive use, tending to adopt different diagnostic criteria by the reports included. There are also a lack of studies discussing etiology of this compulsive behavior. Although known risks, published reports show there is no consciousness of abusive use and possible damages in healthcare by some health professionals. Instead, there are others that can affirm there are unpredictable risks in patient care and tend to stimulate conscience use politics in health settings. Most of them point out smartphone’s app benefits.

Conclusion

Smartphones and its functionalities became part of everyone's life by the various benefits guaranteed. However, an addictive behavior can cause damage, principally in the Health Care setting and health professional’s abusive use must be monitored. Further investigation is needed to determine the motivations of this addictive behavior and if abusive smartphone usage is a new psychiatric classification or merely the substrate of other disorders.

Innovative and Assistive eHealth Technologies for Smart Therapeutic and Rehabilitation Outdoor Spaces for the Elderly Demographic

The use of technology for social connectivity and achieving engagement goals is increasingly essential to the overall well-being of our rapidly ageing population. While much of the extant literature has focused on home automation and indoor remote health monitoring; there is a growing literature that finds personal health and overall well-being improves when physical activities are conducted outdoors. This study presents a review of possible innovative and assistive eHealth technologies suitable for smart therapeutic and rehabilitation outdoor spaces for older persons. The article also presents key performance metrics required of eHealth technologies to ensure robust, timely and reliable biometric data transfer between patients in a therapeutic landscape environment and respective medical centres. A literature review of relevant publications with a primary focus of integrating sensors and eHealth technologies in outdoor spaces to collect and transfer data from the elderly demographic who engage such built landscapes to appropriate stakeholders was conducted. A content analysis was carried out to synthesize outcomes of the literature review. The study finds that research in assistive eHealth technologies and interfaces for outdoor therapeutic spaces is in its nascent stages and has limited generalisability. The level of technology uptake and readiness for smart outdoor spaces is still developing and is currently being outpaced by the growth of elderly fitness zones in public spaces. Further research is needed to explore those eHealth technologies with interactive feedback mechanisms that are suitable for outdoor therapeutic environments.

Using ADAPT-ITT to Modify a Telephone-Based HIV Prevention Intervention for SMS Delivery: Formative Study

BACKGROUND

African American adolescent females are disproportionately affected by sexually transmitted infections (STIs) and HIV. Given the elevated risk of STIs and HIV in African American women, there is an urgent need to identify innovative strategies to enhance the adoption and maintenance of STI and HIV preventive behaviors. Texting is a promising technology for creating preventive maintenance interventions (PMIs) that extend the efficacy of the original intervention. However, little guidance in public health literature is available for developing this type of application.

OBJECTIVE

This paper describes a formative pilot study that incorporates user experience methods to design and test PMI texts for Afiya, an original evidence-based intervention (EBI) specifically designed for African American adolescent females. This study aims to describe the adaptation process of health educator-led phone calling to text-based communication.

METHODS

The formative process followed the assessment, decision, adaptation, production, topical experts-integration, training, testing (ADAPT-ITT) framework for adapting EBIs and using them in a new setting, for a new target population or a modified intervention strategy. This study presents the details of how the phases of the ADAPT-ITT framework were applied to the design of the adaptation. An advisory board was constituted from the target population, consisting of 6 African American women aged 18-24 years, participating in formative activities for 12 weeks, and involving components of the PMI design. As Afiya included a telephone-based PMI, developers of the original Afiya phone scripts crafted the initial design of the SMS-based texts and texting protocol. The advisory board participated in the 1-day Afiya workshop, followed by 4 weeks of texting PMI messages and a midcourse focus group, followed by 4 more weeks of texting PMI messages, ultimately ending with a final focus group. At the advisory board's request, this phase included an optional, additional week of text-based PMI messages.

RESULTS

The methods provided a rich source of data and insights into the fundamental issues involved when constructing SMS-based PMI for this target population and for this EBI. Prior contact and context are essential as the health educator was identified as a key persona in the process and the messages were situated in the original (workshop) context. Narrative adaptations for personas emerged from advisory board discussions. Suggestions on how to expand the PMI to current, specific social contexts indicated that the use of narrative analysis is warranted.

CONCLUSIONS

The use of existing EBIs incorporating telephone-based PMI scripts facilitated the initial design of the texts, with a subsequent narrative analysis of the advisory board data providing additional adjustments given the actual context. Additional examination of the advisory board feedback revealed that personas would offer insight into and opportunities for a persona-specific modification of texting narratives.

Potential Benefits and Risks Resulting From the Introduction of Health Apps and Wearables Into the German Statutory Health Care System: Scoping Review

Background

Germany is the first country worldwide that has introduced a digital care act as an incentive system to enhance the use of digital health devices, namely health apps and wearables, among its population. The act allows physicians to prescribe statutory financed and previously certified health apps and wearables to patients. This initiative has the potential to improve treatment quality through better disease management and monitoring.

Objective

The aim of this paper was to outline the key concepts related to the potential risks and benefits discussed in the current literature about health apps and wearables. Furthermore, this study aimed to answer the research question: Which risks and benefits may result from the implementation of the digital care act in Germany?

Methods

We conducted the scoping study by searching the databases PubMed, Google Scholar, and JMIR using the keywords health apps and wearables. We discussed 55 of 136 identified articles published in the English language from 2015 to March 2019 in this paper using a qualitative thematic analysis approach.

Results

We identified four key themes within the articles: Effectivity of health apps and wearables to improve health; users of health apps and wearables; the potential of bring-your-own, self-tracked data; and concerns and data privacy risks. Within these themes, we identified three main stages of benefits for the German health care system: Usage of health apps and wearables; continuing to use health apps and wearables; and sharing bring-your-own; self-tracked data with different agents in the health care sector.

Conclusions

The digital care act could lead to an improvement in treatment quality through better patient monitoring, disease management, personalized therapy, and better health education. However, physicians should play an active role in recommending and supervising health app use to reach digital-illiterate or health-illiterate people. Age must not be an exclusion criterion. Yet, concerns about data privacy and security are very strong in Germany. Transparency about data processing should be provided at all times for continuing success of the digital care act in Germany.

Comparison of a Mobile Health Electronic Visual Analog Scale App With a Traditional Paper Visual Analog Scale for Pain Evaluation: Cross-Sectional Observational Study

Background

Accurate quantification of pain in a clinical setting is vital. The use of an electronic pain scale enables data to be collected, analyzed, and utilized much faster compared with traditional paper-based scales. The advancement of smart technology in pediatric and adult pain evaluation may offer opportunities to introduce easy-to-use and reliable pain assessment methods within different clinical settings. If promptly introduced within different pediatric and adult pain clinic services, validated and easily accessible mobile health pain apps may lead to early pain detection, promoting improvement in patient’s quality of life and leading to potentially less time off from school or work.

Objective

This cross-sectional observational study aimed to investigate the interchangeability of an electronic visual analog scale (eVAS) app with a traditional paper visual analog scale (pVAS) among Australian children, adolescents, and adults for pain evaluation.

Methods

Healthy participants (age range 10-75 years) were recruited from a sporting club and a secondary school in Melbourne (Australia). The data collection process involved application of pressure (8.5 kg/cm²) from a Wagner Force Dial FDK 20 to the midpoint of the thumb. The pressure was applied twice with a 5-minute interval. At each pressure application, participants were asked to randomly record their pain perception using the “eVAS” accessible via the “Interactive Clinics” app and the traditional pVAS. Statistical analysis was conducted to determine intermethod and intramethod reliabilities.

Results

Overall, 109 healthy participants were recruited. Adults (mean age 42.43 years, SD 14.50 years) had excellent reliability, with an intraclass correlation coefficient (ICC) of 0.94 (95% CI 0.91-0.96). Children and adolescents (mean age 13.91 years, SD 2.89 years) had moderate-to-good intermethod and intramethod reliabilities, with an ICC of 0.80 (95% CI 0.70-0.87) and average ICC of 0.80 (95% CI 0.69-0.87), respectively.

Conclusions

The eVAS app appears to be interchangeable compared with the traditional pVAS among children, adolescents, and adults. This pain evaluation method may offer new opportunities to introduce user-friendly and validated pain assessment apps for patients, clinicians, and allied health professionals.

Citizen-Patient Involvement in the Development of mHealth Technology: Protocol for a Systematic Scoping Review

Background

The development of mobile technology for information retrieval and communication, both at individual and health organizational levels, has been extensive over the last decade. Mobile health (mHealth) technology is rapidly adapting to the health care service contexts to improve treatment, care, and effectiveness in health care services.

Objective

The overall aim of this scoping review is to explore the role of citizen-patient involvement in the development of mHealth technology in order to inform future interventions. By identifying key characteristics of citizen-patient involvement in system development, we aim to improve digital communication and collaboration between health care providers and citizen-patients, including sharing of health care data.

Methods

The systematic scoping review will follow the Joanna Briggs Institute methodology for scoping reviews by searching literature in 3 steps. We will include literature reporting on the public, citizens, and patients participating in the development of mobile technology for health care purposes in MEDLINE, CINAHL, Scopus, EMBASE, and ProQuest Dissertations and Theses. A preliminary search was completed in MEDLINE and Scopus. The screening process will be conducted by 2 of the authors. Data will be extracted using a data extraction tool prepared for the study.

Results

The study is expected to identify research gaps that will inform and motivate the development of mHealth technology. The final report is planned for submission to an indexed journal in November 2020.

Conclusions

To our knowledge, this review will be the first review to provide knowledge about how citizen-patients participate in system developments for mHealth tools and the value that such involvement adds to the system development process.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16781

Communication Technology Use by Caregivers of Adolescents With Mental Health Issues: Systematic Review

Background

Caregivers of adolescents with mental health issues experience challenges that may result in the caregivers having a variety of unmet needs. There is a growing need to support these caregivers. Effective support to strengthen positive caregiving behavior in caregivers may address their challenges. Communication technologies offer novel opportunities to assist these caregivers and may contribute to strengthening caregiver behavior. However, little is known about the use of communication technologies among caregivers of adolescents with mental health issues.

Objective

The study aimed to answer the question: “What is the best evidence available to strengthen positive behavior of caregivers of adolescents with mental health issues using communication technology.”

Methods

A systematic review of articles published between January 2007 and August 2018 was conducted. Searches included articles of multiple study designs from EBSCO Host and Scopus platforms with prespecified eligibility criteria. Methodological quality was evaluated using the applicable Critical Appraisal Skills Programme and Joanna Briggs Institute assessment tools.

Results

The search yielded 1746 articles. Altogether, 5 articles met the eligibility criteria and were included in the review for data synthesis. Data analysis and synthesis identified three thematic conclusions reflecting the types of communication technologies used, caregivers as the target population, and strengthening of positive behavior through determinants of the Integrated Model of Behavior Prediction.

Conclusions

The review reported the usefulness of communication technology by caregivers. Caregivers also demonstrated improvement in self-efficacy, knowledge, parent-child communication, and parental skills reflecting positive behavior. Although the use of communication technology is expanding as a supportive intervention to address caregivers’ needs, the evidence for usefulness among caregivers of adolescents with mental health issues is still scarce. More research and information related to preferred methods of communication delivery among caregivers of adolescents is still needed.

Perceived Usefulness, Satisfaction, Ease of Use and Potential of a Virtual Companion to Support the Care Provision for Older Adults

This article reports a study aiming to determine the perceptions of older adults needing formal care about the usefulness, satisfaction, and ease of use of CaMeLi, a virtual companion based on an embodied conversational agent, and the perceptions of formal caregivers about the potential of virtual companions to support care provision. An observational study involving older adults needing formal care was conducted to assess CaMeLi using a multi-method approach (i.e., an auto-reported questionnaire—the Usefulness, Satisfaction, and Ease of use questionnaire; a scale for the usability assessment based on the opinion of observers—the International Classification of Functioning Disability and Health-based Usability Scale; and critical incident registration). Moreover, a focus group was conducted to collect data regarding the perceived utility of virtual companions to support care provision. The observational study was conducted with 46 participants with an average age of 63.6 years, and the results were associated with a high level of usefulness, satisfaction, and ease of use of CaMeLi. Furthermore, the focus group composed of four care providers considered virtual companions a promising solution to support care provision and to prevent loneliness and social isolation. The results of both the observational study and the focus group revealed good perceptions regarding the role of virtual companions to support the care provision for older adults.

Co-Design in the Development of a Mobile Health App for the Management of Knee Osteoarthritis by Patients and Physicians: Qualitative Study

BACKGROUND

Despite a doubling of osteoarthritis-targeted mobile health (mHealth) apps and high user interest and demand for health apps, their impact on patients, patient outcomes, and providers has not met expectations. Most health and medical apps fail to retain users longer than 90 days, and their potential for facilitating disease management, data sharing, and patient-provider communication is untapped. An important, recurrent criticism of app technology development is low user integration design. User integration ensures user needs, desires, functional requirements, and app aesthetics are responsive and reflect target user preferences.

OBJECTIVE

This study aims to describe the co-design process for developing a knee osteoarthritis minimum viable product (MVP) mHealth app with patients, family physicians, and researchers that facilitates guided, evidence-based self-management and patient-physician communication.

METHODS

Our qualitative co-design approach involved focus groups, prioritization activities, and a pre-post quality and satisfaction Kano survey. Study participants included family physicians, patient researchers and patients with knee osteoarthritis (including previous participants of related collaborative research), researchers, key stakeholders, and industry partners. The study setting was an academic health center in Southern Alberta.

RESULTS

Distinct differences exist between what patients, physicians, and researchers perceive are the most important, convenient, desirable, and actionable app functional requirements. Despite differences, study participants agreed that the MVP should be electronic, should track patient symptoms and activities, and include features customized for patient- and physician-identified factors and international guideline-based self-management strategies. Through the research process, participants negotiated consensus on their respective priority functional requirements. The highest priorities were a visual symptom graph, setting goals, exercise planning and daily tracking, and self-management strategies. The structured co-design with patients, physicians, and researchers established multiple collaborative processes, grounded in shared concepts, language, power, rationale, mutual learning, and respect for diversity and differing opinions. These shared team principles fostered an open and inclusive environment that allowed for effective conceptualization, negotiation, and group reflection, aided by the provision of tangible and ongoing support throughout the research process, which encouraged team members to question conventional thinking. Group-, subgroup-, and individual-level data helped the team reveal how and for whom perspectives about individual functional requirements changed or remained stable over the course of the study. This provided valuable insight into how and why consensus emerged, despite the presence of multiple and differing underlying rationales for functional requirement prioritization.

CONCLUSIONS

It is feasible to preserve the diversity of perspectives while negotiating a consensus on the core functional requirements of an mHealth prototype app for knee osteoarthritis management. Our study sample was purposely constructed to facilitate high co-design interactivity. This study revealed important differences between the patient, physician, and researcher preferences for functional requirements of an mHealth app that did not preclude the development of consensus.

Facilitating the development of cross-platform mHealth applications for chronic supportive care and a case study

Mobile health (mHealth) apps have received increasing attention, due to their abilities to support patients who suffer from various conditions. mHealth apps may be especially helpful for patients with chronic diseases, by providing pertinent information, tracking symptoms, and inspiring adherence to medication regimens. To achieve these objectives, researchers need to prototype mHealth apps with dedicated software architectures. In this paper, a cloud-based mHealth application development concept is presented for chronic patient supportive care apps. The concept integrates existing software platforms and services for simplified app development that can be reused for other target applications. This developmental method also facilitates app portability, through the use of common components found across multiple mobile platforms, and scalability, through the loose coupling of services. The results are demonstrated by the development of native Android and cross-platform web apps, in a case study that presents an mHealth solution for endocrine hormone therapy (EHT). A performance analysis methodology, an app usability evaluation, based on focus group responses, and alpha and pre-beta testing results are provided.

[Digital public health-an overview]

The rapid development and proliferation of digital health technologies have not only changed the medical professions, but offer great potential for public health, particularly in health promotion and disease prevention.At the same time, this emerging field is also characterized by conceptual and terminological fuzziness, a marked lack of high-quality evidence, and an absence of an honest discussion of unintended consequences and side effects. Further challenges for digital public health lie in the fact that the development of new health technologies is mainly driven by technological progress and less by evidence-based needs and research in public health.In this overview paper, we aim at conceptually denoting the field of digital public health, using principal public health functions as guiding principles. We discuss some current applications of digital health technologies in fulfilling public health functions and propose a needs-based development of digital health technologies.We will further address specific challenges to digital public health, in particular socio-economic differences in the usage of and profiting from digital health technologies, data protection and privacy issues, as well as ethical issues.

Promoting healthy teenage behaviour across three European countries through the use of a novel smartphone technology platform, PEGASO fit for future: study protocol of a quasi-experimental, controlled, multi-Centre trial

BACKGROUND

Behaviour change interventions targeting physical activity, diet, sleep and sedentary behaviour of teenagers show promise when delivered through smartphones. However, to date there is no evidence of effectiveness of multicomponent smartphone-based interventions. Utilising a user-centred design approach, we developed a theory-based, multi-dimensional system, PEGASO Fit For Future (PEGASO F4F), which exploits sophisticated game mechanics involving smartphone applications, a smartphone game and activity sensors to motivate teenagers to take an active role in adopting and maintaining a healthy lifestyle. This paper describes the study protocol to assess the feasibility, usability and effectiveness (knowledge/awareness and behavioural change in lifestyle) of the PEGASO system.

METHODS

We are conducting a quasi-experimental controlled cluster trial in 4 sites in Spain, Italy, and UK (England, Scotland) over 6 months. We plan to recruit 525, in a 2:1 basis, teenagers aged 13-16 years from secondary schools. The intervention group is provided with the PEGASO system whereas the comparison group continues their usual educational routine. Outcomes include feasibility, acceptance, and usability of the PEGASO system as well as between and within group changes in motivation, self-reported diet, physical activity, sedentary and sleeping behaviour, anthropometric measures and knowledge about a healthy lifestyle.

DISCUSSION

PEGASO F4F will provide evidence into the cross-cultural similarities and differences in the feasibility, acceptability and usability of a multi-dimensional smartphone based behaviour change intervention for teenagers. The study will explore facilitating factors, challenges and barriers of engaging teenagers to adapt and maintain a healthy lifestyle when using smartphone technology. Positive results from this ICT based multi component intervention may have significant implications both at clinical level, improving teenagers health and at public health level since it can present an influential tool against the development of chronic disease during adulthood.

TRIAL REGISTRATION

https://clinicaltrials.gov Registration number: NCT02930148, registered 4 October 2016.

Mobile Health to Support Ageing in Place

The study reported in this article aimed to identify: i) the most relevant application domains of mHealth to support older adults in their domiciles; ii) the most relevant chronic conditions of older adults, whose management is being supported by mHealth; iii) the characteristics, outcomes and impacts of mHealth tools that might support older adults in their domiciles. The method of a systematic review of reviews and meta-analyses was performed based on a search of the literature. The result of a total of 66 reviews and meta-analyses across several chronic diseases were retrieved. These studies compare mHealth interventions with usual care. The conclusion is that mHealth interventions have positive effects on various health related outcomes, but further research is required to allow their incorporation in the clinical practice.

A Scientific Overview of Smartphone Applications and Electronic Devices for Weight Management in Adults

Worldwide, there are rising trends in overweight and obesity. Therefore, novel digital tools are discussed to improve health-related behaviors. The use of smartphone applications (apps) and wearables (e.g., activity trackers) for self-monitoring of diet and physical activity might have an impact on body weight. By now, the scientific evaluation of apps and wearables for weight management is limited. Although some intervention studies have already investigated the efficacy of aforementioned digital tools on weight management, there are no clear recommendations for its clinical and therapeutic use . Besides the lack in long-term randomized controlled trials, there are also concerns regarding the scientific quality of apps and wearables (e.g., no standards for development and evaluation). Therefore, the objective of present work is: (1) To address challenges and concerns regarding the current digital health market and (2) to provide a selective overview about intervention studies using apps and activity trackers for weight-related outcomes. Based on cited literature, the efficacy of apps and wearables on weight management is assessed. Finally, it is intended to derive potential recommendations for practical guidance.

Apps for Hearing Healthcare

This chapter provides a picture of the evolution of mobile applications (apps) for hearing health care (HHC) in terms of availability, variety, penetration, offered services, and target users. Special emphasis is given to newly developed methods that might assist audiologists and hearing professionals to get meaningful information and guidance for informed adoption of apps for themselves as well as for patients and their families. The chapter also shows how these novel methods can be used to characterize and compare a variety of apps across a wide range of services and target user groups. A representative sample of apps, assessed by using such a standardized framework, is analyzed to derive a multifaceted picture of apps for HHC. The chapter outlines and discusses emerging trends and needs in the area and highlights the open challenges as well as potential opportunities for professionals, researchers, developers, and stakeholders at large.

A systematic review of the effect of mobile health on cardiac rehabilitation among coronary heart disease patients

Objective

Mobile health (mHealth) provides an innovative and effective approach to promote prevention and management of coronary heart disease. However, the magnitude of its effects is unclear. The aim of this systematic review was to examine the impact of mHealth-based cardiac rehabilitation outcomes among coronary heart disease patients.

Methods

Medline, CINAHL, Embase, PubMed, Google Scholar, NICE, and Cochrane library were searched for randomized controlled trials published between January 2002 and March 2017 which compared mHealth with conventional cardiac rehabilitation programs among coronary heart disease patients.

Results

Eight articles were included in this review. The impact of mHealth interventions on physical activity, medicine adherence, smoking cessation, level of anxiety, and quality of life was inconsistent among the articles.

Conclusions

Further research is needed to conclusively determine the impact of mHealth interventions on cardiac rehabilitation outcomes. The limitations of the included studies (e.g., inadequate sample size, failure to address the core components of cardiac rehabilitation programs, and lack of theory-based design) should be taken into account when designing future studies.

Legal and ethical issues surrounding the use of crowdsourcing among healthcare providers

As the pace of medical discovery widens the knowledge-to-practice gap, technologies that enable peer-to-peer crowdsourcing have become increasingly common. Crowdsourcing has the potential to help medical providers collaborate to solve patient-specific problems in real time. We recently conducted the first trial of a mobile, medical crowdsourcing application among healthcare providers in a university hospital setting. In addition to acknowledging the benefits, our participants also raised concerns regarding the potential negative consequences of this emerging technology. In this commentary, we consider the legal and ethical implications of the major findings identified in our previous trial including compliance with the Health Insurance Portability and Accountability Act, patient protections, healthcare provider liability, data collection, data retention, distracted doctoring, and multi-directional anonymous posting. We believe the commentary and recommendations raised here will provide a frame of reference for individual providers, provider groups, and institutions to explore the salient legal and ethical issues before they implement these systems into their workflow.

An overview on the emerging area of identification, characterization, and assessment of health apps

The need to characterize and assess health apps has inspired a significant amount of research in the past years, in search for methods able to provide potential app users with relevant, meaningful knowledge. This article presents an overview of the recent literature in this field and categorizes - by discussing some specific examples - the various methodologies introduced so far for the identification, characterization, and assessment of health apps. Specifically, this article outlines the most significant web-based resources for app identification, relevant frameworks for descriptive characterization of apps' features, and a number of methods for the assessment of quality along its various components (e.g., evidence base, trustworthiness, privacy, or user engagement). The development of methods to characterize the apps' features and to assess their quality is important to define benchmarks and minimum requirements. Similarly, such methods are important to categorize potential risks and challenges in the field so that risks can be minimized, whenever possible, by design. Understanding methods to assess apps is key to raise the standards of quality of health apps on the market, towards the final goal of delivering apps that are built on the pillars of evidence-base, reliability, long-term effectiveness, and user-oriented quality.

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

A pilot study of a smartphone application supporting recovery from drug addiction

BACKGROUND

Mobile health (mHealth) technologies have the potential to facilitate self-monitoring and self-management for individuals with substance use disorders (SUD). S-Health is a bilingual smartphone application based on cognitive behavioral principles and is designed to support recovery from drug addiction by trigger recognition so as to allow practice in-the-moment coping to prevent relapse.

METHOD

For this pilot randomized controlled study, 75 participants were recruited from methadone maintenance treatment clinics and the social worker consortium in Shanghai, China. Participants in the control group (N=25) received text messages from S-Health (e.g., HIV prevention and other educational materials). Participants in the intervention group (N=50) received both text messages and daily surveys on cravings, affects, triggers, responses to triggers, and social contexts.

RESULTS

At the end of the 1-month study trial, 26.2% of the intervention group and 50% of the control group had positive urine test results (p=0.06). Also, the number of days using drug in the past week was significantly lower among participants in the intervention group (Mean=0.71, SD=1.87) relative to the control group (Mean=2.20, SD=3.06) (p<0.05). The two groups did not differ in slopes (i.e., rates of change in outcomes measured weekly) based on the mixed effects model. Participants in the intervention group also preferred answering questions on the cellphone (46.8%) relative to in-person interviews (36.2%).

CONCLUSIONS

This pilot demonstrated the feasibility and potential benefits to deliver mobile health intervention among participants with SUD. Further research with larger samples over a longer period of time is needed to test the effectiveness of S-Health as a self-monitoring tool supporting recovery from addiction.

Evaluating the prevalence and opportunity for technology use in chronic kidney disease patients: a cross-sectional study

BACKGROUND

Chronic kidney disease (CKD) is increasing worldwide and early education to improve adherence to self-management is a key strategy to slow CKD progression. The use of the internet and mobile phone technologies (mHealth) to support patients is considered an effective tool in many other chronic disease populations. While a number of mHealth platforms for CKD exist, few studies have investigated if and how this population use technology to engage in self-management.

METHODS

Using a cross-sectional design across five health districts in Queensland (Australia), a 38-item self-report survey was distributed to adults with CKD attending outpatient clinics or dialysis units to measure current use and type of engagement with mHealth, perceived barriers to use, and opportunities to support CKD self-management. Odds ratio (OR) were calculated to identify associations between demographic characteristic and mHealth use.

RESULTS

Of the 708 participants surveyed, the majority had computer access (89.2%) and owned a mobile phone (83.5%). The most likely users of the internet were those aged ≤ 60 years (OR: 7.35, 95% confidence interval [CI]: 4.25-12.75, p < 0.001), employed (OR: 7.67, 95% CI: 2.58-22.78, p < 0.001), from non-indigenous background (OR: 6.98, 95% CI: 3.50-13.93, p < 0.001), or having completed higher levels of education (OR: 3.69, CI: 2.38-5.73, p < 0.001). Those using a mobile phone for complex communication were also younger (OR: 6.01, 95% CI: 3.55-10.19, p < 0.001), more educated (OR: 1.99, 95% CI: 1.29-3.18, p < 0.01), or from non-indigenous background (OR: 3.22, 95% CI: 1.58-6.55, p < 0.001). Overall, less than 25% were aware of websites to obtain information about renal healthcare. The mHealth technologies most preferred for communication with their renal healthcare teams were by telephone (56.5%), internet (50%), email (48.3%) and text messages (46%).

CONCLUSION

In the CKD cohort, younger patients are more likely than older patients to use mHealth intensively and interactively although all patients' technology literacy ought to be thoroughly assessed by renal teams before implementing in practice. Further research testing mHealth interventions to improve self-management in a range of patient cohorts is warranted.

Mobile applications in children with cerebral palsy

INTRODUCTION

Cerebral palsy (CP) is one of the most common developmental disorders. Technological development has enabled a transformation of the healthcare sector, which can offer more individualised, participatory, and preventive services. Within this context of new technology applied to the healthcare sector, mobile applications, or apps, constitute a very promising tool for the management of children with CP.

OBJECTIVE

The purpose of this article is to perform a systematic review of the information published about various mobile applications either directly related to CP or with potential to be useful in the context of the disease, and to describe, analyse, and classify these applications.

MATERIAL AND METHODS

A literature search was carried out to gather articles published in English or Spanish between 2011 and 2017 which presented, analysed, or validated applications either specifically designed or potentially useful for CP. Furthermore, a search for mobile applications was conducted in the main mobile application markets.

CONCLUSIONS

A total of 63 applications were found in biomedical databases and mobile application markets, of which 40 were potentially useful for CP and 23 were specifically designed for the condition (11 for information, 3 for evaluation, and 9 for treatment). There are numerous mobile applications either specifically designed for or with potential to be useful in the field of CP. However, despite the existing scientific evidence, the low methodological quality of scientific articles makes it impossible to generalise the use of these tools.

Perceptions of Patient Engagement Applications During Pregnancy: A Qualitative Assessment of the Patient's Perspective

Background

With growing demand for medical information and health applications in pregnancy, the potential of electronic health (eHealth) and mobile health (mHealth) solutions in clinical care is increasingly unfolding. However, we still do not know how pregnant women engage with mobile apps, how such apps impact routine medical care, and whether benefit expectations are met. Whereas recent research has raised the subject of user distribution and analyzed the content of pregnancy applications, there is still a significant knowledge gap regarding what pregnant women like and dislike about pregnancy tools, along with how such interventions could be improved.

Objective

The aim of the study was to examine the perceptions and expectations of mobile and Web-based patient-engagement pregnancy applications. We assessed usability requirements, general acceptance of eHealth, and the impact of eHealth and mHealth pregnancy applications on the doctor-patient interaction and daily clinical routine.

Methods

A qualitative study was conducted at the maternity department of a major German university hospital. The sample included 30 women with low- to medium-risk pregnancies. Half of the patients were seen during outpatient care and half were hospitalized for several days. The extent and frequency of Web- and mobile phone app usage were assessed. Semistructured interviews were conducted and analyzed using systematic thematic analysis.

Results

Patients had a high demand for Web-based pregnancy applications. Study findings suggested a strong request for personalization, monitoring, and accessibility for frequent use as main themes derived from the interviews. Fostering patient empowerment in the doctor-patient relationship was also highly valued for a pregnancy app. Participants favored further integration of medical apps in their daily routine and pregnancy care. However, concerns were raised about content quality, trustworthiness of Web sources, and individual data security.

Conclusions

eHealth and mHealth applications are a highly frequented source of information. Expectations and usability requirements for those applications are also high, thus posing a challenge to interdisciplinary service providers. Patients’ attitude toward integrating apps in routine care settings was positive with a favorable influence on patient empowerment. Health care professionals should guide pregnant women toward a successful integration of these educational tools in pregnancy care.