User Needs in the Development of a Health App Ecosystem for Self-Management of Cystic Fibrosis: User-Centered Development Approach

Cross-Cutting mHealth Behavior Change Techniques to Support Treatment Adherence and Self-Management of Complex Medical Conditions: Systematic Review

Background

Mobile health (mHealth) interventions have immense potential to support disease self-management for people with complex medical conditions following treatment regimens that involve taking medicine and other self-management activities. However, there is no consensus on what discrete behavior change techniques (BCTs) should be used in an effective adherence and self-management-promoting mHealth solution for any chronic illness. Reviewing the extant literature to identify effective, cross-cutting BCTs in mHealth interventions for adherence and self-management promotion could help accelerate the development, evaluation, and dissemination of behavior change interventions with potential generalizability across complex medical conditions.

Objective

This study aimed to identify cross-cutting, mHealth-based BCTs to incorporate into effective mHealth adherence and self-management interventions for people with complex medical conditions, by systematically reviewing the literature across chronic medical conditions with similar adherence and self-management demands.

Methods

A registered systematic review was conducted to identify published evaluations of mHealth adherence and self-management interventions for chronic medical conditions with complex adherence and self-management demands. The methodological characteristics and BCTs in each study were extracted using a standard data collection form.

Results

A total of 122 studies were reviewed; the majority involved people with type 2 diabetes (28/122, 23%), asthma (27/122, 22%), and type 1 diabetes (19/122, 16%). mHealth interventions rated as having a positive outcome on adherence and self-management used more BCTs (mean 4.95, SD 2.56) than interventions with no impact on outcomes (mean 3.57, SD 1.95) or those that used >1 outcome measure or analytic approach (mean 3.90, SD 1.93; P=.02). The following BCTs were associated with positive outcomes: self-monitoring outcomes of behavior (39/59, 66%), feedback on outcomes of behavior (34/59, 58%), self-monitoring of behavior (34/59, 58%), feedback on behavior (29/59, 49%), credible source (24/59, 41%), and goal setting (behavior; 14/59, 24%). In adult-only samples, prompts and cues were associated with positive outcomes (34/45, 76%). In adolescent and young adult samples, information about health consequences (1/4, 25%), problem-solving (1/4, 25%), and material reward (behavior; 2/4, 50%) were associated with positive outcomes. In interventions explicitly targeting medicine taking, prompts and cues (25/33, 76%) and credible source (13/33, 39%) were associated with positive outcomes. In interventions focused on self-management and other adherence targets, instruction on how to perform the behavior (8/26, 31%), goal setting (behavior; 8/26, 31%), and action planning (5/26, 19%) were associated with positive outcomes.

Conclusions

To support adherence and self-management in people with complex medical conditions, mHealth tools should purposefully incorporate effective and developmentally appropriate BCTs. A cross-cutting approach to BCT selection could accelerate the development of much-needed mHealth interventions for target populations, although mHealth intervention developers should continue to consider the unique needs of the target population when designing these tools.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Epilepsy self-management mobile health application: A needs assessment in people with epilepsy and caregivers in Viet Nam

OBJECTIVES

This study aimed to determine (1) the needsof Vietnamese people with epilepsy (PWE) and their caregivers for self-management mobile health applications and (2) the self-management features expected to be included in an application.

METHODS

The survey consisted of an anonymous self-administered questionnaire that was distributed to PWE and caregivers from the age of 18 in Vietnam through online platforms and onsite at Nguyen Tri Phuong Hospital and University Medical Center, Ho Chi Minh City, from February 2022 to May 2022. The questionnaire assessed the participants' attitudes toward epilepsy self-management mobile applications, their willingness to use applications, and their expectations of the contents of an application.

RESULTS

Responses from 103 participants were submitted. Eighty-one participants (78.6%) reported using a smartphone, but only 50.6% of those claimed to know about self-management applications. Most respondents (70.9%) thought the applications would be useful for disease self-management, and 68.9% were willing to use epilepsy self-management applications. In addition, the most expected features to be included in self-management applications were epilepsy information, seizure first aid, connecting with medical professionals, and a seizure diary.

CONCLUSION

Most Vietnamese PWE and caregivers had a willingness to use epilepsy self-management applications.The expected features are related to all aspects of self-management, including information, seizure, medication, and safety management.

How to establish digital health ecosystems from the perspective of health service-organizations: A taxonomy developed based on expert interviews conducted as modified Delphi approach

Objective

Digital health ecosystems may be the next revolution in improving citizens' well-being, health delivery, data management, and health system processes, but solutions have not yet been broadly established. Reasons could be that health service-organizations have misaligned interests or lack capabilities. This study investigates reasons from a multi-health-service-organization perspective, differentiating between payers, insurers, healthcare providers, and innovators, detailing the expected value-adds, preferred participation roles, and required capabilities including a rating assessment.

Methods

Findings are based on a taxonomy development methodology, which combines a literature review with semi-structured qualitative expert interviews, conducted using a modified Delphi approach. Interviews were thematically analysed.

Results

In total, 21 experts across the four health service-organization groups were interviewed. The capability taxonomy includes a total of 16 capabilities, categorized in three themes: 'Health market', 'organizational', and 'technology and informatic'. Providers expect a value-add from strengthening their health process economics through efficiency gains but reveal the largest capability gaps, especially in 'interoperability' and 'platform'. Innovators' 'technology and informatic' capabilities complement well with those of payers for the 'health market'.

Conclusions

We present a health service-organization-specific three-stage approach for establishing digital health ecosystems. Payers and insurers should address their 'technology and informatic' capability gaps, using technical enablers or forming new entities to reduce dependencies from legacy information technology systems. Innovators should clarify their monetization models and create positive awareness for their services, possibly entering the market directly. Providers must address interoperability issues and may require incentives to encourage their participation. Findings suggest governmental policymakers to prioritize three health policy initiatives.

Understanding citizens' attitudes within user-centered digital health ecosystems: A sequential mixed method methodology including a web-survey

Objective

Transitioning from digital health applications to digital health ecosystems, leveraging the advances in technologies and informatics, could be the next revolution in digital health. This includes offering centralized access to various health services and improving citizens' well-being, delivery, clinical processes, and data management. However, a limited understanding of citizens may impede adaptation. Therefore, this study investigates citizens' attitudes within digital health ecosystems, differentiated by their characteristics, to support health service-providers and governmental policymakers in establishing user-centered solutions.

Methods

This study follows a three-step sequential mixed method methodology: (1) a literature review. (2) Qualitative thematic analyses based on semi-structured qualitative interviews. (3) Quantitative analyses based on a web-survey (descriptive statistics, one-way analysis of variances, Tukey-honestly, and Cohen's d tests).

Results

N = 15 citizens were interviewed and n = 1289 responded to the web-survey, to our knowledge the largest survey on this topic. Citizens desire a more convenient management of health services and data (M = 5.2, SD = 1.59). Services with peer-to-peer interactions (M = 3.7, SD = 1.81) and lower involvement of health professionals (M = 3.8, SD = 1.75) are less demanded. Data protection is critical (M = 6.2, SD = 1.23). Public payers are mandated as orchestrators (M = 4.3, SD = 1.99), while private companies receive lower acceptance (M = 3.0, SD = 1.42).

Conclusions

Health service-providers could follow a three-staged approach to establish digital health ecosystems: (1) Increasing the convenience for citizens by enabling online management of health services and data. (2) Extending the citizen-healthcare provider partnership through online interactions. (3) Fostering preventative behaviors and quicker recovery by personalizing health services and interactions. Governmental policymakers should integrate an electronic health record.

A content-based review of mobile health applications for breast cancer prevention and education: Characteristics, quality and functionality analysis

Objective

Mobile Health apps could be a feasible and effective tool to raise awareness for breast cancer prevention and to support women to change their behaviour to a healthier lifestyle. The aim of this study was to analyse the characteristics and quality of apps designed for breast cancer prevention and education.

Methods

We conducted a systematic search for apps covering breast cancer prevention topics in the Google Play and Apple App Store accessible from Germany using search terms either in German or in English. Only apps with a last update after June 2020 were included. The apps identified were downloaded and evaluated by two independent researchers. App quality was analysed using the Mobile Application Rating Scale (MARS). Associations of app characteristics and MARS rating were analysed.

Results

We identified 19 apps available in the Google Play Store and seven apps available in the Apple App Store that met all inclusion criteria. The mean MARS score was 3.07 and 3.50, respectively. Functionality was the highest-scoring domain. Operating system, developer (healthcare), download rates and time since the last update were significantly associated with overall MARS score. In addition, the presence of the following app functions significantly influenced MARS rating: breast self-examination tutorial, reminder for self-examination, documentation feature and education about breast cancer risk factors.

Conclusions

Although most of the apps offer important features for breast cancer prevention, none of the analysed apps combined all functions. The absence of healthcare professionals' expertise in developing apps negatively affects the overall quality.

Parent and clinician perceptions and recommendations on a pediatric cancer pain management app: A qualitative co-design study

Pain is one of the most prevalent and burdensome pediatric cancer symptoms for young children and their families. A significant proportion of pain episodes are experienced in environments where management options are limited, including at home. Digital innovations such as apps may have positive impacts on pain outcomes for young children in these environments. Our overall aim is to co-design such an app and the objective of this study was to explore the perceptions of children's parents about app utility, needed system features, and challenges. We recruited parents of young children with cancer and multidisciplinary pediatric oncology clinicians from two pediatric cancer care centers to participate in audio-recorded, semi-structured, co-design interviews. We conducted interviews structured around technology acceptance and family caregiving theories until data saturation was reached. Audio-recordings were then transcribed, coded, and analyzed using thematic analysis. Forty-two participants took part in the process. Participants endorsed the concept of an app as a useful, safe, and convenient way to engage caregivers in managing their young child's pain. Overall, the app was valued as a means to provide real-time, multimodal informational and procedural pain support to parents, while also reducing the emotional burden of pain care. Recommendations for intervention design included accessibility-focused features, comprehensive symptom tracking, and embedded scientific- and clinically-sound symptom assessments and management advice. Predicted challenges to app use included the workload burden it may place on parents and clinicians. The insights gathered will inform the design principles of our future childhood cancer pain digital research.

Mobile health platform for self-management of pediatric cystic fibrosis: Impact on patient-centered care outcomes

BACKGROUND

Previously, we adapted a mobile health platform (Genia) to the needs of patients and families in a pediatric CF center in the United States. In this feasibility study, we tested the impact of Genia on measures of patient-centered care.

METHODS

In a one-group pre-post study with adolescents with CF and caregivers of children with CF, we tested Genia's effect over 6 months on patient satisfaction with chronic illness care (PACIC) and shared decision-making (CollaboRate). Feasibility and acceptability were assessed with exit interviews and app analytics.

RESULTS

The intervention included 40 participants: 30 caregivers of children with CF age ≤14 years and 10 patients with CF age ≥15 years. The use of Genia was associated with increased satisfaction with care (p = 0.024), including delivery system and decision support (p = 0.017), goal setting (p = 0.006), and shared decision-making (p<0.001). The use of Genia was associated with nominal improvements in all QOL domains and symptom scales. The platform was feasible, with participants recording more than 4,400 observations (mean 84.2) and submitting 496 weekly reports (mean 13.8) and 70 quarterly reports (mean 1.8), and acceptable (95% retention rate). For participants, the most useful app feature was pre-visit reports (66.7%), and the top symptom trackers were those for cough (23.7%), appetite (21.1%), energy (18.4%), and medicines (18.4%).

CONCLUSION

The use of Genia over 6 months was feasible, acceptable, and associated with improved measures of patient-centered care. Study results support wider use of Genia in clinical settings. Efficacy for clinical outcomes should be assessed in a randomized clinical trial.

Understanding User Requirements for a Senior-Friendly Mobile Health Application

The advancement of mobile technologies has motivated countries around the world to aim for smarter health management to support senior citizens. However, the use of mobile health applications (mHealth apps) among senior citizens appears to be low. Thus, drawing upon user expectations, the present study examined user requirements for a senior-friendly mHealth application. A total of 74 senior citizens were interviewed to explore the difficulties they encounter when using existing mobile apps. This study followed Nielsen’s usability model to identify user requirements from five aspects, namely learnability, efficiency, memorability, error, and satisfaction. Based on the results, a guideline was proposed pertaining to usability and health management features. This guideline offers suggestions for mHealth app issues related to phrasing, menus, simplicity, error messages, icons and buttons, navigation, and layout, among others. The study also found that speech recognition technology can help seniors access information quickly. The proposed guideline and findings offer valuable input for software and app developers in building more engaging and senior-friendly mHealth apps.

Validation and usability study of the framework for a user needs-centered mHealth app selection

BACKGROUND

Most mHealth app users rely on an app's rankings, star ratings, or reviews, which may not reflect users' individual healthcare needs. To help healthcare providers, researchers, and users select an optimal mHealth app, the Method of App Selection based on User Needs (MASUN) 1.0¹ was developed and tested in prior research. Initial testing found the need for improvement.

OBJECTIVE

This multiple-phase study aimed to simplify and improve MASUN 1.0, resulting in MASUN 2.0, and verify the feasibility and usability of MASUN 2.0.

METHODS

This study was conducted in three phases: (1) modification of MASUN 1.0 to improve its importance, applicability, relevance, and clarity, in consultation with 21 experts in medical or nursing informatics; (2) validation of the draft MASUN 2.0, with 13 experts; and (3) feasibility testing of MASUN 2.0 and usability evaluation of the best app found through MASUN 2.0. Menstrual apps were used to test the framework.

RESULTS

From Phases 1 and 2, MASUN 2.0, the framework for mHealth App selection, was derived with improved simplicity, usability, and applicability through a reduced number of tasks and time required. In Phase 3, after screening and scoring 2377 menstrual apps, five candidate apps were selected and evaluated by five clinical experts, five app experts, and five potential users. Finally, 194 users evaluated the usability of the app selected as the best. The best app helped users understand their health-related syndromes and patterns. Additionally, user-provided scores for impact, usefulness, and ease of use for the app were higher than for others.

CONCLUSIONS

This study successfully modified MASUN 1.0 into MASUN 2.0 and verified MASUN 2.0 through content validity, feasibility, and usability testing. The selected apps through MASUN 2.0 helped health consumers more easily address health discomfort. Future research should extend this work to an automated system and different medical conditions with multiple stakeholders for digital health equity.

Study of the factors influencing the use of MyData platform based on personal health record data sharing system

Background

The application of telemedicine and electronic health (eHealth) technology has grown in importance during the COVID-19 pandemic, and a new approach in personal data management and processing MyData, has emerged. Data portability and informational self-determination are fundamental concepts of MyData. This study analysed the factors that influence acceptance of the MyData platform, which, reflects the right to self-determine personal data.

Methods

The study involved participants having experience using the MyData platform, and the key factors of the unified theory of acceptance and use of technology were used in the research model (performance expectancy, effort expectancy, social influence, facilitation condition and behavioural intention to use). The questionnaire comprided 27 items, and system usage log data were used to confirm that behavioural intention to use affected actual use behaviour through structural equation modeling.

Results

In total, 1153 participants completed the survey. The goodness of fit in the structural equation model indices indicates that the data fit the research model well. Performance expectancy, social influence, and facilitating conditions had direct effects on behavioural intention to use. We used system usage log data to confirm that behavioural intention to use positively affected actual use behaviour. The impact of the main factors in the unified theory of acceptance and use of technology was not moderated by age or gender, except for performance expectancy.

Conclusions

This study is the first to examine the factors influencing the use of the MyData platform based on the personal health record data sharing system in Korea. In addition, the study confirmed the use behaviour of the MyData platform utilising the system’s actual usage log for each function and analysing the effect of the intention of use on actual use. Our study serves as a significant foundation for the acceptance of data portability and sharing concepts. It also lays the foundation for expanding the data economy and ecosystem in the pandemic era.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01929-z.

Achieving the potential of mHealth in medicine requires challenging the ethos of care delivery

Mobile Health (mHealth) interventions have received a mix of praise and excitement, as well as caution and even opposition over recent decades. While the rapid adoption of mHealth solutions due to the COVID-19 pandemic has weakened resistance to integrating these digital approaches into practice and generated renewed interest, the increased reliance on mHealth signals a need for optimizing development and implementation. Despite an historically innovation-resistant medical ethos, mHealth is becoming a normalized supplement to clinical practice, highlighting increased demand. Reaching the full potential of mHealth requires new thinking and investment. The current challenge to broaden mHealth adoption and to ensure equity in access may be overcoming a “design purgatory,” where innovation fails to connect to practice. We recommend leveraging the opportunity presented by the COVID-19 pandemic to disrupt routine practice and with a new focus on theory-driven replicability of mHealth tools and strategies aimed at medical education and professional organizations.

Methods for Human-Centered eHealth Development: Narrative Scoping Review

Background

Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes.

Objective

The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods.

Methods

We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach.

Results

In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided.

Conclusions

This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.

Digital Economy and Health: Does Green Technology Matter in BRICS Economies?

The present study attempts to examine the impact of digitization and green technology on the health outcomes of BRICS countries over the period of 1993-2019. Internet users measure digitalization, and health outcome is determined by life expectancy. The study employed the ARDL estimation approach for empirical investigation of country-specific analysis. GDP per capita and current health expenditures have been incorporated as control variables. The study findings reveal that digitalization results in increasing life expectancy in the long-run in BRICS except for Brazil. While green technology tends to enhance life expectancy in the long-run in Russia and China, it produces an insignificant impact on health outcomes in the short-run. While GDP and health expenditures also improve life expectancy in mostly BRICS economies in the long-run and short-run. Our study provides some policy implications for BRICS nations.

User Requirements for Co-Managed Digital Health & Care (Preprint)

Background

The sustainability of health and social care has led to an imperative to shift the balance of care to communities and support person-centered, integrated, preventive, comanaged, and sustainable care. The digital tool set can support this shift; however, it must extend beyond a clinical focus to include broader personal, social, and environmental needs, experiences, and outcomes. The existing digital health and care design and user requirements literature focuses mainly on specific digital products or design methods. There is little whole-system or whole-of-life consideration, which is crucial to enacting more significant transformations that span different groups and domains.

Objective

This study aimed to present a set of recurring user requirements and themes for comanaged digital health and care services derived from the body of co-design projects within a digital health and care program. This study aimed to enable people and organizations looking to reorient their approach to health and care research and delivery from a system-led and condition-specific approach to a more person-centric, whole-of-life model.

Methods

Participatory design formed the core methodological approach in underlying the design research, from which user requirements were derived. The process of surfacing requirements involved a selection framework for the identification of eligible projects and a structured review process to consolidate user requirements.

Results

This paper presents a set of 14 common user requirements that resulted from a review of co-design projects. The findings demonstrate overlapping and reinforcing sets of needs from citizens and care professionals related to how data are comanaged to improve care and outcomes. This paper discusses the alignment, contrasts, and gaps with broader, comparable literature. It highlights consensus around requirements for personal health storytelling, sharing data on care experiences and how this can support personalized guidance, visualize trends to support decision-making, and generally improve dialog between a citizen and care professionals. These findings identify gaps around how groups and networks of people engage, posing difficult questions for people designing support services as some of the user requirements are not easily met by organizations operating in silos.

Conclusions

This study proposes future recommendations for citizens as active, informed, and consenting partners using new forms of privacy-preserving digital infrastructure that puts the citizen in firm control. It is also recommended that these findings be used by people developing new digital services to ensure that they can start with knowledge of the broader user requirement context. This should inform domain-specific research and development questions and processes. Further work is needed to extend these common requirements to more explicitly consider the trust framework required when citizens comanage their data and care across a broad range of formal and informal actors. Consideration of how authority, delegation, and trust function between members of the public will be critical.

Professionals' and Students' Perceived Needs for an Online Supportive Application for Reducing School Absence and Stimulating Reintegration: Concept Mapping Study

Background

To limit students’ medical absenteeism and premature school dropout in the Netherlands, the Medical Advice for Sick-reported Students (MASS) intervention was developed to enhance collaboration between students, parents, school, and health care professionals. MASS reduces medical absenteeism. However, it does not yet optimally support professionals in monitoring students nor automatically stimulating students’ autonomy regarding their situation.

Objective

This study aimed to identify professionals’ and students’ perceived need for an online supportive application to monitor and reduce absenteeism and stimulate student autonomy and school reintegration.

Methods

Concept mapping sessions were held with professionals (n=23) and secondary school students (n=27) in group meetings or online to identify their perspectives and needs. Multidimensional scaling and hierarchical clustering were done with Ariadne 3.0 software. The resulting concept maps were reclustered and interpreted by 4 researchers.

Results

Three heterogeneous groups of professionals generated 17 clusters (135 unique statements), with a mean importance rating ranging from 2.9 to 4.6 on a Likert scale with scores ranging from 1 to 5. Three heterogeneous groups of secondary school students generated 18 clusters (95 unique statements), with a mean importance rating ranging from 3.2 to 4.6. Professionals considered as most important the following: easily accessible contact with students; supporting, motivating, and rewarding students; monitoring absent students; providing information to students and their parents; exchanging information between professionals. Students considered as most important the following: better teacher-student communication and respect; communication between school professionals on the one hand and parents, other professionals, and students on the other hand; guidance in missed learning materials and tests. Students perceived an online format for support as the obvious option.

Conclusions

Both professionals and students were positive about an online application to support students in dealing with medical absenteeism, especially considering the need for better and easily accessible contact between students and professionals. An eHealth or mobile health (mHealth) application addressing these aspects could stimulate student autonomy and have positive effects on medical absenteeism.

A Smartphone-Based Technique to Detect Dynamic User Preferences for Tailoring Behavioral Interventions: Observational Utility Study of Ecological Daily Needs Assessment

BACKGROUND

Mobile health apps are promising vehicles for delivering scalable health behavior change interventions to populations that are otherwise difficult to reach and engage, such as young adults with psychiatric conditions. To improve uptake and sustain consumer engagement, mobile health interventions need to be responsive to individuals' needs and preferences, which may change over time. We previously created an ecological daily needs assessment to capture microprocesses influencing user needs and preferences for mobile health treatment adaptation.

OBJECTIVE

The objective of our study was to test the utility of a needs assessment anchored within a mobile app to capture individualized, contextually relevant user needs and preferences within the framework of a weight management mobile health app.

METHODS

Participants with an iOS device could download the study app via the study website or links from social media. In this fully remote study, we screened, obtained informed consent from, and enrolled participants through the mobile app. The mobile health framework included daily health goal setting and self-monitoring, with up to 6 daily prompts to determine in-the-moment needs and preferences for mobile health-assisted health behavior change.

RESULTS

A total of 24 participants downloaded the app and provided e-consent (22 female; 2 male), with 23 participants responding to at least one prompt over 2 weeks. The mean length of engagement was 5.6 (SD 4.7) days, with a mean of 2.8 (1.1) responses per day. We observed individually dynamic needs and preferences, illustrating daily variability within and between individuals. Qualitative feedback indicated preferences for self-adapting features, simplified self-monitoring, and the ability to personalize app-generated message timing and content.

CONCLUSIONS

The technique provided an individually dynamic and contextually relevant alternative and complement to traditional needs assessment for assessing individually dynamic user needs and preferences during treatment development or adaptation. The results of this utility study suggest the importance of personalization and learning algorithms for sustaining app engagement in young adults with psychiatric conditions. Further study in broader user populations is needed.

Acceptability and practicability of self-management for patients with Parkinson's disease based on smartphone applications in China

BACKGROUND

China has had about 1.2 billion mobile-phone users, and this number continues to grow. However, mobile-health services (mHealth) are currently in the initial stage, and have not yet prevailed in China. Additionally, the prevalence of Parkinson's disease (PD) in China is 1700/100,000 (≥65 years). Indeed, these PD patients would benefit from mHealth to manage their disease. Therefore, we designed a study to determine attitudes toward smartphone applications (apps) for chronic condition self-management, and to discover the practicality of these apps among PD patients in China.

METHODS

We selected 204 participants with PD between 52 and 87 years old and surveyed their attitudes concerning the use of smartphone apps for chronic condition management via questionnaires.

RESULTS

Among the participants, 65.19% had smartphones. Among these smartphone users, 82.84% expressed a preference for using apps for PD management. This group tended to be younger and more frequent web users with higher education and better medication compliance, and they tended to have a longer PD course and worse conditions (P < 0.001, P = 0.001, P < 0.001, P = 0.041, P < 0.001, P = 0.013). Additionally, the willingness to apply apps for PD self-management was positively related to education (P < 0.001) and negatively related to age and PD course (P = 0.017, P < 0.001).

CONCLUSION

In China, patients with PD have a generally positive attitude towards self-management through smartphone apps. Consequently, improving the coverage of smartphones with practical and handy apps is a promising strategy for PD self-management.

Time to listen: a mixed-method study examining community-based views of mobile technology for interventions to promote physical activity

INTRODUCTION

A mixed-method, co-design approach to studying the adoption of mobile health (mHealth) technology among African-American (AA) women has not been fully explored. Qualitative data may contextualise existing knowledge surrounding perceptions of mHealth among AA women as part of formative work for designing a physical activity application (app).

METHODS

A convenience sample of 16 AA women completed an informatics survey prior to participating in focus groups exploring their use of mobile technology and health apps. Survey responses provided frequency data, while iterative transcript analysis of focus groups identified themes.

RESULTS

The majority of participants (mean age=62.1 years, SD=6.6) felt comfortable using a tablet/smartphone (75.0%). Most (68.8%) reported using health-related apps, primarily focused on physical activity and nutrition. Focus groups revealed four overarching concepts, including (1) user attachment, (2) technology adoption, (3) potential facilitators and (4) potential barriers. Important features which may serve as facilitators or barriers to future adoption of a mobile app for an mHealth intervention include individual app tailoring and software concerns, respectively.

DISCUSSION

Thematic analysis revealed high user attachment to smartphones and described participants' process for adopting new mHealth technology.

CONCLUSION

Early engagement of target end users as a part of a broader co-design and community-based participatory research process for developing mHealth technologies may be useful for sustained adoption of these tools in future mHealth behavioural interventions.

Co-designing a Self-Management App Prototype to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Mixed Methods Study

BACKGROUND

Spinal cord injury is a complex chronic health condition that requires individuals to actively self-manage. Therefore, an evidence-based, self-management app would be of value to support individuals with spinal cord injury in the prevention of pressure injuries.

OBJECTIVE

The main objectives of this study were to (1) establish a co-design approach for developing a high-fidelity prototype app for the self-management of individuals with spinal cord injury, (2) design the prototype that resulted from this process, and (3) conduct the first usability assessment of the prototype app.

METHODS

We adopted a co-design approach to develop an evidence-based app prototype. Starting from a preliminary content model (based on clinical guidelines for the prevention of pressure injuries) and three research-based user personas, we conducted an ideation workshop involving individuals with spinal cord injury and health care professionals. The ideation workshop formed the basis for two consecutive design sprints. The result of this co-design phase was an interactive app prototype. The prototype was evaluated in two rounds of usability testing (N=4 and N=15, respectively) using a combination of qualitative and quantitative methods.

RESULTS

The co-design process resulted in a high-fidelity prototype with two key components: a self-management component and a communication component. The final prototype included a combination of features to support individuals with spinal cord injury in the prevention of pressure injuries, namely a smart camera, pressure injury diary, expert consultation, reminders, and knowledge repository. Findings of the usability testing showed that most participants navigated the app fluently with little back and forth navigation and were able to successfully complete a set of assigned tasks. These positive results are supported by the average system usability score achieved (78.5/100; range 47.5-95.0) and our qualitative analysis of the semistructured interviews. Despite an overall positive evaluation of the app prototype, we identified areas for improvement (eg, inclusion of a search function).

CONCLUSIONS

Individuals with spinal cord injury often need to navigate competing interests and priorities, paired with uncertainty about the accuracy and relevance of clinical recommendations. Understanding what matters to individuals with spinal cord injury can help guide the design of behavioral interventions that are useful and acceptable to these individuals in their daily lives. This study shows that involving individuals with spinal cord injury and health care professionals in co-designing a self-management app can foster knowledge cocreation at the intersection of lived experience, medical expertise, and technical solutions.

Users' Experiences of a Mobile Health Self-Management Approach for the Treatment of Cystic Fibrosis: Mixed Methods Study

Background

Despite a large number of clinical trials aiming at evaluating the digital self-management of chronic diseases, there is little discussion about users’ experiences with digital approaches. However, a good user experience is a critical factor for technology adoption. Understanding users’ experiences can inform the design of approaches toward increased motivation for digital self-management.

Objective

This study aimed to evaluate the self-management of cystic fibrosis (CF) with a focus on gastrointestinal concerns and the care of young patients. Following a user-centered design approach, we developed a self-management app for patients and parents and a web tool for health care professionals (HCPs). To evaluate the proposed solutions, a 6-month clinical trial was conducted in 6 European CF competence centers. This paper analyzes the user acceptance of the technology and the benefits and disadvantages perceived by the trial participants.

Methods

A mixed methods approach was applied. Data were collected through 41 semistructured qualitative interviews of patients, parents, and HCPs involved in the clinical trial. In addition, data were collected through questionnaires embedded in the self-management app.

Results

Support for enzyme dose calculation and nutrition management was found to be particularly useful. Patients and parents rapidly strengthened their knowledge about the treatment and increased their self-efficacy. Reported benefits include reduced occurrence of symptoms and enhanced quality of life. Patients and parents had different skills, requiring follow-up by HCPs in an introductory phase. HCPs valued obtaining precise information about the patients, allowing for more personalized advice. However, the tight follow-up of several patients led to an increased workload. Over time, as patient self-efficacy increased, patient motivation for using the app decreased and the quality of the reported data was reduced.

Conclusions

Self-management enfolds a collaboration between patients and HCPs. To be successful, a self-management approach should be accepted by both parties. Through understanding behaviors and experiences, this study defines recommendations for a complex case—the demanding treatment of CF. We identify target patient groups and situations for which the app is most beneficial and suggest focusing on these rather than motivating for regular app usage over a long time. We also advise the personalized supervision of patients during the introduction of the approach. Finally, we propose to develop guidance for HCPs to facilitate changes in practice. As personalization and technology literacy are factors found to influence the acceptance of digital self-management of other chronic diseases, it is relevant to consider the proposed recommendations beyond the case of CF.

Multidisciplinary Software Design for the Routine Monitoring and Assessment of Pain in Palliative Care Services: The Development of PainCheck

PURPOSE

The use of health information technology (HIT) to support patient and health professional communication is emerging as a core component of modern cancer care. Approaches to HIT development for cancer care are often underreported, despite their implementation in complex, multidisciplinary environments, typically supporting patients with multifaceted needs. We describe the development and evaluation of an e-health tool for pain management in patients with advanced cancer, arising from collaboration between health researchers and a commercial software development company.

METHODS

We adopted a research-led development process, involving patients with advanced cancer and their health professionals, focusing on use within real clinical settings. A software development approach (disciplined agile delivery) was combined with health science research methods (ie, diary studies, face-to-face interviews, questionnaires, prototyping, think aloud, process reviews, and pilots). Three software iterations were managed through three disciplined agile delivery phases to develop PainCheck and prepare it for use in a clinical trial.

RESULTS

Findings from development phases (inception, elaboration, and construction) informed the design and implementation of PainCheck. During the transition phase, where PainCheck was evaluated in a randomized clinical trial, there was variation in the extent of engagement by patients and health professionals. Prior personal experience and confidence with HIT led to a gatekeeping effect among health professionals, who were reluctant to introduce PainCheck to patients. Patients who did use PainCheck seemed to benefit, and no usability issues were reported.

CONCLUSION

Health science research methods seemed to help in the development of PainCheck, although a more rigorous application of implementation science methodologies might help to elucidate further the barriers and facilitators to adoption and inform an evidence-based plan for future implementation.

The Limits of Empowerment: How to Reframe the Role of mHealth Tools in the Healthcare Ecosystem

This article highlights the limitations of the tendency to frame health- and wellbeing-related digital tools (mHealth technologies) as empowering devices, especially as they play an increasingly important role in the National Health Service (NHS) in the UK. It argues that mHealth technologies should instead be framed as digital companions. This shift from empowerment to companionship is advocated by showing the conceptual, ethical, and methodological issues challenging the narrative of empowerment, and by arguing that such challenges, as well as the risk of medical paternalism, can be overcome by focusing on the potential for mHealth tools to mediate the relationship between recipients of clinical advice and givers of clinical advice, in ways that allow for contextual flexibility in the balance between patiency and agency. The article concludes by stressing that reframing the narrative cannot be the only means for avoiding harm caused to the NHS as a healthcare system by the introduction of mHealth tools. Future discussion will be needed on the overarching role of responsible design.

Assessment of a Mobile App by Adolescents and Young Adults With Cystic Fibrosis: Pilot Evaluation

BACKGROUND

Cystic fibrosis (CF) continues to be the most common life-limiting chronic pulmonary disease in adolescents and young adults. Treatment of CF demands a high treatment time investment to slow the progression of lung function decline, the most important contributor to morbidity and mortality. Adherence is challenging in CF due to the high treatment burden and the lack of immediate health consequences in case of nonadherence. Lung function decline is particularly pronounced in the transition phase between 12 and 24 years of age. The improvement of self-management and self-responsibility and independence from parents and desire for normalcy are conflicting aspects for many adolescents with CF, which influence adherence to the time-consuming pulmonary therapy. Mobile health (mHealth) care apps could help to support self-management and independence and thereby reconcile seemingly conflicting goals to improve adherence, quality of life, and ultimately CF life expectancy.

OBJECTIVE

This study aimed to (1) assess user behavior and satisfaction among adolescents and young adults with CF over an observation period of three months using an mHealth app; (2) identify areas of improvement for this mHealth app; and (3) compare overall and disease-specific satisfaction, lung function, and anthropometry before and after using the mHealth app.

METHODS

A total of 27 adolescents and young adults with CF (age range 12-24 years, mean age 16 years, SD 3 years; 14 females, 11 males) used a free mHealth app for three months of whom 25 provided questionnaire data for analysis at the end of the study. Data collection was carried out using questionnaires on usage characteristics and life satisfaction, and standardized assessment of lung function and anthropometry.

RESULTS

The use of the reminder function for medication declined from 70% (15/21) of the participants at week 4 to 65% (13/20) at week 8 of the observation period. At the end of the study, only 17% (4/23) of the participants wanted to continue using the app. Nevertheless, 56% (14/25) of participants saw the mobile app as a support for everyday life. Potential improvements targeting hedonistic qualities were identified to improve mHealth app adherence. Comparisons of satisfaction with different life aspects hinted at improvements or stabilization for the subitem respiration and the subitem lack of handicap by CF, suggesting that app use might stabilize certain CF-specific aspects of the weighted satisfaction with life. Lung function and anthropometry were not affected consistently.

CONCLUSIONS

Most of the patients did not want to continue using the app after the study period. Only a few CF-specific aspects of weighted life satisfaction were possibly stabilized by the mHealth app; clinical parameters were not affected. Adaptation of the functions to adolescent-specific needs could improve the long-term use and thus positively affect the disease course.

Patients' Perceptions of mHealth Apps: Meta-Ethnographic Review of Qualitative Studies

BACKGROUND

Mobile phones and tablets are being increasingly integrated into the daily lives of many people worldwide. Mobile health (mHealth) apps have promising possibilities for optimizing health systems, improving care and health, and reducing health disparities. However, health care apps often seem to be underused after being downloaded.

OBJECTIVE

The aim of this paper is to reach a better understanding of people's perceptions, beliefs, and experience of mHealth apps as well as to determine how highly they appreciate these tools.

METHODS

A systematic review was carried out on qualitative studies published in English, on patients' perception of mHealth apps between January 2013 and June 2018. Data extracted from these articles were synthesized using a meta-ethnographic approach and an interpretative method.

RESULTS

A total of 356 articles were selected for screening, and 43 of them met the inclusion criteria. Most of the articles included populations inhabiting developed countries and were published during the last 2 years, and most of the apps on which they focused were designed to help patients with chronic diseases. In this review, we present the strengths and weaknesses of using mHealth apps from the patients' point of view. The strengths can be categorized into two main aspects: engaging patients in their own health care and increasing patient empowerment. The weaknesses pointed out by the participants focus on four main topics: trustworthiness, appropriateness, personalization, and accessibility of these tools.

CONCLUSIONS

Although many of the patients included in the studies reviewed considered mHealth apps as a useful complementary tool, some major problems arise in their optimal use, including the need for more closely tailored designs, the cost of these apps, the validity of the information delivered, and security and privacy issues. Many of these issues could be resolved with more support from health providers. In addition, it would be worth developing standards to ensure that these apps provide patients accurate evidence-based information.

An Adaptive Mobile Health System to Support Self-Management for Persons With Chronic Conditions and Disabilities: Usability and Feasibility Studies

BACKGROUND

Persons with chronic conditions and disabilities (PwCCDs) are vulnerable to secondary complications. Many of these secondary complications are preventable with proactive self-management and proper support. To enhance PwCCDs' self-management skills and conveniently receive desired support, we have developed a mobile health (mHealth) system called iMHere. In 2 previous clinical trials, iMHere was successfully used to improve health outcomes of adult participants with spina bifida and spinal cord injury. To further expand use of iMHere among people with various types of disabilities and chronic diseases, the system needs to be more adaptive to address 3 unique challenges: 1) PwCCDs have very diverse needs with regards to self-management support, 2) PwCCDs' self-management needs may change over time, and 3) it is a challenge to keep PwCCDs engaged and interested in long-term self-management.

OBJECTIVE

The aim of this study was to develop an adaptive mHealth system capable of supporting long-term self-management and adapting to the various needs and conditions of PwCCDs.

METHODS

A scalable and adaptive architecture was designed and implemented for the new version, iMHere 2.0. In this scalable architecture, a set of mobile app modules was created to provide various types of self-management support to PwCCDs with the ability to add more as needed. The adaptive architecture empowers PwCCDs with personally relevant app modules and allows clinicians to adapt these modules in response to PwCCDs' evolving needs and conditions over time. Persuasive technologies, social support, and personalization features were integrated into iMHere 2.0 to engage and motivate PwCCDs and support long-term usage. Two initial studies were performed to evaluate the usability and feasibility of the iMHere 2.0 system.

RESULTS

The iMHere 2.0 system consists of cross-platform client and caregiver apps, a Web-based clinician portal, and a secure 2-way communication protocol for providing interactions among these 3 front-end components, all supported by a back-end server. The client and caregiver apps have 12 adaptive app modules to support various types of self-management tasks. The adaptive architecture makes it possible for PwCCDs to receive personalized app modules relevant to their conditions with or without support from various types of caregivers. The personalization and persuasive technologies in the architecture can be used to engage PwCCDs for long-term usage of the iMHere 2.0 system. Participants of the usability study were satisfied with the iMHere 2.0 client app. The feasibility evaluation revealed several practical issues to consider when implementing the system on a large scale.

CONCLUSIONS

We developed an adaptive mHealth system as a novel method to support diverse needs in self-management for PwCCDs that can dynamically change over time. The usability of the client app is high, and it was feasible for PwCCDs to use in supporting personalized and evolving self-care needs.

The Potential of Self-Management mHealth for Pediatric Cystic Fibrosis: Mixed-Methods Study for Health Care and App Assessment

Background

Remote care services and patient empowerment have boosted mobile health (mHealth). A study of user needs related to mHealth for pediatric cystic fibrosis (PCF) identified the set of preferred features mobile apps should support; however, the potential use of PCF apps and their suitability to fit into PCF clinical management remains unexplored.

Objective

We examine whether PCF holds potential for the implementation of mHealth care.

Methods

The study is based on a literature review and qualitative analysis of content and was conducted in two parts: (1) we reviewed scientific and gray literature to explore how European countries manage PCF and conducted a qualitative study of 6 PCF units and (2) we performed a systematic review of apps available in the myhealthapps.net repository searching for cystic fibrosis (CF) management and nutrition apps, which we analyzed for characteristics, business models, number of downloads, and usability.

Results

European CF routine care guidelines are acknowledged in most European countries, and treatments are fully covered in almost all countries. The majority of teams in CF units are interdisciplinary. With respect to the systematic review of apps, we reviewed 12 apps for CF management and 9 for general nutrition management in the myhealthapps.net directory. All analyzed apps provided functionalities for recording aspects related to the disease and nutrition such as medication, meals, measurements, reminders, and educational material. None of the apps reviewed in this study supported pancreatic enzyme replacement therapy. CF apps proved to be less appealing and usable than nutrition apps (2.66 [SD 1.15] vs 4.01 [SD 0.90]; P<.001, z-value: –2.6). User needs detected in previous research are partially matched by current apps for CF management.

Conclusions

The health care context for PCF is a unique opportunity for the adoption of mHealth. Well-established clinical guidelines, heterogeneous clinical teams, and coverage by national health care systems provide a suitable scenario for the use of mHealth solutions. However, available apps for CF self-management do not cover essential aspects such as nutrition and education. To increase the adoption of mHealth for CF self-management, new apps should include these features.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2016-014931

Assessing the utility of an IoS application in the perioperative care of spine surgery patients: the NeuroPath Pilot study

BACKGROUND

In an attempt to improve care while decreasing costs and postoperative pain, we developed a novel IoS mobile health application, NeuroPath. The objective of this innovative app is to integrate enhanced recovery after surgery (ERAS) principles, patient education, and real-time pain and activity monitoring in a home setting with unencumbered two-way communication.

METHODS

The NeuroPath application was built over 18 months, with support from Apple, Medable, the Department of Information-Technology and the Department of Neurosurgery. Target areas addressed by NeuroPath include patient prep for surgery, perioperative risk mitigation, activity monitoring, wound care, and opioid use management. These target areas are monitored through a provider app, which is downloaded to the care providers IPad Mini. The provider app permits real time viewing of wound healing (patient incision photographs), activity levels, pain levels, and narcotic usage. Participants are given a daily To-Do list, via the Care Card section of the interface. The To-Do list presents the patient with specific tasks for exercise, instructions to wash incision area, pre-operative instructions, directions for discussing medication with care team, among other patient specific recommendations.

RESULTS

Of the 30 patients enrolled in the pilot study, there was a range of activity on the app. Patients with high involvement in the app logged in nearly every day from a week pre-op to >45 days post-op. Data for patients that utilized the app and uploaded regularly show trends of appropriately healing wounds, decreasing levels of pain, increasing step counts, and discontinuation of narcotics.

CONCLUSIONS

This pilot study of the NeuroPath app demonstrates its potential utility for improving quality of patient care without increased costs. Participants who regularly used the app showed consistent improvement throughout the post-operative recovery period (increasing ambulation, decreasing pain and guided reduction in narcotic usage).

Exploration of Users' Perspectives and Needs and Design of a Type 1 Diabetes Management Mobile App: Mixed-Methods Study

Background

With the popularity of mobile phones, mobile apps have great potential for the management of diabetes, but the effectiveness of current diabetes apps for type 1 diabetes mellitus (T1DM) is poor. No study has explored the reasons for this deficiency from the users’ perspective.

Objective

The aims of this study were to explore the perspectives and needs of T1DM patients and diabetes experts concerning a diabetes app and to design a new T1DM management mobile app.

Methods

A mixed-methods design combining quantitative surveys and qualitative interviews was used to explore users’ needs and perspectives. Experts were surveyed at 2 diabetes conferences using paper questionnaires. T1DM patients were surveyed using Sojump (Changsha ran Xing InfoTech Ltd) on a network. We conducted semistructured, in-depth interviews with adult T1DM patients or parents of child patients who had ever used diabetes apps. The interviews were audio-recorded, transcribed, and coded for theme identification.

Results

The expert response rate was 63.5% (127/200). The respondents thought that the reasons for app invalidity were that patients did not continue using the app (76.4%, 97/127), little guidance was received from health care professionals (HCPs; 73.2%, 93/127), diabetes education knowledge was unsystematic (52.8%, 67/127), and the app functions were incomplete (44.1%, 56/127). A total of 245 T1DM patient questionnaires were collected, of which 21.2% (52/245) of the respondents had used diabetes apps. The reasons for their reluctance to use an app were limited time (39%, 20/52), complicated operations (25%, 13/52), uselessness (25%, 13/52), and cost (25%, 13/52). Both the experts and patients thought that the most important functions of the app were patient-doctor communication and the availability of a diabetes diary. Two themes that were useful for app design were identified from the interviews: (1) problems with patients’ diabetes self-management and (2) problems with current apps. In addition, needs and suggestions for a diabetes app were obtained. Patient-doctor communication, diabetes diary, diabetes education, and peer support were all considered important by the patients, which informed the development of a prototype multifunctional app.

Conclusions

Patient-doctor communication is the most important function of a diabetes app. Apps should be integrated with HCPs rather than stand-alone. We advocate that doctors follow up with their patients using a diabetes app. Our user-centered method explored comprehensively and deeply why the effectiveness of current diabetes apps for T1DM was poor and what T1DM patients needed for a diabetes app and provided meaningful guidance for app design.