Digital mental health interventions for the mental health care of refugees and asylum seekers: Integrative literature review

This study aimed to provide a critical analysis of the current literature on the use of digital mental health interventions (DMHIs) for the management and treatment of mental health disorders among refugees and asylum seekers. These groups are among the most disadvantaged compared to the general population in terms of health and socio-economic status, due to conflicts and wars. The number of refugees fleeing their home countries is growing exponentially, and refugees experience trauma, torture, persecution and human right abuses, which have a profound effect on their mental health and overall well-being. The researchers conducted an integrative literature review from electronic databases Medline, CINAHL and Google Scholar, selecting articles published in English from 2010 to 2023. The thematic analysis of the 10 articles identified in the review revealed four main themes and two sub-themes: (1) types of digital health intervention/apps used; (2) barriers encountered in digital health intervention; (3) user experience of the digital health intervention and (4) mapping gaps. Two sub-themes were identified located in Theme 2: (2.1) Language and demographic barriers and (2.2) Structural barriers. The study showed that the use of DMHIs was associated with positive experiences among refugees and asylum seekers. Limited mental health care is offered to refugees and asylum seekers due to a range of logistical, political, economic, geographical, language, cultural and social barriers. DMHIs have the potential to overcome and/or moderate these barriers. The study concludes that the scaled implementation of effective DMHIs holds the possibility to improve the wider distribution of mental health care among refugees and asylum seekers. However, further research is needed to confirm the effectiveness of DMHIs and to scale up studies for their utilisation among this group. In summary, this study highlights the potential of DMHIs in improving the mental health care of refugees and asylum seekers. The results of this study have important implications for mental health service providers, policymakers and researchers to address the mental health needs of this vulnerable/priority group.

A Chitosan-Based Fluorescent Probe Combined with Smartphone Technology for the Detection of Hypochlorite in Pure Water

Using chitosan as a raw material, 1,8-naphthimide as the fluorescent chromophore, and sulfur-containing compounds as the recognition groups, a novel naphthimide-functionalized chitosan probe, CS-BNS, for the detection of ClO- was successfully synthesized. The modification of chitosan was verified by SEM, XRD, FTIR, mapping, 13C-NMR, TG and the structure of the probe molecule was characterized. The identification performance of the probes was studied using UV and fluorescence spectrophotometers. The results show that CS-BNS exhibits a specific response to ClO- based on the oxidative reaction of ClO- to the recognition motifs, as well as a good resistance to interference. And the probe has high sensitivity and fast response time, and can complete the detection of ClO- in a pure water system within 60 s. The probe can also quantify ClO- (y = 30.698x + 532.37, R2 = 0.9833) with a detection limit as low as 0.27 μM. In addition, the combination of the probe with smartphone technology enables the visualization and real-time monitoring of ClO-. Moreover, an identification system for ClO- was established by combining the probe with smartphone technology, which realized the visualization and real-time monitoring of ClO-.

Impact of Smartphone App-Based Psychological Interventions for Reducing Depressive Symptoms in People With Depression: Systematic Literature Review and Meta-analysis of Randomized Controlled Trials

Background

Depression is a serious, disabling mental disorder that severely affects quality of life. Patients with depression often do not receive adequate treatment. App-based psychotherapy is considered to have great potential to treat depression owing to its reach and easy accessibility.

Objective

We aim to analyze the impact of app-based psychological interventions for reducing depressive symptoms in people with depression.

Methods

We conducted a systematic literature review and meta-analysis. We searched Medline, Embase, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials from inception to December 23, 2020. We selected randomized controlled trials to examine the impact of app-based psychological interventions for reducing depressive symptoms in people with depression. Study selection, data extraction, and critical appraisal (using the Cochrane Risk of Bias tool for randomized studies and the ROBINS-I tool for nonrandomized studies) were conducted independently by 2 reviewers. Where possible, we pooled data using random effects meta-analyses to obtain estimates of the effect size of the intervention. We conducted post hoc meta-regression analyses to explore the factors associated with intervention success.

Results

After screening 3468 unique references retrieved from bibliographic searches and assessing the eligibility of 79 full texts, we identified 12 trials (2859 participants) evaluating 14 different interventions. Of 14 trials, 7 (58%) were conducted in the United States; 3 (25%) trials, in Asia (Japan, South Korea, and China); 1 (8%) trial, in Australia; and 1 (8%) trial, in Germany. Of the 12 trials, 5 (42%) trials presented a low risk of bias. The mean duration of the interventions was 6.6 (SD 2.8) weeks. Two-thirds of the interventions were based on cognitive behavioral therapy alone or included it in combination with cognitive control therapy, positive psychology, brief behavioral activation, or mindfulness- and acceptance-based therapy. With no evidence of publication bias, a pooled analysis of 83% (10/12) of the trials and 86% (12/14) of the interventions showed that app-based interventions, compared with a control group receiving usual care or minimal intervention, produced a moderate reduction in depressive symptoms (standardized mean difference [SMD] −0.51, 95% CI −0.69 to −0.33; 2018/2859, 70.58% of the participants; I²=70%). Our meta-regression analyses indicated that there was a greater reduction in symptoms of depression (P=.04) in trials that included participants with moderate to severe depression (SMD −0.67, 95% CI −0.79 to −0.55), compared with trials with participants exhibiting mild to moderate depression (SMD −0.15, 95% CI −0.43 to −0.12).

Conclusions

App-based interventions targeted at people with depression produce moderate reductions in the symptoms of depression. More methodologically robust trials are needed to confirm our findings, determine which intervention features are associated with greater improvements, and identify those populations most likely to benefit from this type of intervention.

Trial Registration

PROSPERO CRD42019145689; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=145689

Smartphone Technology to Empower People Experiencing Homelessness: Secondary Analysis

BACKGROUND

In the United States, the number of people experiencing homelessness has continually increased over the last 3 years. Homelessness is associated with poor health, and people experiencing homelessness are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite the high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations.

OBJECTIVE

This study aims to investigate how access to smartphone technology facilitates self-management, including the attainment of social needs within the context of homelessness.

METHODS

A secondary analysis of 33 exit interviews from 2 feasibility studies related to mobile health interventions among people experiencing homelessness was conducted. Iterative thematic analysis was used to identify themes representative of participants' experiences using smartphone technology.

RESULTS

Collectively, participants revealed not only how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having a smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management.

CONCLUSIONS

People experiencing homelessness used the tools on a smartphone to make decisions, take action, solve problems, and use the resources-skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to smartphone technology and transportation empowered participants to meet the requirements for the attainment of social needs.

A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial

BACKGROUND

Available smartphone-based interventions for depression predominantly use evidence-based strategies from cognitive-behavioral therapy (CBT), but patient engagement and reported effect sizes are small. Recently, studies have demonstrated that smartphone-based interventions combining CBT with gamified approach-avoidance bias modification training (AAMT) can foster patient engagement and reduce symptoms of several mental health problems.

OBJECTIVE

Based on these findings, we developed a gamified smartphone-based intervention, mentalis Phoenix (MT-Phoenix), and hypothesized the program would both engage patients and produce preliminary evidence for the reduction of depressive symptoms.

METHODS

To test this hypothesis, we evaluated MT-Phoenix in a randomized controlled pilot trial including 77 individuals with elevated depression scores (Patient Health Questionnaire-9 scores ≥5). Participants were either instructed to train for 14 days with MT-Phoenix or assigned to a waitlist control condition. Engagement with the intervention was measured by assessing usage data. The primary outcome was reduction in depressive symptom severity at postassessment.

RESULTS

Data from this pilot trial shows that participants in the intervention group used the smartphone-based intervention for 46% of all days (6.4/14) and reported a significantly greater reduction of depressive symptoms than did participants in the control condition (F_1,74=19.34; P=.001), with a large effect size (d=1.02). Effects were sustained at a 3-month follow-up.

CONCLUSIONS

A gamified smartphone-based intervention combining CBT with AAMT may foster patient engagement and effectively target depressive symptoms. Future studies should evaluate the effectiveness of this intervention in a phase 3 trial using clinical samples. Moreover, the intervention should be compared to active control conditions.

TRIAL REGISTRATION

German Clinical Trial Registry DRKS00012769; https://tinyurl.com/47mw8du7.

Smartphone Usage Among Doctors in the Clinical Setting in Two Culturally Distinct Countries: Cross-sectional Comparative Study

BACKGROUND

Smartphones and mobile applications have seen a surge in popularity in recent years, a pattern that has also been reflected in the health care system. Despite increased reliance among clinicians however, limited research has been conducted on the uptake and impact of smartphone usage in medical practice, especially outside the Western world.

OBJECTIVE

This study aimed to identify the usage of smartphones and medical apps by doctors in the clinical setting in 2 culturally distinct countries: King Hamad University Hospital (KHUH), Bahrain and Queen Mary Hospital (QMH), Hong Kong.

METHODS

A cross-sectional, comparative study was conducted where doctors in both hospitals were asked to take part in a 15-item online survey. The questions were categorized into the following groups: demographics of the study population, ownership and main use of smartphones, number and names of medical apps currently owned, rating usage of smartphones for medical purposes, time spent on a smartphone related to clinical use, clinical reliance on smartphones, and views on further integration of smartphones. The results were then tabulated and analyzed using SPSS Statistics 25 for Mac (IBM Corp Inc, Armonk, NY).

RESULTS

A total of 200 doctors were surveyed, with a total of 99.0% (99/100) of the doctors owning a smartphone in both KHUH and QMH; 58% (57/99) and 55% (54/99) of the doctors from KHUH and QMH, respectively, identified communication as their main use of smartphones in the clinical setting (P=.004). Doctors from KHUH were likely to spend more time on medical apps than doctors from QMH (P=.002). According to the overall results of both hospitals, 48% (32/67) of the junior doctors claimed high reliance on smartphones, whereas only 32.3% (41/127) of the senior doctors said the same (P=.03). Of doctors in KHUH and QMH, 78.0% (78/100) and 69.0% (69/100), respectively, either strongly agreed or agreed that smartphones need to be integrated into the clinical setting. In terms of preferences for future apps, 48% (48/100) and 56% (56/100) of the doctors in KHUH and QMH, respectively, agreed that more medical applications need to be created in order to support smartphone use in the clinical setting.

CONCLUSIONS

These results suggest a substantial acceptance of smartphones by doctors in the clinical setting. It also elicits the need to establish policies to officially integrate smartphone technology into health care in accordance with ethical guidelines. More emphasis should be placed on creating medical applications that aid health care professionals in attaining their information from accurate sources and also regulate a system to monitor the usage of mobile devices within hospitals to prevent a breach of patient privacy and confidentiality.

Can Smartphone-Derived Step Data Predict Laboratory-Induced Real-Life Like Fall-Risk in Community- Dwelling Older Adults?

Background: As age progresses, decline in physical function predisposes older adults to high fall-risk, especially on exposure to environmental perturbations such as slips and trips. However, there is limited evidence of association between daily community ambulation, an easily modifiable factor of physical activity (PA), and fall-risk. Smartphones, equipped with accelerometers, can quantify, and display daily ambulation-related PA simplistically in terms of number of steps. If any association between daily steps and fall-risks is established, smartphones due to its convenience and prevalence could provide health professionals with a meaningful outcome measure, in addition to existing clinical measurements, to identify older adults at high fall-risk. Objective: This study aimed to explore whether smartphone-derived step data during older adults' community ambulation alone or together with commonly used clinical fall-risk measurements could predict falls following laboratory-induced real-life like slips and trips. Relationship between step data and PA questionnaire and clinical fall-risk assessments were examined as well. Methods: Forty-nine community-dwelling older adults (age 60-90 years) completed Berg Balance Scale (BBS), Activities-specific Balance Confidence scale (ABC), Timed Up-and-Go (TUG), and Physical Activity Scale for the Elderly (PASE). One-week and 1-month smartphone steps data were retrieved. Participants' 1-year fall history was noted. All participants' fall outcomes to laboratory-induced slip-and-trip perturbations were recorded. Logistic regression was performed to identify a model that best predicts laboratory falls. Pearson correlations examined relationships between study variables. Results: A model including age, TUG, and fall history significantly predicted laboratory falls with a sensitivity of 94.3%, specificity of 58.3%, and an overall accuracy of 85.1%. Neither 1-week nor 1-month steps data could predict laboratory falls. One-month steps data significantly positively correlated with BBS (r = 0.386, p = 0.006) and ABC (r = 0.369, p = 0.012), and negatively correlated with fall history (r _p = -0.293, p = 0.041). Conclusion: Older participants with fall history and higher TUG scores were more likely to fall in the laboratory. No association between smartphone steps data and laboratory fall-risk was established in our study population of healthy community-dwelling older adults which calls for further studies on varied populations. Although modest, results do reveal a relationship between steps data and functional balance deficits and fear of falls.

The Validity, Reliability, and Sensitivity of a Smartphone-Based Seated Postural Control Assessment in Wheelchair Users: A Pilot Study

Seated postural control is essential for wheelchair users to maintain proper position while performing activities of daily living. Clinical tests are commonly used to measure seated postural control, yet they are subjective and lack sensitivity. Lab-based measures are highly sensitive but are limited in scope and restricted to research settings. Establishing a valid, reliable, and accessible measurement tool of seated postural control is necessary for remote, objective assessments. Therefore, the purpose of this study was to examine the validity, reliability, and sensitivity of smartphone-based postural control assessments in wheelchair users. Eleven participants (age: 35.4 ± 17.9) completed two experimental visits 1-week apart consisting of three clinical tests: Trunk Control Test (TCT), Function in Sitting Test (FIST), and Tee-shirt Test, as well as, standardized instrumented balance tasks that manipulated vision (eyes open and closed), and trunk movement (functional reach and stability boundary). During these tasks, participants held a smartphone instrumented with a research-grade accelerometer to their chest. Maximum and root mean square (RMS) acceleration in the medial-lateral (ML) and anterior-posterior (AP) axes were derived. Participants were grouped into non-impaired and impaired postural groups based on FIST scores. Spearman rank-order correlations were conducted between the two devices' outcome measurements and between these measures and those of the clinical tests. Receiver operating characteristic (ROC) curves and the area under the curves (AUC) were determined to distinguish participants with and without impaired postural control. The reliability of outcome variables was assessed using inter-class correlations. Strong correlations between outputs derived from the smartphone and research-grade accelerometer were seen across balance tasks (ρ = −0.75–1.00; p ≤ 0.01). Numerous significant moderate correlations between clinical test outcomes and smartphone and research-grade RMS ML accelerometry were seen (ρ = −0.62 to 0.83 (p ≤ 0.044)]. On both devices, the AUC for ROC plots were significant for RMS ML sway during the eyes open task and functional stability boundary (p < 0.05). Reliability of smartphone accelerometry was comparable to the research-grade accelerometer and clinical tests. This pilot study illustrated that smartphone-based accelerometry may be able to provide a valid and reliable assessment of seated postural control and have the ability to distinguish between those with and without impaired postural control.

Improving Critical Value Notification through Secure Text Messaging

BACKGROUND

To improve communication between clinical providers and the laboratory, we recently implemented secure text messaging for our critical value notifications. This was done to communicate laboratory critical values (CV) to providers faster so changes to patient care could be done faster. Our previous method of communicating CV to providers was paging and relied on a call back to receive the critical value.

METHODS

We implemented delivery of CV through a secure texting application in which the CV was directly communicated to the provider on their smart phone device.

RESULTS

The mean pre-implementation turnaround time (TAT) was 11.3 minutes (median: 7 minutes, range: 0 - 210 minutes). The mean post- secure text messaging implementation TAT was 3.03 minutes (median: 0.89 minutes, range: < 1 - 95 minutes).When comparing pre- and post-implementation, there was a significant reduction in the TAT from using secure text messaging (p < 0.001). Of the 234 surveys sent out, 81 providers responded (35%). Of these responses, 85% reported that critical value notification by secure text messaging has increased their efficiency and 95% reported that critical value notification is more effective than a pager-phone-call based system. 83% of providers reported that they were able to provide better, faster care to their patients.

CONCLUSIONS

Using secure text messaging (STM) to deliver critical values significantly reduces the CV TAT. Furthermore, providers noted they preferred to receive CV notifications through STM and reported that they were able to provide more effective care to their patients.

Pediatric, Family-Centered, "At-Home" Otologic Physical Examination in the COVID-19 Era

SARS-CoV-2, the novel coronavirus resulting in the present COVID-19 pandemic, has increased the otolaryngologist's reliance on telemedicine to manage outpatient pathology. The nature of telemedicine, however, limits a provider's ability to obtain a comprehensive physical examination, specifically of the tympanic membrane. Various smartphone-based otoscopic attachments are now available that facilitate patient-obtained otoscopic image capture of the tympanic membrane. Here, we present 3 cases in which a patient-purchased, over-the-counter otoscope was utilized to alter otologic management during the time of social distancing. Further research is necessary to improve our understanding the safety and efficacy of patient-based "at-home" otoscopic examination and to optimize the use of these devices.

Use of Apps to Promote Childhood Vaccination: Systematic Review

BACKGROUND

Vaccination is a critical step in reducing child mortality; however, vaccination rates have declined in many countries in recent years. This decrease has been associated with an increase in the outbreak of vaccine-preventable diseases. The potential for leveraging mobile platforms to promote vaccination coverage has been investigated in the development of numerous mobile apps. Although many are available for public use, there is little robust evaluation of these apps.

OBJECTIVE

This systematic review aimed to assess the effectiveness of apps supporting childhood vaccinations in improving vaccination uptake, knowledge, and decision making as well as the usability and user perceptions of these apps.

METHODS

PubMed, Excerpta Medica Database (EMBASE), Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Education Resources Information Center (ERIC) databases were systematically searched for studies published between 2008 and 2019 that evaluated childhood vaccination apps. Two authors screened and selected studies according to the inclusion and exclusion criteria. Data were extracted and analyzed, and the studies were assessed for risk of bias.

RESULTS

A total of 28 studies evaluating 25 apps met the inclusion criteria and were included in this analysis. Overall, 9 studies assessed vaccination uptake, of which 4 reported significant benefits (P<.001 or P=.03) of the implementation of the app. Similarly, 4 studies indicated a significant (P≤.054) impact on knowledge and on vaccination decision making. Patient perceptions, usability, and acceptability were generally positive. The quality of the included studies was found to be moderate to poor, with many aspects of the methodology being unclear.

CONCLUSIONS

There is little evidence to support the use of childhood vaccination apps to improve vaccination uptake, knowledge, or decision making. Further research is required to understand the dichotomous effects of vaccination-related information provision and the evaluation of these apps in larger, more robust studies. The methodology of studies must be reported more comprehensively to accurately assess the effectiveness of childhood vaccination apps and the risk of bias of studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16929.

Comparison of Features of a Mobile Application to Report School Violence Through Benchmarking

BACKGROUND

At a time and educational context favorable to technologies and innovations, we took the initiative to mobile phone applications (apps) relevant to school violence in an effort to be responsive to a growing public health problem in multiple countries.

METHODS

In this study, we compared and verified the features of 10 apps for reporting violence in schools. We used a benchmarking tool for integrative review of these mobile apps.

RESULTS

There were 13 apps on the Google Play platform, 11 apps in the App Store, and 5 apps on both platforms, totaling 19 apps. We selected 10 apps for comparative analysis.

CONCLUSIONS

Through benchmarking, we determined the relevant features of the apps with recommendations for improving app development in the future.

Large-scale audience participation in live music using smartphones

We present a study and reflection about the role and use of smartphone technology for a large-scale musical performance involving audience participation. We evaluated a full design and development process from initial ideation to a final performance concept. We found that the smartphone became the design tool, the technical device and the musical instrument at the same time. As a technical device that uses ultrasound communication as interaction technique, the smartphone became inspirational for the artist's creative work. In aiming to support the artist, we observed pervasive importance of retaining artistic control to realise artistic intent. This concerns the co-design process and the resulting concept of audience participation and supports recommendations for such participatory work.

Use of Apps to Promote Childhood Vaccination: Protocol for a Systematic Review

Background

The decline in the uptake of routine childhood vaccinations has resulted in outbreaks of vaccine-preventable diseases. Vaccination apps can be used as a tool to promote immunization through the provision of reminders, dissemination of information, peer support, and feedback.

Objective

The aim of this review is to systematically review the evidence on the use of apps to support childhood vaccination uptake, information storage, and record sharing.

Methods

We will identify relevant papers by searching the following electronic databases: PubMed, Embase by Ovid, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Education Resources Information Center (ERIC). We will review the reference lists of those studies that we include to identify relevant additional papers not initially identified using our search strategy. In addition to the use of electronic databases, we will search for grey literature on the topic. The search strategy will include only terms relating to or describing the intervention, which is app use. As almost all titles and abstracts are in English, 100% of these will be reviewed, but retrieval will be confined to papers written in the English language. We will record the search outcome on a specifically designed record sheet. Two reviewers will select observational and intervention studies, appraise the quality of the studies, and extract the relevant data. All studies will involve the use of apps relating to child vaccinations. The primary outcome is the uptake of vaccinations. Secondary outcomes are as follows: (1) use of app for sharing of information and providing vaccination reminders and (2) use of app for storage of vaccination information; knowledge and decision making by parents regarding vaccination (ie, risks and benefits of vaccination); costs and cost-effectiveness of vaccination apps; use of the app and measures of usability (eg, usefulness, acceptability, and experiences of different users: parents and health care professionals); use of technical standards for development of the app; and adverse events (eg, data leaks and misinformation). We will exclude studies that do not study an app. We anticipate a limited scope for meta-analysis and will provide a narrative overview of findings and tabular summaries of extracted data.

Results

This project was funded by the Sir David Cooksey Fellowship in Healthcare Translation at the University of Oxford, Oxford, United Kingdom. We will submit the full systematic review for publication in the Journal of Medical Internet Research.

Conclusions

This review will follow, where possible, the Cochrane Collaboration and the Centre for Review and Dissemination methodologies for conducting systematic reviews. We will report our findings based on guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The review results will be used to inform the development of a vaccination app.

International Registered Report Identifier (IRRID)

PRR1-10.2196/16929

Outcomes of a randomized controlled trial assessing a smartphone Application to reduce unmet needs among people diagnosed with CancEr (ACE)

BACKGROUND

Smartphone technology represents an opportunity to deliver practical solutions for people affected by cancer at a scale that was previously unimaginable, such as information, appointment monitoring, and improved access to cancer support services. This study aimed to determine whether a smartphone application (app) reduced the unmet needs among people newly diagnosed with cancer.

METHODS

A single blind, multisite randomized controlled trial to determine the impact of an app-based, 4-month intervention. Newly diagnosed cancer patients were approached at three health service treatment clinics.

RESULTS

Eighty-two people were randomized (intervention; n = 43 and control; n = 39), average age was 59.5 years (SD: 12.9); 71% female; 67% married or in a de facto relationship. At baseline, there were no differences in participants' characteristics between the groups. No significant effects, in reducing unmet needs, were demonstrated at the end of intervention (4-month) or 12-month follow-up. Overall, 94% used the app in weeks 1-4, which decreased to 41% in weeks 13-16. Mean app use time per participant: Cancer Information, 6.9 (SD: 18.9) minutes; Appointment Schedule, 5.1 (SD: 9.6) minutes; Cancer Services 1.5 minutes (SD: 6.8); Hospital Navigation, 1.4 (SD: 2.8) minutes.

CONCLUSIONS

Despite consumer involvement in the design of this smartphone technology, the app did not reduce unmet needs. This may have been due to the study being underpowered. To contribute to a meaningful understanding and improved implementation of smartphone technology to support people affected by cancer, practical considerations, such as recruitment issues and access to, and confidence with, apps, need to be considered. Australian New Zealand Clinical Trials Registration (ACTRN) Trial Registration: 12616001251415; WEF 7/9/2016.

Can a smartphone-delivered tool facilitate the assessment of surgical site infection and result in earlier treatment? Tracking wound infection with smartphone technology (TWIST): protocol for a randomised controlled trial in emergency surgery patients

INTRODUCTION

National data suggest that surgical site infection (SSI) complicates 2%-10% of general surgery cases, although the patient-reported incidence is much higher. SSIs cause significant patient morbidity and represent a significant burden on acute healthcare services, in a cohort predominantly suitable for outpatient management. Over three-quarters of UK adults now own smartphones, which could be harnessed to improve access to care. We aim to investigate if a smartphone-delivered wound assessment tool results in earlier treatment.

METHODS AND ANALYSIS

This is a randomised controlled trial aiming to recruit 500 patients across National Health Service (NHS) hospitals. All emergency abdominal surgery patients over the age of 16 who own smartphones will be considered eligible, with the exclusion of those with significant visual impairment. Participants will be randomised in a 1:1 ratio between standard postoperative care and the intervention - use of the smartphone tool in addition to standard postoperative care. The main outcome measure will be time-to-diagnosis of SSI with secondary outcome measures considering use of emergency department and general practitioner services and patient experience. Follow-up will be conducted by clinicians blinded to group allocation. Analysis of time-to-diagnosis will be by comparison of means using an independent two sample t-test.

ETHICS AND DISSEMINATION

This is the first randomised controlled trial on the use of a smartphone-delivered wound assessment tool to facilitate the assessment of SSI and the impact on time-to-diagnosis. The intervention is being used in addition to standard postoperative care. The study design and protocol were reviewed and approved by Southeast Scotland Research and Ethics Committee (REC Ref: 16/SS/0072 24/05/2016). Study findings will be presented at academic conferences, published in peer-reviewed journals and are expected in 2020. A written lay summary will be available to study participants on request.

TRIAL REGISTRATION NUMBER

NCT02704897; Pre-results.

Community Health Workers Improve Linkage to Hypertension Care in Western Kenya

BACKGROUND

Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality.

OBJECTIVES

This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP.

METHODS

The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data.

RESULTS

A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change.

CONCLUSIONS

A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596).

Using Smartphone-Based Psychoeducation to Reduce Postnatal Depression Among First-Time Mothers: Randomized Controlled Trial

Background

Smartphone-based psychoeducation interventions may be a low-cost, user-friendly alternative to resource-consuming, face-to-face antenatal classes to educate expectant mothers.

Objective

This study aimed to empirically examine whether such an intervention would lead to reduced postnatal depression, anxiety, or stress and result in a better health-related quality of life.

Methods

A single-blind randomized controlled trial was conducted in Hong Kong. All first-time expectant mothers with less than 24 weeks of gestation remaining and attending the antenatal clinic at a public hospital were included. Participants were assigned to the intervention group or the control group by drawing lots. The lots, presented in sealed opaque envelopes, were randomly designated as “intervention” or “control” by stratified randomization. The intervention, a psychoeducational mobile app, was provided in addition to the treatment as usual (TAU) services from the hospital. Follow up with participants took place at 4 weeks postpartum. The primary outcome was the difference in the levels of antenatal and postnatal depression, assessed by the Edinburgh Postnatal Depression Scale (EPDS). The intention-to-treat approach was employed in the analyses.

Results

The final sample was 660 expectant mothers (n_intervention=330 and n_control=330). The mean difference in EPDS scores between the two groups was −0.65 (95% CI −1.29 to 0.00; P=.049) after adjusting for confounding factors. Associations were found between participation in the intervention and reduced depression, and attendance in TAU classes and increased stress levels.

Conclusions

The smartphone-based intervention plus TAU services was effective in reducing postnatal depression at 4 weeks postpartum compared with a control condition of TAU only, making this a cost-effective alternative to TAU education for expectant mothers. Limitations of the study included the short postpartum period after which the follow-up assessment was conducted and the inclusion of first-time mothers rather than all mothers.

Trial Registration

HKU Clinical Trials Registry HKUCTR-2024; http://www.hkuctr.com/Study/Show/ 34f62a2f6d594273a290491827206384

Surveillance of Pediatric Hypertension Using Smartphone Technology

INTRODUCTION

Elevated blood pressure is becoming increasingly common in the pediatric population. Hypertension costs nearly $51 billion/year, and cardiovascular disease is responsible for 17% of the nation's health care expenditures. Traditionally, time-consuming and complicated interpretation standards result in infrequent pediatric blood pressure screenings. This may lead to the under-diagnosis of pediatric hypertension. Early detection of elevated blood pressure is important in order to prevent hypertension related conditions such as, target organ damage, left ventricular hypertrophy, and cerebrovascular disease. The aim of this study was to observe the prevalence of pediatric hypertension among children and adolescents age 3-18 using the smartphone application Pedia BP®. The purpose of this study was to (1) identify the prevalence of elevated blood pressure in a sample of children and adolescents and (2) evaluate any association between BMI, age, and blood pressure classification.

METHOD

A quantitative, descriptive study was conducted to evaluate the prevalence of pediatric hypertension in 81 preschool and school age children. App users were trained with the online take2heart course available at take2heart.com. The manual systolic and diastolic blood pressure readings were entered into the application, along with the patient's gender, age, height, and weight. Pedia BP® instantly calculated the blood pressure classification of the patient based on percentiles. Quantitative data from the Pedia BP® data repository were analyzed using descriptive statistics.

RESULTS

We found that 54.3% of our sample were normotensive, 23.5% had prehypertension, 13.6% had stage 1 hypertension, and 8.6% had stage 2 hypertension. As seen in Figure 3, the majority of subjects with stage 1 (72.7%) and stage 2 hypertension (57.1%) were found in school-age children. We found that 3.7% of children were underweight, 48.1% were at a healthy weight, 21% were overweight, and 27.2% were obese.

DISCUSSION

Pedia BP® was shown to be an effective screening tool to easily classify blood pressure readings on an individual basis. The prevalence of hypertension in our sample was higher than previously reported in the literature. Annual evaluation of blood pressures in preschool and school age children are warranted to identify and address hypertension. Pedia BP® was shown to be an effective screening tool to easily classify blood pressure readings on an individual basis. Pedia BP® offers benefits not only for patients, but for primary care providers, nurses, economists, insurance companies, hospitals, and clinics. Ultimately, Pedia BP® (1) increases awareness of elevated blood pressures among children and adolescents, (2) engages the health care community to screen for elevated blood pressures, (3) implements innovative technology, and (4) activates the potential for a population-based surveillance tool.

Randomized Trial of Smartphone-Based Evaluation for an Obstetrics and Gynecology Clerkship

OBJECTIVE

We hypothesized that compared to paper evaluations, a smartphone-based quick response (QR) evaluation tool would improve timeliness of feedback, enhance efficacy of giving and receiving feedback, and be as easy to use.

DESIGN

We performed a randomized controlled trial of student and instructor experience with two evaluation tools in the OB/GYN clerkship at University of Washington School of Medicine (UWSOM). Sites were randomized to the QR or paper tool; students at QR sites received individualized QR codes at the beginning of the clerkship. Instructors and students completed postintervention surveys regarding the evaluation tool and associated feedback. We compared responses between groups using chi-squared tests.

SETTING

Participating clerkship sites included primary, tertiary, private practice and institutional settings affiliated with the University of Washington in the Washington, Wyoming, Alaska, Montana and Idaho region.

PARTICIPANTS

Of the 29 OB/GYN UWSOM clerkship sites, 18 agreed to participate and were randomized. Of 29 eligible instructors, 25 (86%) completed the survey, with n = 18 using QR and n = 7 using paper. Of 161 eligible students, 102 (63%) completed the survey, with n = 54 using QR and n = 48 using paper.

RESULTS

Compared to those using paper evaluations, instructors using QR evaluations were significantly more likely to agree that the evaluation tool was easy to understand (100% QR vs 43% paper, p = 0.002), the tool was effective in providing feedback (78% QR vs 29% paper, p = 0.002), and they felt comfortable approaching students with the tool (89% QR vs 43% paper, p = 0.002). Compared to those using paper evaluations, students using QR evaluations were less likely to agree the tool was effective in eliciting feedback (QR 43% vs paper 55%, p = 0.042).

CONCLUSION

Instructors found QR evaluations superior to paper evaluations for providing feedback to medical students, whereas students found QR evaluations less effective for feedback.

Non-Contact Smartphone-Based Monitoring of Thermally Stressed Structures

The in-situ measurement of thermal stress in beams or continuous welded rails may prevent structural anomalies such as buckling. This study proposed a non-contact monitoring/inspection approach based on the use of a smartphone and a computer vision algorithm to estimate the vibrating characteristics of beams subjected to thermal stress. It is hypothesized that the vibration of a beam can be captured using a smartphone operating at frame rates higher than conventional 30 Hz, and the first few natural frequencies of the beam can be extracted using a computer vision algorithm. In this study, the first mode of vibration was considered and compared to the information obtained with a conventional accelerometer attached to the two structures investigated, namely a thin beam and a thick beam. The results show excellent agreement between the conventional contact method and the non-contact sensing approach proposed here. In the future, these findings may be used to develop a monitoring/inspection smartphone application to assess the axial stress of slender structures, to predict the neutral temperature of continuous welded rails, or to prevent thermal buckling.

Colorimetric Sensor Arrays for the Detection and Identification of Chemical Weapons and Explosives

There is a significant demand for devices that can rapidly detect chemical–biological–explosive (CBE) threats on-site and allow for immediate responders to mitigate spread, risk, and loss. The key to an effective reconnaissance mission is a unified detection technology that analyzes potential threats in real time. In addition to reviewing the current state of the art in the field, this review illustrates the practicality of colorimetric arrays composed of sensors that change colors in the presence of analytes. This review also describes an outlook toward future technologies, and describes how they could possibly be used in areas such as war zones to detect and identify hazardous substances.

FoodSwitch: A Mobile Phone App to Enable Consumers to Make Healthier Food Choices and Crowdsourcing of National Food Composition Data

BACKGROUND

Front-of-pack nutrition labeling (FoPL) schemes can help consumers understand the nutritional content of foods and may aid healthier food choices. However, most packaged foods in Australia carry no easily interpretable FoPL, and no standard FoPL system has yet been mandated. About two thirds of Australians now own a smartphone.

OBJECTIVE

We sought to develop a mobile phone app that would provide consumers with easy-to-understand nutrition information and support the selection of healthier choices when shopping for food.

METHODS

An existing branded food database including 17,000 Australian packaged foods underpinned the project. An iterative process of development, review, and testing was undertaken to define a user interface that could deliver nutritional information. A parallel process identified the best approach to rank foods based on nutritional content, so that healthier alternative products could be recommended.

RESULTS

Barcode scanning technology was identified as the optimal mechanism for interaction of the mobile phone with the food database. Traffic light labels were chosen as the preferred format for presenting nutritional information, and the Food Standards Australia New Zealand nutrient profiling method as the best strategy for identifying healthier products. The resulting FoodSwitch mobile phone app was launched in Australia in January 2012 and was downloaded by about 400,000 users in the first 18 months. FoodSwitch has maintained a 4-plus star rating, and more than 2000 users have provided feedback about the functionality. Nutritional information for more than 30,000 additional products has been obtained from users through a crowdsourcing function integrated within the app.

CONCLUSIONS

FoodSwitch has empowered Australian consumers seeking to make better food choices. In parallel, the huge volume of crowdsourced data has provided a novel means for low-cost, real-time tracking of the nutritional composition of Australian foods. There appears to be significant opportunity for this approach in many other countries.