The Quality and Accuracy of Mobile Apps to Prevent Driving After Drinking Alcohol

Technology-Based Interventions for Substance Use Treatment Among People Who Identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native: Scoping Review

BACKGROUND

In the United States, racial and ethnic disparities in substance use treatment outcomes are persistent, especially among underrepresented minority (URM) populations. Technology-based interventions (TBIs) for substance use treatment show promise in reducing barriers to evidence-based treatment, yet no studies have described how TBIs may impact racial or ethnic health equity.

OBJECTIVE

This study explored whether TBIs in substance use treatment research promote health equity among people who identify as African American or Black, Hispanic or Latino, and American Indian or Alaska Native through their inclusion in research. We explored whether research that includes the aforementioned groups consciously considers race and/or ethnicity beyond including these populations as participants.

METHODS

We conducted a scoping review of 5 electronic databases to identify TBIs in substance use treatment studies published in English between January 2000 and March 2021. Studies were included if ≥50% of participants identified as African American or Black, Hispanic or Latino, or American Indian or Alaska Native when combined. Included studies were evaluated for conscious consideration of race and ethnicity in at least one manuscript section. Finally, we conducted a critical appraisal of each study's potential to facilitate insights into the impact of a TBI for members of specific URM groups.

RESULTS

Of 6897 titles and abstracts screened and 1158 full-text articles assessed for eligibility, nearly half (532/1158, 45.9%) of the full-text articles were excluded due to the absence of data on race, ethnicity, or not meeting the aforementioned demographic eligibility criteria. Overall, 110 studies met the inclusion criteria. Study designs included 39.1% (43/110) randomized trials, and 35.5% (39/110) feasibility studies. In total, 47.3% (52/110) of studies used computer-based interventions, including electronic screening, brief interventions, and referrals to treatment, whereas 33.6% (37/110) used interactive voice response, ecological momentary assessment or interventions, or SMS text messaging via mobile phones. Studies focused on the following substances: alcohol or drugs (45/110, 40.9%), alcohol alone (26/110, 23.6%), opioids (8/110, 7.3%), cannabis (6/110, 5.5%), cocaine (4/110, 3.6%), and methamphetamines (3/110, 2.7%). Of the studies that consciously considered race or ethnicity (29/110, 26.4%), 6.4% (7/110) explicitly considered race or ethnicity in all manuscript sections. Overall, 28.2% (31/110) of the studies were critically appraised as having a high confidence in the interpretability of the findings for specific URM groups.

CONCLUSIONS

While the prevalence of TBIs in substance use treatment has increased recently, studies that include and consciously consider URM groups are rare, especially for American Indian or Alaska Native and Hispanic or Latino groups. This review highlights the limited research on TBIs in substance use treatment that promotes racial and ethnic health equity and provides context, insights, and direction for researchers working to develop and evaluate digital technology substance use interventions while promoting health equity.

Developing a mobile-based brief intervention to reduce cannabis-impaired driving among youth: An intervention mapping approach

Behaviour change interventions delivered via smartphones have the potential to reduce youth cannabis use and driving under the influence of cannabis (DUIC). Countless smartphone applications (either downloadable or web-based) are available to help reduce substance use and impaired driving. However, most are developed without evidence-based content and theory, and many have poor user engagement. This study aims to: (1) describe the systematic development and theoretical foundations of a youth DUIC smartphone intervention, and (2) describe the pre-testing among a sample of youth and adult cannabis educators (prior to efficacy testing). A 6-step Intervention Mapping approach was utilized to combine theory, evidence, and user feedback to develop and implement the 'High Alert' intervention. This evidence-based and iterative process entailed: (1) conducting a needs assessment, (2) identifying intervention objectives, which map on the following DUIC determinants: knowledge, attitudes, risk perception, perceived norms, and self-efficacy, (3) selecting intervention theory and design, (4) developing of the intervention, (5) implementation, and (6) evaluation. Application of Intervention Mapping resulted in a smartphone web-based application that could support reductions in cannabis use and DUIC. The 'High Alert' intervention was created to include four modules with contents focusing on educating youth on the dangers and legal risks of DUIC, limiting risky situations, avoiding riding with an impaired driver, planning a safe ride home, and promoting safer cannabis use. Future research will test the efficacy of the intervention in reducing risky cannabis use and DUIC among youth.

A physiologically-based digital twin for alcohol consumption-predicting real-life drinking responses and long-term plasma PEth

Alcohol consumption is associated with a wide variety of preventable health complications and is a major risk factor for all-cause mortality in the age group 15-47 years. To reduce dangerous drinking behavior, eHealth applications have shown promise. A particularly interesting potential lies in the combination of eHealth apps with mathematical models. However, existing mathematical models do not consider real-life situations, such as combined intake of meals and beverages, and do not connect drinking to clinical markers, such as phosphatidylethanol (PEth). Herein, we present such a model which can simulate real-life situations and connect drinking to long-term markers. The new model can accurately describe both estimation data according to a χ2 -test (187.0 < Tχ2 = 226.4) and independent validation data (70.8 < Tχ2 = 93.5). The model can also be personalized using anthropometric data from a specific individual and can thus be used as a physiologically-based digital twin. This twin is also able to connect short-term consumption of alcohol to the long-term dynamics of PEth levels in the blood, a clinical biomarker of alcohol consumption. Here we illustrate how connecting short-term consumption to long-term markers allows for a new way to determine patient alcohol consumption from measured PEth levels. An additional use case of the twin could include the combined evaluation of patient-reported AUDIT forms and measured PEth levels. Finally, we integrated the new model into an eHealth application, which could help guide individual users or clinicians to help reduce dangerous drinking.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Preliminary Evaluation of Mobile Phone Apps to Curb Alcohol Consumption

Mobile apps have become increasingly prevalent in modern society, and persuasive technology has a broader market than ever. Mobile-based alcohol cessation apps can promote positive behaviour change in users and improve the overall health of our society. This research aimed to understand the various features users respond to and make design recommendations for alcohol cessation apps. This paper reports on three sources of feedback (user ratings, user reviews, MARS App Quality score) provided on 20 alcohol cessation apps in the Google Play Store. Our findings suggest that self-control type apps received much greater positive user reviews than motivational apps. In addition, this trend was not observed through numeric user ratings. We also speculate on design recommendations for apps that are meant to inhibit alcohol intake.

Considerations of diversity, equity, and inclusion in mental health apps: A scoping review of evaluation frameworks

Mental health applications or apps are a promising approach to reduce the pervasive unmet mental health need observed among marginalized groups. However, these groups face unique challenges to engage in and benefit from these interventions, and apps that consider issues of diversity, equity, and inclusion (DEI) may be better positioned to reach them. App evaluation frameworks emerge as crucial tools for researchers, clinicians, and users to select evidence-based apps. Nevertheless, it is unclear the extent to which existing assessment tools capture DEI factors. The present scoping review identified 68 studies that employed one or more assessment tools to evaluate a mental health app, leading to 44 unique app evaluation frameworks. Results showed that most frameworks were developed after 2015, and only 58% of them considered at least one DEI criterion. Frameworks that performed exceptionally well were those that combined multiple standardized and validated measures. This lack of consideration for DEI variables may limit the ability of app-based interventions to serve marginalized communities, or even worse, create new disparities. Therefore, we provide recommendations to improve current app evaluation frameworks' cultural robustness and clinical utility, maximizing their effectiveness when working with individuals from marginalized communities.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Mobile Phone Apps for Food Allergies or Intolerances in App Stores: Systematic Search and Quality Assessment Using the Mobile App Rating Scale (MARS)

Background

Food allergies and intolerances are increasing worldwide, and mobile phone apps could be a promising tool for self-management of these issues.

Objective

This study aimed to systemically search and assess food allergy or intolerance apps in app stores using the multidimensional Mobile App Rating Scale (MARS) to rate the objective and subjective quality and to identify critical points for future improvements.

Methods

This systematic search identified apps through the keywords “food allergy,” “food intolerance,” and “allergens” in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ≥3 (of 5 stars) to limit the selection to the most highly rated apps; ≥1000 reviews as an indicator of reliability; and the most recent update performed up to 2017. Then, the apps were divided according to their purpose (searching for allergen-free “food products,” “restaurants,” or recipes in “meal planners”) and evaluated on a scale of 1 to 5 points using the MARS in terms of (1) app classification category with a descriptive aim; (2) app subjective and objective quality categories comprised of engagement, functionality, esthetics, and information sections (Medline was searched for eligible apps to check whether they had been tested in trials); and (3) an optional app-specific section. Furthermore, the output and input features were evaluated. Differences between MARS sections and between app purposes and correlations among MARS sections, star ratings, and numbers of reviews were evaluated.

Results

Of the 1376 apps identified, 14 were included: 12 related to food allergies and intolerances that detect 2-16 food allergens and 2 related only to gluten intolerance. The mean (SD) MARS scores (maximum 5 points) were 3.8 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5 (SD 0.6) for subjective quality; and 3.6 (SD 0.7) for the app-specific section. Therefore, a rating ≥3 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1, SD 0.6), esthetics (mean 4, SD 0.5), and information (mean 3.8, SD 0.4). However, when the apps were compared by purpose, critical points were identified: meal planner apps showed significantly higher engagement (mean 4.1, SD 0.4) than food product (mean 3.0, SD 0.6; P=.05) and restaurant (mean 3.2, SD 0.3; P=.02) apps.

Conclusions

In this systematic search of food allergy or intolerance apps, acceptable MARS quality was identified, although the engagement section for food product and restaurant purpose apps should be improved and the included apps should be tested in trials. The critical points identified in this systematic search can help improve the innovativeness and applicability of future food allergy and intolerance apps.

The Arabic Version of the Mobile App Rating Scale: Development and Validation Study

Background

With thousands of health apps in app stores globally, it is crucial to systemically and thoroughly evaluate the quality of these apps due to their potential influence on health decisions and outcomes. The Mobile App Rating Scale (MARS) is the only currently available tool that provides a comprehensive, multidimensional evaluation of app quality, which has been used to compare medical apps from American and European app stores in various areas, available in English, Italian, Spanish, and German. However, this tool is not available in Arabic.

Objective

This study aimed to translate and adapt MARS to Arabic and validate the tool with a sample of health apps aimed at managing or preventing obesity and associated disorders.

Methods

We followed a well-established and defined “universalist” process of cross-cultural adaptation using a mixed methods approach. Early translations of the tool, accompanied by confirmation of the contents by two rounds of separate discussions, were included and culminated in a final version, which was then back-translated into English. Two trained researchers piloted the MARS in Arabic (MARS-Ar) with a sample of 10 weight management apps obtained from Google Play and the App Store. Interrater reliability was established using intraclass correlation coefficients (ICCs). After reliability was ascertained, the two researchers independently evaluated a set of additional 56 apps.

Results

MARS-Ar was highly aligned with the original English version. The ICCs for MARS-Ar (0.836, 95% CI 0.817-0.853) and MARS English (0.838, 95% CI 0.819-0.855) were good. The MARS-Ar subscales were highly correlated with the original counterparts (P<.001). The lowest correlation was observed in the area of usability (r=0.685), followed by aesthetics (r=0.827), information quality (r=0.854), engagement (r=0.894), and total app quality (r=0.897). Subjective quality was also highly correlated (r=0.820).

Conclusions

MARS-Ar is a valid instrument to assess app quality among trained Arabic-speaking users of health and fitness apps. Researchers and public health professionals in the Arab world can use the overall MARS score and its subscales to reliably evaluate the quality of weight management apps. Further research is necessary to test the MARS-Ar on apps addressing various health issues, such as attention or anxiety prevention, or sexual and reproductive health.

Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review

OBJECTIVE

To summarize the research literature about safety concerns with consumer-facing health apps and their consequences.

MATERIALS AND METHODS

We searched bibliographic databases including PubMed, Web of Science, Scopus, and Cochrane libraries from January 2013 to May 2019 for articles about health apps. Descriptive information about safety concerns and consequences were extracted and classified into natural categories. The review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) statement.

RESULTS

Of the 74 studies identified, the majority were reviews of a single or a group of similar apps (n = 66, 89%), nearly half related to disease management (n = 34, 46%). A total of 80 safety concerns were identified, 67 related to the quality of information presented including incorrect or incomplete information, variation in content, and incorrect or inappropriate response to consumer needs. The remaining 13 related to app functionality including gaps in features, lack of validation for user input, delayed processing, failure to respond to health dangers, and faulty alarms. Of the 52 reports of actual or potential consequences, 5 had potential for patient harm. We also identified 66 reports about gaps in app development, including the lack of expert involvement, poor evidence base, and poor validation.

CONCLUSIONS

Safety of apps is an emerging public health issue. The available evidence shows that apps pose clinical risks to consumers. Involvement of consumers, regulators, and healthcare professionals in development and testing can improve quality. Additionally, mandatory reporting of safety concerns is needed to improve outcomes.

Smartphones in mental health: a critical review of background issues, current status and future concerns

There has been increasing interest in the use of smartphone applications (apps) and other consumer technology in mental health care for a number of years. However, the vision of data from apps seamlessly returned to, and integrated in, the electronic medical record (EMR) to assist both psychiatrists and patients has not been widely achieved, due in part to complex issues involved in the use of smartphone and other consumer technology in psychiatry. These issues include consumer technology usage, clinical utility, commercialization, and evolving consumer technology. Technological, legal and commercial issues, as well as medical issues, will determine the role of consumer technology in psychiatry. Recommendations for a more productive direction for the use of consumer technology in psychiatry are provided.

Needs Analysis for a Parenting App to Prevent Unintentional Injury in Newborn Babies and Toddlers: Focus Group and Survey Study Among Chinese Caregivers

Background

With the growing popularity of mobile health technology, app-based interventions delivered by smartphone have become an increasingly important strategy toward injury prevention.

Objective

This study aimed to develop a framework supporting the design of an app-based intervention to prevent unintentional injury, targeted for caregivers of Chinese children aged 0 to 6 years.

Methods

A theory-based mixed-method study, including focus groups and Web-based quantitative survey, was performed. Adult caregivers who care for children aged 0 to 6 years and own a smartphone were recruited into 2 sequential stages of research. First, focus groups were conducted among the caregivers at community health care centers and preschools from December 2015 to March 2016. Focus groups (8-10 participants per group) explored awareness, experiences, and opinions of caregivers toward using an app to prevent unintentional injury among children. Second, based on the focus groups findings, a Web-based quantitative survey was designed and distributed to caregivers in November 2016; it collected information on specific needs for the app-based intervention. Thematic analysis and quantitative descriptive analyses were performed.

Results

In total, 12 focus groups were completed, involving 108 caregivers. Most participants expressed a strong desire to learn knowledge and skills about unintentional child injury prevention and held positive attitudes toward app-based interventions. Participants expressed multiple preferences concerning the app-based intervention, including their contents, functions, interactive styles, installation and registration logistics, and privacy protection and information security. Following the focus groups, 1505 caregivers completed a WeChat-based quantitative survey, which generated roughly similar results to those of focus groups and added numerical metrics concerning participants’ preferences on what to learn, when to learn it, and how to learn it. A detailed framework was established involving 5 components: (1) content design, (2) functional design, (3) interactive style, (4) installation and registration logistics, and (5) privacy protection and information security, and 15 specific requirements.

Conclusions

We developed a framework that can be used as a guide to design app-based interventions for parents and caregivers, specifically for unintentional injury prevention of children aged 0 to 6 years.

Characteristics and quality of genetics and genomics mobile apps: a systematic review

Mobile applications (apps) have been increasingly utilized to access the latest and abundant information related to genetics/genomics for resources, risk assessments, and individualized recommendations. Nevertheless, the number and quality of the current apps in genetics/genomics remain unknown. Thus, in this review, we aimed to identify existing genetic/genomic apps, summarize their characteristics, and examine their quality. A systematic search of genetics/genomics apps was conducted on Apple Store and Google Play. We adapted a validated evaluation scale, Mobile App Rating Scale (MARS), to examine the quality of genetics/genomics apps. Eighty-eight genetics/genomics apps, with the cost ranging from free to $49.99, formed the final sample. Findings showed that the majority of the apps had reference/resource as a feature (95.5%), had health professional students as the target audience (86.4%), and did not focus on specific diseases (78.5%). Only 21.6% of the apps were developed by reliable or authoritative agencies, and the apps' overall quality was slightly above average based on the criteria of the MARS. Therefore, while genetics/genomics mobile apps might be useful resources, their quality still needs improvement, especially with respect to the credibility and evidence-based items of app information as well as the customization items of app engagement; caution must be taken when using those apps.

Assessing the Quality of Mobile Phone Apps for Weight Management: User-Centered Study With Employees From a Lebanese University

Background

Evaluating the quality of mobile health apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call for more research on multidimensional aspects of app quality, especially involving end users, as there are already many expert reviews on this domain. However, no quantitative study has investigated how laypersons see popular apps for weight management and perceive different dimensions of app quality.

Objective

This study aimed to explore how laypersons evaluate the quality of 6 free weight management apps (My Diet Coach, SparkPeople, Lark, MyFitnessPal, MyPlate, and My Diet Diary), which achieved the highest quality ratings in a related and recent expert review.

Methods

A user-centered study was conducted with 36 employees of a Lebanese university. Participants enrolled in the study on a rolling basis between October 2016 and March 2017. Participants were randomly assigned an app to use for 2 weeks. App quality was evaluated at the end of the trial period using the Mobile App Rating Scale user version (uMARS). uMARS assesses the dimensions of engagement, functionality, aesthetics, information, and subjective quality on 5-point scales. Internal consistency and interrater agreement were examined. The associations between uMARS scores and users’ demographic characteristics were also explored using nonparametric tests. Analyses were completed in November 2017.

Results

Overall, the 6 apps were of moderately good quality (median uMARS score 3.6, interquartile range [IQR] 0.3). The highest total uMARS scores were achieved by Lark (mean 4.0 [SD 0.5]) and MyPlate (mean 3.8 [SD 0.4]), which also achieved the highest subjective quality scores (Lark: mean 3.3 [SD 1.4]; MyPlate: mean 3.3 [SD 0.8]). Functionality was the domain with the highest rating (median 3.9, IQR 0.3), followed by aesthetics (median 3.7, IQR 0.5), information (median 3.7, IQR 0.1), and engagement (median 3.3, IQR 0.2). Subjective quality was judged low (median 2.5, IQR 0.9). Overall, subjective quality was strongly and positively related (P<.001) with total uMARS score (ρ=.75), engagement (ρ=.68), information, and aesthetics (ρ=.60) but not functionality (ρ=.40; P=.02). Higher engagement scores were reported among healthy (P=.003) and obese individuals (P=.03), who also showed higher total uMARS (P=.04) and subjective quality (P=.05) scores.

Conclusions

Although the apps were considered highly functional, they were relatively weak in engagement and subjective quality scores, indicating a low propensity of using the apps in the future. As engagement was the subdomain most strongly associated with subjective quality, app developers and researchers should focus on creating engaging apps, holding constant the functionality, aesthetics, and information quality. The tested apps (in particular Lark and MyPlate) were perceived as more engaging and of higher quality among healthy, obese individuals, making them a promising mode of delivery for self-directed interventions promoting weight control among the sampled population or in similar and comparable settings.

Mobile Apps for Management of Tinnitus: Users' Survey, Quality Assessment, and Content Analysis

Background

Tinnitus is the perception of a sound without any outside source. It affects 6 million people in the United Kingdom. Sound therapy is a core component of many tinnitus management programs. Potential mechanisms of benefit include making tinnitus less noticeable, habituation, distracting attention from tinnitus, relaxation, and promoting neuroplastic changes within the brain. In recent years, there has been a substantial increase in the use of mobile technology. This provided an additional medium through which people with tinnitus can access different tinnitus management options, including sound therapy.

Objective

The aim of this study was to (1) generate the list of apps that people use for management of their tinnitus, (2) explore reasons for app use and nonuse, (3) perform quality assessment of the most cited apps, and (4) perform content analysis to explore and describe options and management techniques available in the most cited apps.

Methods

A Web-based survey consisting of 33 open and closed questions captured (1) demographic information, information about tinnitus, and hearing loss and (2) mobile app–specific information about the motivation to use an app, the apps which respondents used for tinnitus, important factors when choosing an app, devices used to access apps, and reasons for not using apps. The quality of the most cited apps was assessed using the Mobile Apps Rating Scale (MARS). Content and features of the most cited apps were analyzed.

Results

Data from 643 respondents were analyzed. The majority of respondents (482/643, 75.0%) had never used an app for management of tinnitus mainly because of lack of awareness (381/643, 59.3%). The list of the 55 apps that people use for their tinnitus was generated. These included apps that were developed specifically for the management of tinnitus; however, the majority of cited apps were developed for other problems (eg, sleep, depression or anxiety, and relaxation). Quality assessment of the 18 most popular apps using MARS resulted in a range of mean scores from 1.6 to 4.2 (out of 5). In line with the current model of tinnitus management, sound was the main focus of the majority of the apps. Other components included relaxation exercises, elements of cognitive behavioral therapy, information and education, and hypnosis.

Conclusions

People used apps for the management of their tinnitus; however, this was done mostly as a self-help option, without conjunction with management provided by hearing health care professionals. Further research should consider the place for apps in tinnitus management (stand-alone self-management intervention vs part of the management by a hearing professional). As the content of the apps varies with respect to sound options, information, and management strategies, it seems that the choice of the best management app should be guided by individual patient’s needs and preferences.

Use of Mental Health Apps by Breast Cancer Patients and Their Caregivers in the United States: Protocol for a Pilot Pre-Post Study

Background

Over one-third of cancer patients experience clinically significant mental distress, and distress in caregivers can exceed that of the cancer patients for whom they care. There is an urgent need to identify scalable and cost-efficient ways of delivering mental health interventions to cancer patients and their loved ones.

Objective

The aim of this study is to describe the protocol to pilot a mobile app–based mental health intervention in breast cancer patients and caregivers.

Methods

The IntelliCare mental health apps are grounded in evidence-based research in psychology. They have not been examined in cancer populations. This pilot study will adopt a within-subject, pre-post study design to inform a potential phase III randomized controlled trial. A target sample of 50 individuals (with roughly equal numbers of patients and caregivers) at least 18 years of age and fluent in English will be recruited at a US National Cancer Institute designated clinical cancer center. Consent will be obtained in writing and a mobile phone will be provided if needed. Self-report surveys assessing mental health outcomes will be administered at a baseline session and after a 7-week intervention. Before using the apps, participants will receive a 30-min coaching call to explain their purpose and function. A 10-min coaching call 3 weeks later will check on user progress and address questions or barriers to use. Self-report and semistructured interviews with participants at the end of the study period will focus on user experience and suggestions for improving the apps and coaching in future studies.

Results

This study is ongoing, and recruitment will be completed by the end of 2018.

Conclusions

Results from this study will inform how scalable mobile phone-delivered programs can be used to support breast cancer patients and their loved ones.

Trial Registration

ClinicalTrials.gov NCT03488745; https://clinicaltrials.gov/ct2/show/NCT03488745

International Registered Report Identifier (IRRID)

DERR1-10.2196/11452

Dichotomies in the Development and Implementation of Digital Mental Health Tools

The uptake and clinical adoption of digital mental health tools, such as smartphone apps, remain limited. Although some technology barriers remain, the greatest challenges are no longer technical. Instead, dichotomous directions and efforts divide the space and limit the potential of digital tools. This column focuses on six of these dichotomies, including randomized trials versus pragmatic studies, precision medicine versus population health, free market versus regulation, consumer versus clinical uses, big data versus privacy, and open versus proprietary software. Because no panacea exists, the authors suggest a more flexible approach to the uptake and clinical adoption of digital mental health tools-an approach that offers a pragmatic solution to better appreciate the landscape and pave the way toward progress.

Behavior Change for Youth Drivers: Design and Development of a Smartphone-Based App (BackPocketDriver)

Background

The over-representation of youth in road crash injury and fatality rates is a major public health issue globally. In New Zealand, youth drivers are most vulnerable in the restricted license period when they can drive without the requirement for supervision by an experienced adult. Behavioral change interventions delivered using mobile phone technology to young drivers could serve as a useful mechanism to develop safe driving skills, but this potential remains to be fully explored.

Objective

This study aimed to apply behavioral change principles to design and develop a smartphone-based intervention with the aim of helping youth drivers to develop and hone safe driving skills.

Methods

An iterative process was used to support development of the smartphone intervention. We reviewed behavioral change literature, identifying fundamental principles and exploring use of behavior change techniques (BCTs) in other areas of public health. We engaged with key stakeholders, including young drivers, government agencies, and relevant organizations. We also took into account technology adoption considerations when designing the app.

Results

We developed BackPocketDriver (BPD), an Android smartphone app that uses in-built sensors to monitor and infer driver behavior. The app implements features that were identified during the design process and are traceable to BCTs and theory. A key feature is messaging, which is used to instruct, motivate, educate, and relay feedback to participants. In addition, messaging addresses attitudes and beliefs. Other features include journey feedback summaries, goal setting, achievements, and leaderboards.

Conclusions

BPD’s design rests on a sound foundation of theory and evidence. With explicit links between theory and features, the app aims to be an effective intervention to change and improve youth driver behavior. The next phase of this study is to run a small pilot study to assess BPD’s effectiveness.

Mobile Apps for Blood Pressure Monitoring: Systematic Search in App Stores and Content Analysis

BACKGROUND

Using a mobile app for self-management could make it easier for patients to get insight into their blood pressure patterns. However, little is known about the availability, quality, and features of mobile apps targeting blood pressure.

OBJECTIVE

The goal of the research was to determine the availability, functionality, and quality of mobile apps that could be used for blood pressure monitoring purposes.

METHODS

A systematic app search was performed based on the standards for systematic reviews. We searched the Dutch official app stores for Android and iOS platforms using predefined keywords and included all English and Dutch mobile apps targeting blood pressure. Two independent assessors determined eligibility and quality of the apps using the 5-point Mobile App Rating Scale (MARS). Quality scores of the apps with and without 17 a priori selected characteristics were compared using independent sample t tests.

RESULTS

A total of 184 apps (104 Android, 80 iOS) met the inclusion criteria. The mean overall MARS score was 2.63 (95% CI 2.55-2.71) for Android and 2.64 (95% CI 2.56-2.71) for iOS. The apps Bloeddruk (4.1) and AMICOMED BP (3.6) had the highest quality scores on the Android and iOS platforms, respectively. Of the app characteristics recorded, only pricing, in-app advertisements, and local data storage were not associated with the quality scores. In only 3.8% (7/184) of the apps, involvement of medical experts in its development was mentioned, whereas none of the apps was formally evaluated with results published in a peer-reviewed journal.

CONCLUSIONS

This study provides an overview of the best apps currently available in the app stores and important key features for self-management that can be used by health care providers and patients with hypertension to identify a suitable app targeting blood pressure monitoring. However, the majority of the apps targeting blood pressure monitoring were of poor quality. Therefore, it is important to involve medical experts in the developmental stage of health-related mobile apps to improve the quality of these apps.

A systematic evaluation of mobile apps to improve the uptake of and adherence to HIV pre-exposure prophylaxis

Background Pre-exposure prophylaxis, or PrEP, has been shown to be effective at reducing the risk of HIV infection, yet persons at-risk for acquiring HIV exhibit suboptimal uptake of and adherence to this prevention modality. Although PrEP use among all at-risk groups is low, mobile apps have been shown to increase the use of PrEP; however, it is unknown whether currently available apps have been designed with features to facilitate PrEP uptake and adherence.

METHODS

The Google Play store and Apple App store were systematically searched for currently available PrEP-related apps. A qualitative evaluation was conducted on apps that met the inclusion criteria for the presence of features that can contribute to PrEP uptake and adherence, and the quality of apps was assessed using the Mobile Apps Rating Scale (MARS) tool.

RESULTS

From the systematic search, less than 2% (11/621) of the identified apps were relevant to improving PrEP uptake and adherence. Demonstrating a moderate capacity for facilitating PrEP use, the 11 PrEP-related apps, on average, contained features that addressed two of four factors that can contribute to the uptake of PrEP, particularly features that provided comprehensive information on PrEP and resources to locate providers and clinics offering PrEP services. Findings from the app quality assessment suggested that existing PrEP-related apps are of acceptable quality (mean overall MARS score: 3.2 on a five-point scale).

CONCLUSION

Overall, currently available mobile apps for PrEP demonstrate some promise as potential avenues for increasing PrEP uptake and adherence among persons at-risk for HIV infection.

Smartphone Applications to Support Sleep Self-Management: Review and Evaluation

STUDY OBJECTIVES

Mobile health (mHealth) tools such as smartphone applications (apps) have potential to support sleep self-management. The objective of this review was to identify the status of available consumer mHealth apps targeted toward supporting sleep self-management and assess their functionalities.

METHODS

We searched four mobile app stores (iTunes Appstore, Android Google Play, Amazon Appstore, and Microsoft Appstore) using the terms "sleep", "sleep management," "sleep monitoring," and "sleep tracking." Apps were evaluated using the Mobile Application Rating Scale (MARS) and the IMS Institute for Healthcare Informatics functionality scores.

RESULTS

We identified 2,431 potentially relevant apps, of which 73 met inclusion criteria. Most apps were excluded because they were unrelated to sleep self-management, simply provided alarm service, or solely played relaxation sounds in an attempt to improve sleep. The median overall MARS score was 3.1 out of 5, and more than half of apps (42/73, 58%) had a minimum acceptability score of 3.0. The apps had on average 7 functions based on the IMS functionality criteria (range 2 to 11). A record function was present in all apps but only eight had the function to intervene. About half of the apps (33/73, 45%) collected data automatically using embedded sensors, 27 apps allowed the user to manually enter sleep data, and 14 apps supported both types of data recording.

CONCLUSIONS

The findings suggest that few apps meet prespecified criteria for quality, content, and functionality for sleep self-management. Despite the rapid evolution of sleep self-management apps, lack of validation studies is a significant concern that limits the clinical value of these apps.

Effectiveness of an app-based intervention for unintentional injury among caregivers of preschoolers: protocol for a cluster randomized controlled trial

Background

Each year, over 15,000 preschoolers die from unintentional injuries in China. Many interventions proven to work in other nations have not been implemented nationwide in China. The rapid popularity of smartphones offers an opportunity to overcome this limitation and disseminate evidence-based interventions to the large population of China. This study aims to assess the effectiveness of an app-based intervention for caregivers of preschoolers to prevent unintentional injury among young Chinese children.

Method

A single-blinded, 6-month, parallel-group cluster randomized controlled trial with 1:1 allocation ratio will be conducted in Changsha, China. In total, 2626 caregivers of preschoolers ages 3–6 years old who own a smartphone will be recruited from 20 preschools. Clusters will be randomized at the preschool level and allocated to either the control group (routine education plus app-based parenting education excluding unintentional injury prevention) or the intervention group (routine education plus app-based parenting education including unintentional injury prevention). The app-based injury prevention program was developed based on the Theory of Planned Behavior, the Haddon Matrix, the Mobile Learning framework, and a needs assessment. Data collection will be conducted at baseline, 3-month, and 6-month follow-up via app-based survey plus printed questionnaire survey. The primary outcome measure is unintentional injury incidence among preschoolers in the past 3 months. Secondary outcome measures include economic losses due to unintentional injury in the past 3 months, the Incremental Cost-Effectiveness Ratios (ICERs), and parent’s attitudes and behaviors concerning supervision to prevent preschooler unintentional injury in the past week. An intention-to-treat approach will be used to evaluate outcome measures. Chi-square tests will examine differences for outcome measures between groups at each time point and generalized estimation equations (GEE) will test the overall effectiveness of the app-based intervention. Missing outcome data will be imputed using the Expectation Maximization algorithm (EM).

Discussion

This trial will examine evidence concerning the effectiveness of an innovative app-based intervention for caregivers of Chinese preschoolers. If effective, the app-based intervention could offer an effective population-based intervention option to cost-effectively promote unintentional injury prevention in countries and regions where injury control is under-supported.

Trial registration

ChiCTR-IOR-17010438. Registered 15 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5790-1) contains supplementary material, which is available to authorized users.

A qualitative study of barriers to genetic counseling and potential for mobile technology education among women with ovarian cancer

Background

National guidelines recommend genetic counseling for all ovarian cancer patients because up to 20% of ovarian cancers are thought to be due to hereditary cancer syndromes and effective cancer screening and prevention options exist for at-risk family members. Despite these recommendations, uptake of genetic counselling and testing is low. The goal of this study was to identify barriers to and motivators for receipt of genetic counseling along with preferences regarding potential use of a mobile application to promote genetic counseling.

Methods

Three focus groups were conducted including 14 women with a diagnosis of epithelial ovarian, primary peritoneal or fallopian tube cancer. Topics included understanding of genetic counseling, perceived pros and cons, preferences for receiving health information, and familiarity with mobile phone technology. Transcripts were analyzed using standard procedures of qualitative thematic text analysis and descriptive coding techniques.

Results

Six major themes regarding barriers to and motivators of genetic counseling and use of mobile technology in promoting genetic counseling emerged: (1) need for information, (2) relevance, (3) emotional concerns, (4) family concerns, (5) practical concerns, and (6) mobile application considerations.

Conclusions

These data reiterate previously reported barriers to genetic counseling as observed in other populations. Participants were supportive of the use of mobile technology for promoting uptake of genetic counseling.

Sexual Abuse Prevention Mobile Application (SAP_MobAPP) for Primary School Children in Korea

This study aimed to develop and evaluate the effects of a sexual abuse prevention mobile application, SAP_MobAPP, for primary school children. Forty-five subjects were trained for 40 minutes once a week. The experimental group received education that utilized the SAP_MobAPP. Control group A received Web based sexual abuse prevention education, while control group B received textbook based sexual abuse prevention education. Effectiveness was verified through a survey on child sexual abuse recognition and avoidance skills administered before and after training. The SAP_MobAPP program improved recognition (awareness) and the child's skills to avoid child sexual abuse situations, and the effects were long-lasting. However, differences between groups were not statistically significant. This study developed a sexual abuse prevention application and verified its effectiveness. Awareness and skills to avoid child sexual abuse after app education increased immediately after training and four weeks later. The SAP_MobAPP could be used for sexual abuse prevention education in schools.

Mobile Apps for Eye Care in Canada: An Analysis of the iTunes Store

Background

Mobile phone screens can facilitate stimulation to various components of the visual system and many mobile apps are accepted as a means of providing clinical assessments for the oculo-visual system. Although many of these apps are intended for use in clinical settings, there is a growing number of apps in eye care developed for self-tests and eye exercises for lay people. These and other features, however, have not yet been well described.

Objective

Our objective was to identify, describe, and categorize mobile apps related to eye care that are available to users in the Canadian iTunes market.

Methods

We conducted an extensive search of the Apple iTunes Store for apps related to eye care. We used the terms “eye,” “eye care,” “vision,” and “eye test” and included apps that are targeted at both lay people and medical professionals. We excluded apps whose primary function is not related to eye care. Eligible apps were categorized by primary purpose, based on how they were described by their developers in the iTunes Store.

Results

Our search yielded 10,657 apps, of which 427 met our inclusion criteria. After removing duplicates, 355 unique apps were subject to further review. We assigned the eligible apps to three distinct categories: 39/355 apps (11.0%) were intended for use by medical professionals, 236 apps (66.5%, 236/355) were intended for use by lay people, and 80 apps (22.5%, 80/355) were intended for marketing eye care and eye-care products. We identified 9 subcategories of apps based on the descriptions of their primary functions. Apps for medical professionals fell into three subcategories: clinical calculators (n=6), clinical diagnostic tools (n=18), and education and networking apps for professionals (n=15). Apps for lay people fell into four subcategories: self-testing (n=153), eye exercises (n=30), patient tools and low vision aids (n=35), and apps for patient education (n=18). Mixed-use apps (n=80) were placed into two subcategories: marketing of individual practitioners or eye-care products (n=72) and marketing of multiple eye-care products or professional services.

Conclusions

The most extensive subcategory pertaining to eye care consisted of apps for use by lay people, especially for conducting self-tests (n=236). This study revealed a previously uncharacterized category of apps intended for use by doctors and patients, of which the primary goal is marketing of eye-care services and products (n=80).