Apps as Artefacts: Towards a Critical Perspective on Mobile Health and Medical Apps

An investigation of mHealth and digital health literacy among new parents during COVID-19

Introduction

Especially during the COVID-19 pandemic, parents were expected to understand increasingly sophisticated information about health issues and healthcare systems and access online resources as a part of their caregiving role. Yet little is known about parents' online digital technology use and digital health literacy skill. This study aimed to investigate parents' digital technology use, their self-reported digital health literacy skill, and demographic information as potential factors influencing their use of digital technologies.

Methods

An online survey utilizing convenience sampling was administered to new parents during the COVID-19 pandemic that inquired about their demographic information, digital technology use, and digital health literacy skills within Ontario, Canada.

Results

A total of 151 individuals responded to the survey; these were primarily mothers (80%) who self-reported as white (72%), well-educated 86%), heterosexual (86%) females (85%) with incomes over $100,00 per year (48%). Participants reported consistent and persistent online activity related to their parenting role and mostly via mobile smartphone devices (92%). Participants had moderate to high digital health literacy skills, greater than the Canadian national average. Almost half of participants reported negative health and well-being consequences from their digital online behaviours. There were no significant relationships between technology use, digital health literacy skill, and demographic variables.

Discussion

The COVID-19 pandemic has reinforced the need for and importance of effective and equitable digital health services. Important opportunities exist within clinical practice and among parenting groups to proactively address the physical and mental health implications of digital parenting practices. Equally important are opportunities to insert into clinical workflow the inquiry into parents' online information-seeking behaviours, and to include digital health literacy as part of prenatal/postnatal health education initiatives.

Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care

Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.

Does fear drive health app adoption? The role of threat perception in diabetes app usage

BACKGROUND AND AIM

This study explores the interplay between fear or threat perception and adoption of health apps among individuals with diabetes. It draws on the concept of "fear" as an emotional response stemming from perceived threat, raising the question of whether threat perception drives the uptake of health apps.

METHODS

This study investigates the influence of diabetes threat perception on app adoption, akin to the role of fear appeal in behavior change communication. This study employed both a handout questionnaire and an online survey tool, Survey Monkey, for data collection. Using purposive sampling, data were collected from 222 individuals aged 35 years and above with diabetes in Chennai.

RESULTS

The results indicate that threat perception can trigger health app usage among people with high diabetic conditions, supporting the broader literature on fear appeal. Additionally, the perceived threat of diabetes is elevated among app users. Notably, a significant positive correlation exists between perceived threat of diabetes, daily app usage, and consistent app use.

CONCLUSION

This study underscores that the extent of perceived harm or vulnerability to threats influences individuals' behavioral changes. It introduces new avenues for encouraging health app usage among high-risk groups.

Sustainable Development for Mobile Health Apps Using the Human-Centered Design Process

Well-documented scientific evidence indicates that mobile health (mHealth) apps can improve the quality of life, relieve symptoms, and restore health for patients. In addition to improving patients' health outcomes, mHealth apps reduce health care use and the cost burdens associated with disease management. Currently, patients and health care providers have a wide variety of choices among commercially available mHealth apps. However, due to the high resource costs and low user adoption of mHealth apps, the cost-benefit relationship remains controversial. When compared to traditional expert-driven approaches, applying human-centered design (HCD) may result in more useable, acceptable, and effective mHealth apps. In this paper, we summarize current HCD practices in mHealth development studies and make recommendations to improve the sustainability of mHealth. These recommendations include consideration of factors regarding culture norms, iterative evaluations on HCD practice, use of novelty in mHealth app, and consideration of privacy and reliability across the entire HCD process. Additionally, we suggest a sociotechnical lens toward HCD practices to promote the sustainability of mHealth apps. Future research should consider standardizing the HCD practice to help mHealth researchers and developers avoid barriers associated with inadequate HCD practices.

The piety of optimization: The rhetoric of health awareness in ParticipACTION and Fitbit

This article uses the tools of rhetorical study to investigate how health awareness, as both a concept and a set of beliefs that reinforce ideals of health, permeates everyday life and affects ways of being. I explore how health awareness is communicated through both public health and commercial marketing campaigns, and argue that as the sources of information change, so too do the ideas of health that we are asked to be aware of. Through an analysis of the websites of ParticipACTION, a publicly funded health and fitness campaign, and Fitbit, a corporation that produces wearable technologies, I show that these organizations provide their audiences with instructions for self-conduct in the pursuit of health through the piety that time is a resource to be managed. Through this piety, ParticipACTION and Fitbit's websites each reify an altar of health where health is represented as a socially and physically fitter (optimized) self, always just out of reach and attainable in the future. I conclude with a call for critical descriptions of health awareness to move beyond the explanatory power of neoliberalization of health, and turn to the work of Rachel Sanders, Annmarie Mol, and Donna Haraway as possible avenues for resisting optimization.

The Use of Mobile Health Interventions for Outcomes among Middle-Aged and Elderly Patients with Prediabetes: A Systematic Review

BACKGROUND

There are currently limited systematic reviews of mobile health interventions for middle-aged and elderly patients with prediabetes from trial studies. This review aimed to gather and analyze information from experimental studies investigating the efficacy of mobile health usability for outcomes among middle-aged and elderly patients with prediabetes.

METHODS

We conducted a literature search in five databases: Clinicaltrials.gov, the International Clinical Trials Registry Platform (ICTRP), PubMed, ProQuest, and EBSCO, with a date range of January 2007 to July 2022 written in English, following a registered protocol on PROSPERO (CRD42022354351). The quality and possibility of bias were assessed using the Jadad score. The data extraction and analysis were conducted in a methodical manner.

RESULTS

A total of 25 studies were included in the qualitative synthesis, with 19 studies using randomized trial designs and 6 studies with non-randomized designs. The study outcomes were the incidence of diabetes mellitus, anthropometric measures, laboratory examinations, measures of physical activity, and dietary behavior. During long-term follow-up, there was no significant difference between mobile health interventions and controls in reducing the incidence of type 2 diabetes. The findings of the studies for weight change, ≥3% and ≥5% weight loss, body mass index, and waist circumference changes were inconsistent. The efficacy of mobile health as an intervention for physical activity and dietary changes was lacking in conclusion. Most studies found that mobile health lacks sufficient evidence to change hbA1c. According to most of these studies, there was no significant difference in blood lipid level reduction.

CONCLUSIONS

The use of mobile health was not sufficiently proven to be effective for middle-aged and elderly patients with prediabetes.

Health and wellness but at what cost? Technology media justifications for wearable technology use in organizations

Wearable technology (WT) use in organizations is accelerating despite ethical concerns about personal privacy, data security, and stress from increased surveillance. Technology media, a key producer of meanings about WT, gives some attention to these issues but they also routinely promote WT as if they are a panacea for employee wellness. We critically analyze 150 media articles to understand how they justify the adoption of WT into organizational life. We contribute by extending previous work on surveillance technology to show how and why WT media discourses use neo-liberal justifications to justify WT implementation. We explore implications including competing health and wellness discourses and make suggestions for further research.

The materialities and embodiments of mundane software: exploring how apps come to matter in everyday life

Purpose

In this article, the authors aim to explore mobile apps as both mundane and extraordinary digital media artefacts, designed and promoted to improve or solve problems in people's lives. Drawing on their “App Stories” project, the authors elaborate on how the efficiencies and affordances credited to technologies emerge and are performed through the specific embodied practices that constitute human–app relationships.

Design/methodology/approach

The project involved short written accounts in an online survey from 200 Australian adults about apps. Analysis was conducted from a sociomaterial perspective, surfacing the emotional and embodied responses to and engagements with the apps; the relational connections described between people and their apps or with other people or objects; and what the apps enabled or motivated people to do.

Findings

Findings point to three salient concerns about apps: (1) the need for efficiency; (2) the importance and complexity of human relationships and maintaining these connections; and (3) the complex relationships people have with their bodies. These concerns are expressed through themes that reflect how everyday efficiencies are produced through human–app entanglements; apps as relational agents; apps' ability to know and understand users; and future app imaginaries.

Originality/value

This project explores the affective and embodied dimensions of app use and thinks through the tensions between the extraordinary and mundane dimensions of contemporary techno-social landscapes, reflecting on how apps “matter” in everyday life. Our analysis surfaces the active role of the body and bodily performances in the production of app efficiencies and underlines the ways mobile apps are always situated in relation to other media and materialities.

Ethical Implications of e-Health Applications in Early Preventive Healthcare

As a means of preventive medicine early detection and prevention examinations can identify and treat possible health disorders or abnormalities from an early age onwards. However, pediatric examinations are often widely spaced, and thus only snapshots of the children’s and adolescents’ developments are obtained. With e-health applications parents and adolescents could record developmental parameters much more frequently and regularly and transmit data directly for ongoing evaluation. AI technologies could be used to search for new and previously unknown patterns. Although e-health applications could improve preventive healthcare, there are serious concerns about the unlimited use of big data in medicine. Such concerns range from general skepticism about big data in medicine to specific challenges and risks in certain medical areas. In this paper, we will focus on preventive health care in pediatrics and explore ethical implications of e-health applications. Specifically, we will address opportunities and risks of app-based data collection and AI-based data evaluation for complementing established early detection and prevention examinations. To this end, we will explore the principle of the best interest of the child. Furthermore, we shall argue that difficult trade-offs need to be made between group benefit on the one hand and individual autonomy and privacy on the other.

Direct-to-consumer detection of atrial fibrillation in a smartwatch electrocardiogram: Medical overuse, medicalisation and the experience of consumers

The Apple Watch Electrocardiogram (ECG) is a digital feature that detects signs of atrial fibrillation (AFib), a heart arrhythmia that can lead to stroke. Unlike AFib detection offered in a clinical setting to patients or those at higher risk, the Apple Watch ECG is a direct-to-consumer (DTC) product marketed to the healthy as a self-performed medical test. The feature is incorporated in the design as one of many applications in a multifunctional smartwatch. The Apple Watch ECG signals the movement of consumer wearables into the domain of medical devices, and the highly contested practice of AFib screening. This article examines how this technology produces new avenues for medical overuse among people who are unlikely to gain clinical benefit, and who as active consumers become medicalised via taking part in disease-specific monitoring. Interviews with Apple Watch ECG consumers suggest their strongly trust in the Apple brand is amplified by the promissory quality of screening and technical innovation. What would otherwise be a costly clinical procedure is condensed into an accessible function in a wearable device. Consequently, AFib screening loses its clinical purpose, and is instead refashioned into a component of healthy lifestyle behaviour. Repeat self-screening becomes 'bundled' with similar health monitoring practices routinised in consumer wearables. Active uptake supports a market for the product and adds to the reputation of the Apple brand such that consumers become complicit in legitimising a medical practice that has limited clinical justification.

Digital Self-monitoring of Multiple Sclerosis: Interview Study With Dutch Health Care Providers on the Expected New Configuration of Roles and Responsibilities

Background

Digital self-monitoring allows patients to produce and share personal health data collected at home. This creates a novel situation in which health care providers and patients must engage in a reconfiguration of roles and responsibilities. Although existing research pays considerable attention to the perceptions of patients regarding digital self-monitoring, less attention has been paid to the needs, wishes, and concerns of health care providers. As several companies and public institutions are developing and testing digital self-monitoring at the time of writing, it is timely and relevant to explore how health care providers envision using these technologies in their daily work practices. Our findings can be considered in decision-making processes concerning the further development and implementation of digital self-monitoring.

Objective

This study aims to explore how health care providers envisage using smartphone apps for digital self-monitoring of multiple sclerosis (MS) in their daily work practices, with a particular focus on physician-patient communication and on how health care providers respond to self-monitoring data and delegate tasks and responsibilities to patients.

Methods

We conducted semistructured in-depth interviews with 14 MS health care providers: 4 neurologists, 7 MS specialist nurses, and 3 rehabilitation professionals. They are affiliated with 3 different hospitals in the Netherlands that will participate in a pilot study to assess the efficiency and effectiveness of a specific smartphone app for self-monitoring.

Results

The interviewed health care providers seemed willing to use these smartphone apps and valued the quantitative data they produce that can complement the narratives that patients provide during medical appointments. The health care providers primarily want to use digital self-monitoring via prescription, meaning that they want a standardized smartphone app and want to act as its gatekeepers. Furthermore, they envisioned delegating particular tasks and responsibilities to patients via digital self-monitoring, such as sharing data with the health care providers or acting on the data, if necessary. The health care providers expected patients to become more proactive in the management of their disease. However, they also acknowledged that not all patients are willing or able to use digital self-monitoring apps and were concerned about the potential psychological and emotional burden on patients caused by this technology.

Conclusions

Our findings show that health care providers envisage a particular type of patient empowerment and personalized health care in which tensions arise between health care providers acting as gatekeepers and patient autonomy, between patient empowerment and patient disempowerment, and between the weight given to quantitative objective data and that given to patients’ subjective experiences. In future research, it would be very interesting to investigate the actual experiences of health care providers with regard to digital self-monitoring to ascertain how the tensions mentioned in this paper play out in practice.

Mobile technology: A tool for healthcare and a boon in pandemic

Healthcare systems deal with disease prevention, early detection, diagnosis, investigation, and timely, affordable, and safe treatment. For the delivery of services in the health sector, communication is the key to linking the service provider and the patients. Mobile technology in the recent past has rendered various platforms of communications for the healthcare system. Thus, in health, mobile technology has greatly contributed to time management and cost reduction for healthcare at every level including hospital visits to individual appointments with doctors, hence the convenience. With advancements in mobile technologies and the growing number of mobile users, newer opportunities have opened up for the use of mobiles for patient care. Emerging information and communication technologies with the help of the Internet of Things (IoT) have been instrumental in integrating different domains of the health sector with mobile technology. Thus, the technology may have the potential to become powerful medical tools to support the health sector at all levels of care. In this review, the concept, applications, and advantages of mobile technology for health and the present pandemic have been discussed. It also discusses mobile health technology, as a support system for convenient and safer healthcare for public health, and the opportunities to improve its applications for unseen future health crises.

A Review of the Quality and Impact of Mobile Health Apps

Mobile health applications (apps) have transformed the possibilities for health promotion and disease self-management; however, their promise is not fully realized owing to their reliance on commercial ecosystems for development and distribution. This review provides an overview of the types of mobile health apps and describes key stakeholders in terms of how apps are used, developed, and regulated. I outline key challenges facing consumers, public health professionals, and policy makers in evaluating the quality of health apps and summarize what is known about the impact of apps on health outcomes and health equity. I suggest that factors within the wider mobile ecosystem largely define the impact of health apps and, most notably, practices around the collection and commercialization of user data. Finally, I suggest that upstream public health strategies, grounded in an understanding of corporate influences on health, are necessary to promote healthy digital environments in which mobile health app innovation can flourish. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Exploring the impact of COVID-19 on mobile dating: Critical avenues for research

In this digitally mediated world, initiating sexual or romantic intimacy now frequently occurs on mobile dating apps, which both requires people to navigate new technologies, but also enables them to explore different possibilities for intimacy. The opportunities that mobile dating holds for creating intimacy, and how people take these up, is particularly relevant in light of the global pandemic of COVID-19, when human connection and contact are entangled with varying worries about viral contamination, risk and future uncertainty. But how does the pandemic impact on mobile dating? How are affect and risk intertwined-or even negotiated-by people in their search for intimacy in this pandemic? What possibilities do mobile dating apps hold for people in their search for connection with others? In this commentary, I provide a brief overview of how risk has been examined previously in mobile dating research and explore what future directions could be taken in this field. I argue for research that acknowledges and prioritises: the plurality of people's sociomaterial conditions; the interrelationship between people, digital technologies and COVID-19; and the discursive context that furnishes people's sense of risk and emotional possibility across different sociocultural contexts. These new directions in the field offer opportunities to conduct critical research that is responsive to this dynamic context, and that illuminates the various ways that people are navigating intimacy, risk and emotion across different living conditions during this pandemic.

Development and Validation of a Mobile Clinical Decision Support Tool for the Diagnosis of Drug Allergy in Adults: The Drug Allergy App

BACKGROUND

Penicillin allergy overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased health care costs.

OBJECTIVE

To develop and validate a questionnaire-based algorithm built in a mobile application to support clinicians in collecting accurate history of previous reactions and diagnosing drug allergy appropriately.

METHODS

A survey was completed by 164 medical and nonmedical prescribers to understand barriers to best practice. Based on the survey recommendations, we created a 10-item questionnaire-based algorithm to allow classification of drug allergy history in line with the National Institute for Health and Care Excellence guidelines on drug allergy. The algorithm was incorporated into a mobile application and retrospectively validated using anonymized clinical databases at regional immunology and dermatology centers in Manchester, United Kingdom.

RESULTS

A total of 55.2% of prescribers (95% confidence interval, 47% to 63.4%) thought it impossible to draw a firm conclusion based on history alone and 59.4% (95% CI, 51.4% to 67.5%) believed that regardless of the details of the penicillin allergy history, they would avoid all β-lactams. A drug allergy mobile application was developed and retrospectively validated, which revealed a low risk for misclassification of outcomes compared with reference standard drug allergy investigations in the allergy and dermatology clinics.

CONCLUSIONS

Perceived lack of time and preparedness to collect an accurate drug allergy history appear to be important barriers to appropriate antimicrobial prescribing. The Drug Allergy App may represent a useful clinical decision support tool to diagnose drug allergy correctly and support appropriate antibiotic prescribing.

Understanding and Predicting the Adoption of Fitness Mobile Apps: Evidence from China

Increasing global interest in diet and fitness mobile applications (apps) has prompted the question: What are the factors affecting users' adoption and usage behaviors on a specific fitness app? By combining the unified theory of acceptance and use of technology (UTAUT) with the health belief model (HBM), and including risk perception of information technology with the farsighted planner and myopic doer from the theory of self-control, we explore the understanding of this academic question. We analyzed data from 8,840 users of Boohee, a diet and fitness app (ranked first in the weight-loss category on the App Store in China). Structural equation modeling revealed that self-efficacy as well as the perceived benefits, barriers, and threats of weight loss significantly influence a fitness app's performance expectancy, which, in turn, predicts users' intention to adopt it. Furthermore, actual usage behavior (i.e., diet, exercise, weight, and login records within 30 days after respondents completed the questionnaire) is positively affected by weight-loss intention and behavioral intention to use the app and negatively affected by users' risk perception. The main findings of this research could help healthcare practitioners and app developers find better ways to encourage people to adopt health apps for various reasons. App developers should attach more importance to users' actual continuous use behavior than to their intention to use an app. They should provide sufficient introductory information about their apps, thereby reducing users' risk perception and generating reasonable performance expectancy of the app, so as to improve users' actual continuous use behavior.

Patient experience data as enacted: Sociomaterial perspectives and 'singular-multiples' in health care quality improvement research

Over the last three decades, sociomaterial approaches to the study of health care practices have made an important contribution to the sociology of health care. Significant attention has been paid to the role of technology and artefacts in health care and the operation of actor-networks but less space has been given to questions of ontological multiplicity in health care practices. In this paper, we draw upon our study of patient experience data in five acute hospitals in England to illustrate how treating patient experience data as 'singular-multiples' can enable useful insights into patient experience data work in health care organisations. Our data was generated during 12 months of fieldwork at five participating hospitals and included organisational documents, field notes, informal and formal interviews with frontline and managerial staff and patient representatives at the study sites. We use the examples of the Friends and Family Test (FFT) and the National Cancer Patient Experience Survey (NCPES) in England to consider the multiple nature of data as it is enacted in practice and the work data does when coordinated as an entity in the singular. We argue that, and discuss how, the sociomaterial insights we discuss here are relevant to health care quality and improvement research and practice.

Patient use of a self-monitoring app during eating disorder treatment: Naturalistic longitudinal cohort study

OBJECTIVE

To explore patients' use of the self-monitoring app Recovery Record during 26 weeks of naturalistic eating disorder treatment.

METHODS

Selected patient characteristics at baseline were explored as predictors of app use using linear regression. Patients were grouped according to diagnosis (anorexia versus bulimia), and mixed-effects analyses were used to explore differences in app use between diagnoses across four time periods (weeks 1-4; weeks 5-8; weeks 9-12; weeks 13-26).

RESULTS

Eighty-four patients were included of which 41 had anorexia and 43 had bulimia. The total number of logs varied greatly (mean (SD): 592 (628.50)), and patient app activity almost ceased at week 13. Increasing age and no previous eating disorder treatment predicted increased app activity (p = .007; p = .039, respectively). Patients with anorexia logged over four times more often than patients with bulimia in the last time period (median (CI): 4.27 (1.28;14.31); p = .018). Time predicted declining app use (all p ≤ .007).

CONCLUSION

Future research on long-term app engagement should investigate associations between patients' app use and changes in their eating disorder symptom severity over time.

A scoping review of the information provided by fertility smartphone applications

The growth of smartphone application use across areas of female reproductive health has led to increased interest into their functions and benefits. This scoping review aims to determine the nature and extent of the peer-reviewed literature presented on fertility-based apps, to identify the reliability of the information within the apps, and to determine the ability of this information to educate users. A systematic search of six databases was conducted in April 2020, returning a total of 21,158 records. After duplicate removal, title and abstract screening exclusionary steps, 27 records were reviewed and charted. Records covered a variety of reproductive health themes including contraception, sexual health, and family planning, and used a range of methodologies. The accuracy of fertility information within the apps reported in these studies was variable, but overall there was a lack of depth in the coverage of content in apps. It was common for studies in this review to base fertile window algorithms on stringent cycle length and variability requirements, limiting the applicability of information delivered to users. Furthermore, studies from app affiliates often lacked collaborations with researchers, minimising the potential for fertility knowledge improvements integrated across the suite of female reproductive health apps.

'The Internet Both Reassures and Terrifies': exploring the more-than-human worlds of health information using the story completion method

Lay people are now encouraged to be active in seeking health and medical information and acting on it to engage in self-care and preventive health practices. Over the past three decades, digital media offering ready access to health information resources have rapidly expanded. In this article, I discuss findings from my study that sought to investigate health information practices by bringing together the social research method of story completion with more-than-human theory and postqualitative inquiry. Narratives of health, illness and embodiment are powerful ways to portray people's experiences and identify the shared cultural norms and discourses that give meaning and context to these experiences. The research method of story completion is a novel approach to eliciting narratives that involve participants' responses to hypothetical situations. Participants were asked to use an online questionnaire format to complete three stories involving characters faced with a different health problem. This approach sought to identify the human and non-human enabling resources with which the characters engaged as they tried to address and resolve their problem, with a particular interest in how both digital technologies and non-digital resources were used. This analysis highlighted the affective and relational dimensions of humans' enactments of health, illness and embodiment. The stories surfaced the relations of sense-making, embodiment and care and how they are distributed between humans and non-humans. Agential capacities were closed off by elements such as too much information online creating confusion or anxiety, self-consciousness about the appearance of one's body, feelings of embarrassment and shame, or not wanting to appear to be too weak or vulnerable. Capacities for change, wellness and recovery were opened by finding helpful information, making connections with others and finding therapeutic spaces and places.

Patient and provider perceptions on utilizing a mobile technology platform to improve surgical outcomes in the perioperative setting

BACKGROUND AND OBJECTIVES

Patient engagement software is a ubiquitous and expensive commercially available tool designed to improve transitions of care. There are currently no high-quality patient and provider-level data about the usability of these products for surgical oncology patients. This study aims to better understand patient and provider attitudes and perceptions about the implementation of such technology.

METHODS

Focused interviews were conducted following the demonstration of a provider-built mobile technology platform. Interviews were audio-recorded, transcribed, and analyzed. Data were consensus coded inductively and categorized into themes regarding patient and provider perspectives on the usability and implementation of MobiMD.

RESULTS

Our interviews revealed four consistent themes: (1) patients feel there is a lack of reliable resources for patient education; (2) both patients and providers are supportive of using a mobile application; (3) providers perceive patient onboarding as an added burden on current workflows; and (4) after onboarding, providers express that such an application would optimize current workflows.

CONCLUSIONS

Patients perceive a need for improved perioperative education. Providers and patients agree that a mobile technology platform would be an effective solution in addressing this need. Effective implementation of such an intervention may improve patient education and engagement, leading to improved patient outcomes.

Pay to skip the line: The political economy of digital testing services for HIV and other sexually transmitted infections

The value of digital healthcare has been lauded in Canada at local, provincial, and national levels. Digital medicine is purported to enhance patient access to care while promising cost savings. Using institutional ethnography, we examined the potential for publicly funded digital testing for HIV and other sexually transmitted infections (STI) in Ontario, Canada. Our analyses draw from 23 stakeholder interviews with healthcare professionals conducted between 2019 and 2020, and textual analyses of government documents and private, for-profit digital healthcare websites. We uncovered a "two-tiered" system whereby private digital STI testing services enable people with economic resources to "pay to skip the line" queuing at public clinics and proceed directly to provide samples for diagnostics at local private medical labs. In Ontario, private lab corporations compete for fee-for-service contracts with government, which in turn organises opportunities for market growth when more patient samples are collected vis-à-vis digital testing. However, we also found that some infectious disease specimens (e.g., HIV) are re-routed for analysis at government public health laboratories, who may be unable to manage the increase in testing volume associated with digital STI testing due to state budget constraints. Our findings on public-private laboratory funding disparities thus discredit the claims that digital healthcare necessarily generates cost savings, or that it enhances patients' access to care. We conclude that divergent state funding relations together with the creeping privatisation of healthcare within this "universal" system coordinate the conditions through which private corporations capitalise from digital STI testing, compounding patient access inequities. We also stress that our findings bring forth large scale implications given the context of the global COVID-19 pandemic, the rapid diffusion of digital healthcare, together with significant novel coronavirus testing activities initiated by private industry.

Assessment of Data Usage of Cancer e-Interventions (ADUCI) Framework for Health App Use of Cancer Patients and Their Caregivers: Framework Development Study

Background

Multimedia interventions can provide a cost-effective solution to public health needs; however, user engagement is low. Multimedia use within specific populations such as those affected by cancer differs from that of the general population. To our knowledge, there are no frameworks on how to accurately assess usage within this population to ensure that interventions are appropriate for the end users. Therefore, a framework was developed to improve the accuracy of determining data usage. Formative work included creating a data usage framework during target audience testing for smartphone app development and analysis in a pilot study.

Objective

The purpose of this study was to develop a framework for assessing smartphone app usage among people living with cancer and their caregivers.

Methods

The frequency and duration of use were compared based on manual data extraction from two previous studies and the newly developed Assessment of Data Usage of Cancer e-Interventions (ADUCI) Framework.

Results

Manual extraction demonstrated that 279 logins occurred compared with 241 when the ADUCI Framework was applied. The frequency of use in each section of the app also decreased when the ADUCI Framework was used. The total duration of use was 91,256 seconds (25.3 hours) compared with 53,074 seconds (14.7 hours) when using the ADUCI Framework. The ADUCI Framework identified 38 logins with no navigation, and there were 15 discrepancies in the data where time on a specific page of the app exceeded the login time. Practice recommendations to improve user engagement and capturing usage data include tracking data use in external websites, having a login function on apps, creating a five-star page rating functionality, using the ADUCI Framework to thoroughly clean usage data, and validating the Framework between expected and observed use.

Conclusions

Applying the ADUCI Framework may eliminate errors and allow for more accurate analysis of usage data in e-research projects. The Framework can also improve the process of capturing usage data by providing a guide for usage data analysis to facilitate evidence-based assessment of user engagement with apps.

Seeking Meaningful Innovation: Lessons Learned Developing, Evaluating, and Implementing the Electronic Patient-Reported Outcome Tool

Digital health solutions, in particular information communication technologies, often experience implementation failures leading to slower adoption than expected. This implementation challenge has spurred the development of frameworks to help navigate this uncertain and messy process. These frameworks point to environmental, organizational, individual, and technological factors that can drive or hinder implementation, with some in the field suggesting that perceived value may play a pivotal role. However, the concept of value can have varying meanings and be challenging to operationalize as a means to support implementation. Attending to philosophical and psychological meaningfulness for users and organizations in which technologies are adopted may offer a useful lens, by linking perceived value to individual behavior changes often required as part of implementing digital health technologies. Lessons learned from developing, evaluating, and implementing the electronic Patient-Reported Outcome (ePRO) tool demonstrate how qualitative methods can be used to uncover meaningfulness. By drawing from this example and other similar studies, this viewpoint offers suggestions on how future inquiry could deepen an understanding of meaningful innovation to help drive the implementation of digital health technologies.

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.

The Influence of Fitness-App Usage on Psychological Well-Being and Body Awareness-A Daily Diary Randomized Trial

Self-tracking via fitness apps is popular and has been described as a means to enhance body awareness and well-being. However, the effects of fitness-app use and specific app functions on well-being and body awareness have yet to be targeted in controlled experimental studies. In two randomized groups, a fitness tracker was used for 6 weeks, and in one group a daily step target was implemented. In a third control group, participants documented their physical activity. A daily diary method was used to measure well-being and body trusting. In Bayesian multilevel analyses, no time, group, or interaction effects were found. These results were robust when controlling for diverse variables. It can be concluded that exercise-related self-tracking and specific step goals do not substantially influence psychological well-being and body trusting. Considering the large variability in effects, potential effects can be assumed under conditions that are to be identified in further studies.

Factors Related to User Ratings and User Downloads of Mobile Apps for Maternal and Infant Health: Cross-Sectional Study

BACKGROUND

Mobile health apps related to maternal and infant health (MIH) are prevalent and frequently used. Some of these apps are extremely popular and have been downloaded over 5 million times. However, the understanding of user behavior and user adoption of these apps based on consumer preferences for different app features and categories is limited.

OBJECTIVE

This study aimed to examine the relationship between MIH app characteristics and users' perceived satisfaction and intent to use.

METHODS

The associations between app characteristics, ratings, and downloads were assessed in a sample of MIH apps designed to provide health education or decision-making support to pregnant women or parents and caregivers of infants. Multivariable linear regression was used to assess the relationship between app characteristics and user ratings, and ordinal logistic regression was used to assess the relationship between app characteristics and user downloads.

RESULTS

The analyses of user ratings and downloads included 421 and 213 apps, respectively. The average user rating was 3.79 out of 5. Compared with the Apple App Store, the Google Play Store was associated with high user ratings (beta=.33; P=.005). Apps with higher standardized user ratings (beta=.80; P<.001), in-app purchases (beta=1.12; P=.002), and in-app advertisements (beta=.64; P=.02) were more frequently downloaded. Having a health care organization developer as part of the development team was neither associated with user ratings (beta=-.20; P=.06) nor downloads (beta=-.14; P=.63).

CONCLUSIONS

A majority of MIH apps are developed by non-health care organizations, which could raise concern about the accuracy and trustworthiness of in-app information. These findings could benefit app developers in designing better apps and could help inform marketing and development strategies. Further work is needed to evaluate the clinical accuracy of information provided within the apps.

Novel design of smart sleep-lighting system for improving the sleep environment of children

BACKGROUND

Children struggle to fall asleep by themselves because of their physiological characteristics. Therefore, research has been carried on various devices (such as a smartphone) to assist in improving the sleep quality of children. However, all such devices need to be controlled by parents and do not have functions for monitoring the sleep environment.

OBJECTIVE

In this paper, a smart sleep-lighting system that includes a sleep-lighting device and a smartphone dongle is developed to improve the sleep environment of children.

METHODS

The temperature, humidity, and luminance of the sleep environment are monitored and analyzed by the sleep-lighting device to control multi-color light and audio components. The colored light emitted by the multi-color light can be adjusted to improve the sleep atmosphere. Also, the audio component can play white noise to induce sleep. In addition, parents can use a smartphone dongle with a multi-channel wireless communication method to monitor and control one or more lighting devices in different locations in real time.

RESULTS

For environmental monitoring, average difference between proposed device and commercial sensor from chamber setting temperature 15∘C to 35∘C was 0.588∘C ± 0.10∘C, and average error value of the humidity measurement was 0.74% at 40% ∼ 60% RH. Also, the manufactured sleep-lighting device shows good performance in multi-color light emission, and playing of white noise. As result, the smartphone connected to the proposed smartphone dongle enables monitoring and control of the proposed lighting device in a wireless well.

CONCLUSIONS

The manufactured sleep-lighting device has a high-precision temperature and humidity sensor and a luminance sensor that can accurately monitor the sleeping environment. The lighting device can play white noise to induce sleep in children. Also, a multi-color LED light is operated via a smartphone application to improve the sleep atmosphere. The measured data will be sent to the lighting device and processed together with sleep environment data in order to improve the sleep quality. Additionally, the final system will be tested for real end-users with clinical experiments by sleep research center of a university hospital.

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.

Re-thinking Digital Health: Data, Appisation and the (im)possibility of 'Opting out'

Presented as providing cost-, time- and labour- effective tools for the (self)management of health, health apps are often celebrated as beneficial to all. However, their negative effects - commodification of user data and infringement on privacy - are rarely addressed. This article focuses on one particularly troubling aspect: the difficulty of opting out of data sharing and aggregation during app use or after unsubscribing/uninstalling the app. Working in the context of the new European General Data Protection Regulation and its implementation in the UK health services, our analysis reveals the discrepancy between the information presented to users, and the apps' actual handling of user data. We also point to the fundamental tension in the digitisation of health, between the neoliberal model where both health and data concerns are viewed as an individual's responsibility, and the digital-capitalist model, which puts forward, and capitalises on, collective ('Big') data. Pulled between the 'biopolitics of the self' and the 'biopolitics of the population' (concepts coined by Btihaj Ajana), opting out of health datafication therefore cannot be resolved as a matter of individual right alone. The article offers two contributions. Methodologically, we present a toolkit for a multi-level assessment of apps from the perspective of opting out, which can be adapted and used in future research. Conceptually, the article brings together critical digital health scholarship with the perspective of data justice, offering a new approach to health apps, which focuses on opt-out as a legal, social and technical possibility, and as a collective citizen and user right.

Adolescents' participation in their healthcare: A sociomaterial investigation of a diabetes app

OBJECTIVE

This article explores how a diabetes app called Diapplo affected adolescents' participation in their healthcare by investigating adolescents' meaning-making in relation to their use of the app.

METHODS

Using a qualitative single case-study design, we adopted a multimethod responsive approach to data generation that included written data from the app development process, individual and group interviews and observations of the adolescents in the clinical situation. This article presents the results from a qualitative content analysis of group and individual semi-structured interviews conducted with five adolescents diagnosed with type 1 diabetes during and after the four-week test phase of a prototype of the app.

RESULTS

The adolescents appreciated the diabetes app's design and interface and having an overview of their blood glucose values. However, they stated that the app's content only partly met their needs and they considered several of its features unnecessary. They would have liked the app to have a social platform and emphasized that the app should be compatible with their blood glucose monitors and pumps for them to continue using it.

CONCLUSIONS

The participants in our study highlighted the value of social platforms integrated in health apps for patient participation, as well as their preference for health app features that reduced the effort of managing their chronic condition and facilitate greater knowledge. Theories of sociomateriality and material participation helped to account for the challenges of integrating users' perspectives, suggesting the value of early, comprehensive identification and prioritization of users' values when developing mobile health technologies.

Can digital health save democracy? Meeting the cosmopolitical challenge of digital worlds

This article explores the challenges and opportunities of social media health activisms to shape public participation in the digital future of healthcare. As health becomes ever more entangled with digital technologies, a growing ecology of digital health services promise greater individual autonomy to learn about and managing medical conditions, as well as accessing health services and engaging in forms of self-care. Cautioning against optimist visions of digital health and their promise of empowerment and autonomy, the article explores how health activisms on social media are reclaiming visions of healthcare that move beyond individual and depoliticised models of health technologies. The notion of cosmopolitics is employed to conceptualise relations between technology and health that implicate human and non-human interests in entanglements between health, morality and technology.

Between empowerment and self-discipline: Governing patients' conduct through technological self-care

Recent health policy renders patients increasingly responsible for managing their health via digital technology such as health apps and online patient platforms. This paper discusses underlying tensions between empowerment and self-discipline embodied in discourses of technological self-care. It presents findings from documentary analysis and interviews with key players in the English digital health context including policy makers, health designers and patient organisations. We show how discourses ascribe to patients an enterprising identity, which is inculcated with economic interests and engenders self-discipline. However, this reading does not capture all implications of technological self-care. A governmentality lens also shows that technological self-care opens up the potential for a de-centring of medical knowledge and its subsequent communalization. The paper contributes to Foucauldian healthcare scholarship by showing how technology could engender agential actions that operate at the margins of an enterprising discourse.

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Digital health policy in UK assumes an enterprising & empowered patient identity.

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Tensions between empowerment & discipline occur as patients self-care digitally.

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Digital health creates space for agential actions that improve communal health.

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A health-making agency operates in the margins of governmental self-care discourse.

A mixed methods exploratory study of women's relationships with and uses of fertility tracking apps

Digital self-tracking is rising, including tracking of menstrual cycles by women using fertility tracking apps (FTAs). However, little is known about users’ experiences of FTAs and their relationships with them. The aim of this study was to explore women’s uses of and relationships with FTAs. This exploratory study employed a mixed methods approach, involving the collection and analysis of an online survey and follow-up interviews. Qualitative analysis of survey and interview data informed hypothesis development. Online surveys yielded 241 responses and 11 follow-up interviews were conducted. Just over a third of women surveyed had experience of using FTAs (89/241) and follow-up interviews were conducted with a proportion of respondents (11/241). Four main motivations to use FTAs were identified: (a) to observe cycle (72%); (b) to conceive (34%); (c) to inform fertility treatment (12%); and (d) as contraception (4%). Analysis of the free-text survey questions and interviews using grounded theory methodology highlighted four themes underpinning women’s relationships with FTAs: (a) medical grounding; (b) health trackers versus non-trackers; (c) design; and (d) social and ethical aspects. Participants who used other health apps were more likely to use FTAs (p = 0.001). Respondents who used contraception were less likely to use FTAs compared with respondents who did not use contraception (p = 0.002). FTA usage also decreases (p = 0.001) as age increases. There was no association between FTA usage and menstrual status (p = 0.259). This research emphasises the differing motivations for FTA use. Future research should further explore the diverse relationships between different subgroups of women and FTAs.

Individuals on alert: digital epidemiology and the individualization of surveillance

This article examines how digital epidemiology and eHealth coalesce into a powerful health surveillance system that fundamentally changes present notions of body and health. In the age of Big Data and Quantified Self, the conceptual and practical distinctions between individual and population body, personal and public health, surveillance and health care are diminishing. Expanding on Armstrong's concept of "surveillance medicine" to "quantified self medicine" and drawing on my own research on the symbolic power of statistical constructs in medical encounters, this article explores the impact of digital health surveillance on people's perceptions, actions and subjectivities. It discusses the epistemic confusions and paradoxes produced by a health care system that increasingly treats patients as risk profiles and prompts them to do the same, namely to perceive and manage themselves as a bundle of health and security risks. Since these risks are necessarily constructed in reference to epidemiological data that postulate a statistical gaze, they also construct or make-up disembodied "individuals on alert".

Social media for health promotion: What messages are women receiving about cardiovascular disease risk by the Canadian Heart and Stroke Foundation?

The aim of this study was to explore the meanings of women's cardiovascular disease constructed within the Canadian Heart and Stroke Foundation Facebook page. Posts from Heart and Stroke Foundation and public user comments surrounding the launch of the Heart and Stroke Foundation re-branding were of interest. Ethnographic content analysis was employed to analyse text (n = 40), images (n = 32), videos (n = 6), user comments and replies (n = 42) from November 2016 to March 2017. Constructions (re)presented on Facebook of 'typical' women at risk and risk reduction were problematic as women most at risk were excluded through the use of consumerist, medicalized identities which also excluded promotion of healthy behaviour changes.

New Kinds of (Ab)normal?: Public Pedagogies, Affect, and Youth Mental Health in the Digital Age

Academic, policy, and public concerns are intensifying around how to respond to increasing mental health problems amongst young people in OECD countries such as the UK and Australia. In this paper we make the case that public knowledge about mental health promotion, help-seeking, support and recovery can be understood as an enactment of public pedagogy—as knowledge practices and processes that are produced within and beyond formal spaces of learning. We explore the question of how new pedagogic modes of address are produced through digital technologies—social media, gamified therapies, e-mental health literacy, wearable technology—as they invite particular ways of knowing embodied distress as “mental illness or ill health.” The rapid growth of formal and informal pedagogical sites for learning about youth mental health raises questions about the affective arrangements that produce new kinds of (ab)normal in the digital era. Through a posthumanist perspective that connects critical mental health studies and public pedagogy, this paper offers an original contribution that theorises pedagogic sites within the cultural formation of public-personal knowledge about mental (ill) health.

Nutritional monitoring of patients post-bariatric surgery: implications for smartphone applications

BACKGROUND

Optimal results from bariatric surgery are contingent on patient commitment to dietary and lifestyle changes and follow-up care. The present study aimed to investigate the attitudes and use of mobile health (mHealth) smartphone applications (apps) as a potential tool for maintaining connectivity between dietitians and patients post-bariatric surgery.

METHODS

A cross-sectional online survey was developed and distributed to a purposeful sample of bariatric dietitians and bariatric patients in Australia. The survey questions explored technology penetration (smartphone and app use), communication preferences, nutrition monitoring methods, professional relationship expectations and reasons for loss to follow-up.

RESULTS

Survey completion rate was 85% (n = 50/59) for dietitians and 80% (n = 39/49) for patients. Smartphone ownership was 98% and 95% for dietitians and patients, respectively. Common reasons given for losing patients to follow-up suggest that a traditional in-clinic practice setting could be a barrier for some. Most dietitians (n = 48; 91%) prefer to see patients face-to-face in their clinic, whereas patient preferences extended to e-mail and mobile messaging. Sixty-eight percent of bariatric patients were receptive to two-way communication with dietitians via an app between clinic visits. Both cohorts recognised the potential for emerging technologies to be used in practice, although there was no single routinely recommended mHealth app.

CONCLUSIONS

The present study provides the first insight into the use of mobile devices and apps by post-bariatric patients and the dietitians who support them. A mixture of traditional methods and smartphone technology is desirable to both dietitians and patients. The utility and effectiveness of such technologies should be confirmed in future intervention studies.

Digital Technology Healthcare Solutions in an Era of Moving Populations and Chronic Illnesses: Are We Being Realistically Smart?

In 2015, the world recorded its highest numbers of international migrants and forced displacement since World War II. With this historic rise in migrants, refugees, and displaced persons around the world, there is a huge risk of chronic illness burden on healthcare systems. Thus, healthcare systems may need to incorporate innovative digital healthcare solutions into their processes and procedures. The purpose of this article is to present the argument that for effective prevention and management of chronic illnesses in ever-increasing migrant societies to be achieved, mobile digital healthcare technologies must be realistically smart and strategically adopted. Beginning with an overview of the current global migration trend, this article considers the implications of this trend for chronic illnesses and the potential for mobile health technologies to support achievement of healthcare outcomes. It highlights three core reasons why digital innovations may be limited as tools for helping to address the global chronic illness challenge and identifies important directions for mobile health technology developers, healthcare professionals, researchers, government and funding agencies, and public health ministries, with a focus on the strategic development and adoption of ‘realistically smart’ phones. The article concludes with recommendations for research and public health education.