mHealth and mobile medical Apps: a framework to assess risk and promote safer use

The use of mobile medical apps by clinicians and others has grown considerably since the introduction of mobile phones. Medical apps offer clinicians the ability to access medical knowledge and patient data at the point of care, but several studies have highlighted apps that could compromise patient safety and are potentially dangerous. This article identifies a range of different kinds of risks that medical apps can contribute to and important contextual variables that can modify these risks. We have also developed a simple generic risk framework that app users, developers, and other stakeholders can use to assess the likely risks posed by a specific app in a specific context. This should help app commissioners, developers, and users to manage risks and improve patient safety.

mHealth and memory aids: levels of smartphone ownership in patients

BACKGROUND

The use of mobile devices to deliver healthcare has not yet been exploited in neuropsychological rehabilitation. Smartphones have the potential to serve as multi-functional memory aids.

AIMS

To investigate whether patients attending a clinic for mixed memory problems own smartphones, to determine whether this could be a widely applicable medium to use as a memory aids device.

METHODS

A questionnaire on smartphone ownership was given to an opportunity sample of consecutive patients attending a neuropsychiatry and memory disorders outpatient clinic. Data were collected in 2012 and repeated 12 months later in 2013 to assess changes over time.

RESULTS

Ownership of mobile phones was stable between 2012 (81%) and 2013 (85%), but ownership of smartphones showed a significant increase (from 26% to 40%). Age negatively predicted smartphone ownership.

CONCLUSION

Despite cognitive or psychiatric problems, our patient group are as likely to own a mobile phone as a member of the general population. Ownership levels are at 40% and likely to increase in the future. Exploring how smartphones and their apps could function as memory aids is likely to be useful for a large enough number of patients to be clinically worthwhile.

Mobile phones to support adherence to antiretroviral therapy: what would it cost the Indian National AIDS Control Programme?

INTRODUCTION

Adherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low-cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP).

METHODS

The study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one-time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national-programme level, individual ART-centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs.

RESULTS

The Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27-1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scale-up of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five-year national-programme budget.

CONCLUSIONS

The cost of the mHealth intervention for ART-adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively.

INTEGRATING TECHNOLOGICAL ADVANCEMENTS IN BEHAVIORAL INTERVENTIONS TO PROMOTE HEALTH: UNPRECEDENTED OPORTUNITIES FOR BEHAVIOR ANALYSTS

The use of mobile devices is growing worldwide in both industrialized and developing nations. Alongside the worldwide penetration of web-enabled devices, the leading causes of morbidity and mortality are increasingly modifiable lifestyle factors (e.g., improving one's diet and exercising more). Behavior analysts have the opportunity to promote health by combining effective behavioral methods with technological advancements. The objectives of this paper are (1) to highlight the public health gains that may be achieved by integrating technology with a behavior analytic approach to developing interventions, and (2) to review some of the currently, under-examined issues related to merging technology and behavior analysis (enhancing sustainability, obtaining frequent measures of behavior, conducting component analyses, evaluating cost-effectiveness, incorporating behavior analysis in the creation of consumer-based applications, and reducing health disparities). Thorough consideration of these issues may inspire the development, implementation, and dissemination of innovative, efficacious interventions that substantially improve global public health.

Text messaging intervention for teens and young adults with diabetes

Adolescents and young adults use text messaging as their primary mode of communication, thus providing an opportunity to use this mode of communication for mobile health (mHealth) interventions. Youth with diabetes are an important group for these mHealth initiatives, as diabetes management requires an enormous amount of daily effort and this population has difficulty achieving optimal diabetes management. Goal setting and self-efficacy are 2 factors in the management of diabetes. We examined the feasibility of a healthy lifestyle text messaging program targeting self-efficacy and goal setting among adolescents and young adults with diabetes. Participants, ages 16-21, were assigned to either a text messaging group, which received daily motivational messages about nutrition and physical activity, or a control group, which received paper-based information about healthy lifestyle. Both groups set goals for nutrition and physical activity and completed a measure of self-efficacy. Participants' mean age was 18.7 ± 1.6 years old, with diabetes duration of 10.0 ± 4.6 years, and A1c of 8.7 ± 1.7%. The text messaging intervention was rated highly and proved to be acceptable to participants. Self-efficacy, glycemic control, and body mass index did not change over the course of the short, 1-month pilot study. Positive, daily, motivational text messages may be effective in increasing motivation for small goal changes in the areas of nutrition and physical activity. These interventions may be used in the future in youth with diabetes to improve diabetes care. Utilizing more targeted text messages is an area for future research.

A New Frontier: Integrating Behavioral and Digital Technology to Promote Health Behavior

Modifiable behavioral risk factors such as cigarette smoking, physical inactivity, and obesity contribute to over 40 % of premature deaths in the USA. Advances in digital and information technology are creating unprecedented opportunities for behavior analysts to assess and modify these risk factors. Technological advances include mobile devices, wearable sensors, biomarker detectors, and real-time access to therapeutic support via information technology. Integrating these advances with behavioral technology in the form of conceptually systematic principles and procedures could usher in a new generation of effective and scalable behavioral interventions targeting health behavior. In this selective review of the literature, we discuss how technological tools can assess and modify a range of antecedents and consequences of healthy and unhealthy behavior. We also describe practical, methodological, and conceptual advantages for behavior analysts that stem from the use of technology to assess and treat health behavior.

Smartphone breast applications - what's the evidence?

INTRODUCTION

There are around 40,000 healthcare applications (apps) available for smartphones. Apps have been reviewed in many specialties. Breast cancer is the most common malignancy in females with almost 1.38 million new cases a year worldwide. Despite the high prevalence of breast disease, apps in this field have not been reviewed to date. We have evaluated apps relevant to breast disease with an emphasis on their evidence base (EB) and medical professional involvement (MPI).

METHODS

Searching the major app stores (apple iTunes, Google Play, BlackBerry World, Windows Phone) using the most common breast symptoms and diseases identified relevant apps. Extracted data for each app included target consumer, disease focus, app function, documentation of any EB, documentation of MPI in development, and potential safety concerns.

RESULTS

One-hundred-and-eighty-five apps were reviewed. The majority focused on breast cancer (n = 139, 75.1%). Educational (n = 94) and self-assessment tools (n = 30) were the most common functions demonstrated. EB and MPI was identified in 14.2% and 12.8% of apps respectively. Potential safety concerns were identified in 29 (15.7%) apps.

CONCLUSIONS

There is a lack of EB and MPI in the development of current breast apps. Safety concerns highlight the need for regulation, full authorship disclosure and clinical trials. A robust framework for identifying high quality applications is necessary. This will address the current barrier pertaining to a lack of consumer confidence in their use and further aid to promote their widespread implementation within healthcare.

Commercially available mobile phone headache diary apps: a systematic review

Background

Headache diaries are often used by headache sufferers to self-monitor headaches. With advances in mobile technology, mobile electronic diary apps are becoming increasingly common.

Objective

This review aims to identify and evaluate all commercially available mobile headache diary apps for the two most popular mobile phone platforms, iOS and Android.

Methods

The authors developed a priori a set of 7 criteria that define an ideal headache diary app intended to help headache sufferers better understand and manage their headaches, while providing relevant data to health professionals. The app criteria were intended as minimum requirements for an acceptable headache diary app that could be prescribed by health care professionals. Each app was evaluated and scored against each criterion.

Results

Of the 38 apps identified, none of the apps met all 7 app criteria. The 3 highest scoring apps, meeting 5 of the app criteria, were iHeadache (developed by Better QOL), ecoHeadache (developed by ecoTouchMedia), and Headache Diary Pro (developed by Froggyware). Only 18% of the apps were created with scientific or clinical headache expertise and none of the apps reported on psychometric properties.

Conclusions

Despite the growing market and demand, there is a concerning lack of scientific expertise and evidence base associated with headache diary apps.

Novel interventions for HIV self-management in African American women: a systematic review of mHealth interventions

The purpose of this systematic review was to assess the quality of interventions using mobile health (mHealth) technology being developed for and trialed with HIV-infected African American (AA) women. We aimed to assess rigor and to ascertain if these interventions have been expanded to include the broad domain of self-management. After an extensive search using the PRISMA approach and reviewing 450 records (411 published studies and 39 ongoing trials at clinicaltrials.gov), we found little completed research that tested mHealth HIV self-management interventions for AA women. At clinicaltrials.gov, we found several mHealth HIV intervention studies designed for women in general, forecasting a promising future. However, most studies were exploratory in nature and focused on a single narrow outcome, such as medication adherence. Given that cultural adaptation is the key to successfully implementing any effective self-management intervention, culturally relevant, gender-specific mHealth interventions focusing on HIV-infected AA women are warranted for the future.

Interactive Monitoring Service and COPD: Is it Possible to Reduce Nonadherence?

Chronic obstructive pulmonary disease (COPD) represents one of the main causes of death worldwide. It affects hundreds of millions of people and is likely to spread further in the coming years. Despite the chronic nature of the disease and the proven efficacy of current therapies, treatment nonadherence is unfortunately common and too often related to treatment failure, disease exacerbations, hospitalizations, and high healthcare costs. At present, studies aimed to assess and improve patients' adherence in chronic respiratory diseases--and especially in COPD--are limited, but a review of the few data available makes it clear that there is a need for an innovative approach that leverages health technology to encourage patients to adhere to prescribed chronic treatments.

Universal mobile electrochemical detector designed for use in resource-limited applications

This paper describes an inexpensive, handheld device that couples the most common forms of electrochemical analysis directly to "the cloud" using any mobile phone, for use in resource-limited settings. The device is designed to operate with a wide range of electrode formats, performs on-board mixing of samples by vibration, and transmits data over voice using audio--an approach that guarantees broad compatibility with any available mobile phone (from low-end phones to smartphones) or cellular network (second, third, and fourth generation). The electrochemical methods that we demonstrate enable quantitative, broadly applicable, and inexpensive sensing with flexibility based on a wide variety of important electroanalytical techniques (chronoamperometry, cyclic voltammetry, differential pulse voltammetry, square wave voltammetry, and potentiometry), each with different uses. Four applications demonstrate the analytical performance of the device: these involve the detection of (i) glucose in the blood for personal health, (ii) trace heavy metals (lead, cadmium, and zinc) in water for in-field environmental monitoring, (iii) sodium in urine for clinical analysis, and (iv) a malarial antigen (Plasmodium falciparum histidine-rich protein 2) for clinical research. The combination of these electrochemical capabilities in an affordable, handheld format that is compatible with any mobile phone or network worldwide guarantees that sophisticated diagnostic testing can be performed by users with a broad spectrum of needs, resources, and levels of technical expertise.

Mobile health (mHealth) for mental health in Asia: objectives, strategies, and limitations

Mobile technologies are transforming the way in which we interact with one another, access resources, find information, and conduct business around the world. Harnessing the capabilities of mobile technologies to support health care initiatives worldwide has developed into a new interdisciplinary field called mobile health (mHealth). In the current paper, we review the penetration of mobile technology in Asia, and consider the integration of mobile technologies into the study, diagnoses, and treatment of mental disorders in the region. We outline how mHealth programs could improve mental health literacy, provide greater access to mental health services, extend community-based outreach and engagement, support self-management of illness, and regulate medication distribution. We end with a consideration of the potential barriers and limitations of mHealth for mental health, including funding, language and literacy barriers, power supply considerations, data security, and privacy issues.

Feasibility, acceptability and potential effectiveness of a mobile health (mHealth) weight management programme for New Zealand adults

Background

Mobile health (mHealth) behaviour change programmes use mobile phones and the internet to deliver health information and behaviour change support to participants. Such programmes offer a potentially cost-effective way to reach many individuals who do not currently access weight loss services. We developed a mHealth weight management programme using proven face-to-face behaviour change techniques and incorporating target population input. Our aim was to evaluate the feasibility, acceptability and potential effectiveness of this programme for ethnically diverse adults with a view to informing a larger trial.

Results

Fifty three adults who had a BMI of ≥25 kg/m² and wanted to lose weight (81% female, mean age 42 years, mean BMI 35.7 kg/m², 26% Maori, 34% Pacific) received the eight-week mHealth weight loss programme. Anthropometric measures were taken at two face-to-face assessments at baseline and 12-weeks (i.e. four weeks after cessation of intervention).

Twelve-week follow-up measurements were available for 36/53 participants (68%). Non-completers were younger and more likely to be male and of Pacific ethnicity. Thirty five participants (66%) reported reading ‘all or most’ text messages sent and 96% responded to at least one text data collection question over the eight-week active intervention period. Eighty one per cent of participants logged in to the study website at least once during the eight-week study period. In the intention-to-treat analysis, mean weight change was -1.0 kg (SD 3.1) at 12 weeks (p = 0.024) and change in BMI was -0.34 kg/m² (SD 1.1) (p = 0.026). In the completers only analysis (n = 36), mean weight change was -1.4 kg (SD 3.6) (p = 0.023) and change in BMI was -0.50 kg/m² (SD 1.3) (p = 0.025).

Conclusions

A mHealth weight management programme is feasible to deliver to an ethnically diverse population. Changes in body weight and BMI at 12 weeks indicate that the programme could be effective in supporting people with weight loss. However, the high dropout rate indicates a need for further improvements to the programme.

Trial registration

ACTRN12612000850875

Comparative analysis of online health queries originating from personal computers and smart devices on a consumer health information portal

Background

The number of people using the Internet and mobile/smart devices for health information seeking is increasing rapidly. Although the user experience for online health information seeking varies with the device used, for example, smart devices (SDs) like smartphones/tablets versus personal computers (PCs) like desktops/laptops, very few studies have investigated how online health information seeking behavior (OHISB) may differ by device.

Objective

The objective of this study is to examine differences in OHISB between PCs and SDs through a comparative analysis of large-scale health search queries submitted through Web search engines from both types of devices.

Methods

Using the Web analytics tool, IBM NetInsight OnDemand, and based on the type of devices used (PCs or SDs), we obtained the most frequent health search queries between June 2011 and May 2013 that were submitted on Web search engines and directed users to the Mayo Clinic’s consumer health information website. We performed analyses on “Queries with considering repetition counts (QwR)” and “Queries without considering repetition counts (QwoR)”. The dataset contains (1) 2.74 million and 3.94 million QwoR, respectively for PCs and SDs, and (2) more than 100 million QwR for both PCs and SDs. We analyzed structural properties of the queries (length of the search queries, usage of query operators and special characters in health queries), types of search queries (keyword-based, wh-questions, yes/no questions), categorization of the queries based on health categories and information mentioned in the queries (gender, age-groups, temporal references), misspellings in the health queries, and the linguistic structure of the health queries.

Results

Query strings used for health information searching via PCs and SDs differ by almost 50%. The most searched health categories are “Symptoms” (1 in 3 search queries), “Causes”, and “Treatments & Drugs”. The distribution of search queries for different health categories differs with the device used for the search. Health queries tend to be longer and more specific than general search queries. Health queries from SDs are longer and have slightly fewer spelling mistakes than those from PCs. Users specify words related to women and children more often than that of men and any other age group. Most of the health queries are formulated using keywords; the second-most common are wh- and yes/no questions. Users ask more health questions using SDs than PCs. Almost all health queries have at least one noun and health queries from SDs are more descriptive than those from PCs.

Conclusions

This study is a large-scale comparative analysis of health search queries to understand the effects of device type (PCs vs SDs) used on OHISB. The study indicates that the device used for online health information search plays an important role in shaping how health information searches by consumers and patients are executed.

The impact of adherence on costs and effectiveness of telemedical patient management in heart failure: a systematic review

OBJECTIVE

This paper analyzes evidence of the impact of patients' adherence to pharmacological and non-pharmacological recommendations on the treatment costs of heart failure (HF) patients.

METHODS

A systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Papers were searched using various combinations of the following keywords: 'telemedicine', 'telemonitoring', 'telehealth', 'eHealth', 'remote monitoring', 'adherence', 'compliance', 'cost-effectiveness', 'cost-benefit', 'heart failure', 'healthcare costs', 'hospitalization', and 'drug costs'. We included only papers written in English or German, published between 1998 and 2014, and having one of our search terms in the title.

RESULTS

Initially, 73 papers were selected. After a detailed review, these were narrowed done to 9 that reported an association between adherence and/or compliance and costs. However, none established a quantitative relationship between adherence and total healthcare costs.

CONCLUSION

A model-based cost-effectiveness analysis that appropriately considers adherence has not been carried out so far, but is needed to fully understand the potential economic benefits of telehealth.

A game plan: Gamification design principles in mHealth applications for chronic disease management

Effective chronic disease management is essential to improve positive health outcomes, and incentive strategies are useful in promoting self-care with longevity. Gamification, applied with mHealth (mobile health) applications, has the potential to better facilitate patient self-management. This review article addresses a knowledge gap around the effective use of gamification design principles, or mechanics, in developing mHealth applications. Badges, leaderboards, points and levels, challenges and quests, social engagement loops, and onboarding are mechanics that comprise gamification. These mechanics are defined and explained from a design and development perspective. Health and fitness applications with gamification mechanics include: bant which uses points, levels, and social engagement, mySugr which uses challenges and quests, RunKeeper which uses leaderboards as well as social engagement loops and onboarding, Fitocracy which uses badges, and Mango Health, which uses points and levels. Specific design considerations are explored, an example of the efficacy of a gamified mHealth implementation in facilitating improved self-management is provided, limitations to this work are discussed, a link between the principles of gaming and gamification in health and wellness technologies is provided, and suggestions for future work are made. We conclude that gamification could be leveraged in developing applications with the potential to better facilitate self-management in persons with chronic conditions.

mSpray: a mobile phone technology to improve malaria control efforts and monitor human exposure to malaria control pesticides in Limpopo, South Africa

Recent estimates indicate that malaria has led to over half a million deaths worldwide, mostly to African children. Indoor residual spraying (IRS) of insecticides is one of the primary vector control interventions. However, current reporting systems do not obtain precise location of IRS events in relation to malaria cases, which poses challenges for effective and efficient malaria control. This information is also critical to avoid unnecessary human exposure to IRS insecticides. We developed and piloted a mobile-based application (mSpray) to collect comprehensive information on IRS spray events. We assessed the utility, acceptability and feasibility of using mSpray to gather improved homestead- and chemical-level IRS coverage data. We installed mSpray on 10 cell phones with data bundles, and pilot tested it with 13 users in Limpopo, South Africa. Users completed basic information (number of rooms/shelters sprayed; chemical used, etc.) on spray events. Upon submission, this information as well as geographic positioning system coordinates and time/date stamp were uploaded to a Google Drive Spreadsheet to be viewed in real time. We administered questionnaires, conducted focus groups, and interviewed key informants to evaluate the utility of the app. The low-cost, cell phone-based "mSpray" app was learned quickly by users, well accepted and preferred to the current paper-based method. We recorded 2865 entries (99.1% had a GPS accuracy of 20 m or less) and identified areas of improvement including increased battery life. We also identified a number of logistic and user problems (e.g., cost of cell phones and cellular bundles, battery life, obtaining accurate GPS measures, user errors, etc.) that would need to be overcome before full deployment. Use of cell phone technology could increase the efficiency of IRS malaria control efforts by mapping spray events in relation to malaria cases, resulting in more judicious use of chemicals that are potentially harmful to humans and the environment.

Pilot study using mobile health to coordinate the diabetic patient, diabetologist, and ophthalmologist

In the United States, more than 25 million adults have diabetes, 40% of diabetics have diabetic retinopathy, and diabetes is the leading cause of blindness in people 20 to 74 years of age. Clinical trials have shown that strict control of blood glucose level and other risk factors delays diabetic retinopathy onset, progression, and vision loss. Patients with Type 1 or Type 2 diabetes mellitus, access to an Apple iPhone or iPad, and no psychological or medical condition that would interfere with the study participated in a nonrandomized clinical trial using SightBook™, a free mobile app that enables self-measurement of visual function and creates a password-protected web account for each patient. Sixty patients enrolled in the clinical trial over a 6 month period. Twenty-six participants were men and 34 were women, with ages from 23 to 72 years (mean 45 ± 15) and diabetes duration of 1.5 to 50 years (mean 15.5 ± 11.5). Thirty-nine (65%) patients reported Type 1 diabetes and 21 (35%) patients reported Type 2 diabetes. Every patient established a personal web account on SightBook and invited participation of treating physicians; 51 (85%) patients completed the validated self-reported outcome assessments. Diabetologist examinations of 49 (82%) patients demonstrated systolic hypertension (≥140 mgHg) in 20% and hemoglobin A1c ≥ 7.0% in 56%. Ophthalmology examinations of 45 patients showed visual acuity in the worse-seeing eye of < 20/40 in 18% and diabetic retinopathy in 42% of patients. This clinical trial used a mobile health app to incorporate diabetic patient self-measurement of vision and coordinate the diabetic patient, diabetologist, and ophthalmologist for control of diabetes and diabetic retinopathy risk factors.

Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers

BACKGROUND

Primary prevention of cardiovascular disease (CVD),by identifying individuals at risk is a well-established, but costly strategy when based on measurements that depend on laboratory analyses. A non-laboratory, paper-based CVD risk assessment chart tool has previously been developed to make screening more affordable in developing countries. Task shifting to community health workers (CHWs) is being investigated to further scale CVD risk screening. This study aimed to develop a mobile phone CVD risk assessment application and to evaluate its impact on CHW training and the duration of screening for CVD in the community by CHWs.

METHODS

A feature phone application was developed using the open source online platform, CommCare(©). CHWs (n=24) were trained to use both paper-based and mobile phone CVD risk assessment tools. They were randomly allocated to using one of the risk tools to screen 10-20 community members and then crossed over to screen the same number, using the alternate risk tool. The impact on CHW training time, screening time and margin of error in calculating risk scores was recorded. A focus group discussion evaluated experiences of CHWs using the two tools.

RESULTS

The training time was 12.3h for the paper-based chart tool and 3h for the mobile phone application. 537 people were screened. The mean screening time was 36 min (SD=12.6) using the paper-base chart tool and 21 min (SD=8.71) using the mobile phone application, p=<0.0001. Incorrect calculations (4.3% of average systolic BP measurements, 10.4% of BMI and 3.8% of CVD risk score) were found when using the paper-based chart tool while all the mobile phone calculations were correct. Qualitative findings from the focus group discussion corresponded with the findings of the pilot study.

CONCLUSION

The reduction in CHW training time, CVD risk screening time, lack of errors in calculation of a CVD risk score and end user satisfaction when using a mobile phone application, has implications in terms of adoption and sustainability of this primary prevention strategy to identify people with high CVD risk who can be referred for appropriate diagnoses and treatment.

Obesity and outpatient rehabilitation using mobile technologies: the potential mHealth approach

Obesity is currently an important public health problem of epidemic proportions (globesity). Inpatient rehabilitation interventions that aim at improving weight-loss, reducing obesity-related complications and changing dysfunctional behaviors, should ideally be carried out in a multidisciplinary context with a clinical team composed of psychologists, dieticians, psychiatrists, endocrinologists, nutritionists, physiotherapists, etc. Long-term outpatient multidisciplinary treatments are likely to constitute an essential aspect of rehabilitation. Internet-based technologies can improve long-term obesity rehabilitation within a collaborative approach by enhancing the steps specified by psychological and medical treatment protocols. These outcomes may be augmented further by the mHealth approach, through creating new treatment delivery methods to increase compliance and engagement. mHealth (m-health, mobile health) can be defined as the practice of medicine and public health, supported by mobile communication devices for health services and information. mHealth applications which can be implemented in weight loss protocols and obesity rehabilitation are discussed, taking into account future research directions in this promising area.

Refining a personalized mHealth intervention to promote medication adherence among HIV+ methamphetamine users

Mobile health (mHealth) interventions to promote antiretroviral therapy (ART) adherence have shown promise; however, among persons living with HIV who abuse methamphetamine (MA), effective tailoring of content to match the expressed needs of this patient population may be necessary. This study aimed (1) to understand patient perspectives of barriers and facilitators of ART adherence among people with HIV who use MA, and (2) to obtain feedback on the thematic content of an mHealth intervention in order to tailor the intervention to this subgroup. Two separate focus groups, each with 10 HIV+/MA+ individuals, were conducted. Transcribed audio recordings were qualitatively analyzed to identify emergent themes. Inter-rater reliability of themes was high (mean Kappa = .97). Adherence barriers included MA use, misguided beliefs about ART adherence, memory and planning difficulties, social barriers and perceived stigma, and mental heath issues. Facilitators of effective ART adherence were cognitive compensatory strategies, promotion of well-being, health-care supports, adherence education, and social support. Additionally, the focus groups generated content for reminder text messages to be used in the medication adherence intervention. This qualitative study demonstrates the feasibility of using focus groups to derive patient-centered intervention content to address the health challenge at hand in targeted populations.

Using mHealth Tools to Improve Rural Diabetes Care Guided by the Chronic Care Model

BACKGROUND AND OBJECTIVE

Used as an integrated tool, mHealth may improve the ability of healthcare providers in rural areas to provide care, improve access to care for underserved populations, and improve biophysical outcomes of care for persons with diabetes in rural, underserved populations. Our objective in this paper is to present an integrated review of the impact of mHealth interventions for community dwelling individuals with type two diabetes.

MATERIALS AND METHODS

A literature search was performed using keywords in PubMed to identify research studies which mHealth technology was used as the intervention.

RESULTS AND DISCUSSION

Interventions using mHealth have been found to improve outcomes, be cost effective, and culturally relevant. mHealth technology that has been used to improve outcomes include: seeking out health information via the web, access to appointment scheduling and medication refills, secure messaging, computerized interventions to manage a chronic condition, use of a personal health record, use of remote monitoring devices, and seeking support from others with similar health concerns through social networks.

CONCLUSION

Using the validated Chronic Care Model to translate what is known about mHealth technology to clinical practice has the potential to improve the ability of healthcare providers in rural areas to provide care, improve access to care for underserved populations, and improve biophysical outcomes of care for persons with diabetes in rural underserved populations. While these approaches were effective in improving some outcomes, they have not resulted in the establishment of the necessary electronic infrastructure for a sustainable mobile healthcare delivery model.

A Persuasive and Social mHealth Application for Physical Activity: A Usability and Feasibility Study

BACKGROUND

Advances in smartphones and the wide usage of social networking systems offer opportunities for the development of innovative interventions to promote physical activity. To that end, we developed a persuasive and social mHealth application designed to monitor and motivate users to walk more every day.

OBJECTIVE

The objectives of this project were to conduct a focused review on the fundamental characteristics of mHealth for physical activity promotion, to develop an mHealth application that meets such characteristics, and to conduct a feasibility study to deploy the application in everyday life.

METHODS

This project started as an analytical study to review the fundamental characteristics of the technologies used in physical activity monitoring and promotion. Then, it was followed by a technical development of the application. Next, a 4 week deployment was conducted where participants used the application as part of their daily life. A think-aloud method and in-depth semistructured interviews were conducted following the deployment. A qualitative description method was used to thematically analyze the interviews. Feasibility measures included, adherence to the program, user-system interactions, motivation to use, and experience with physical activity and online social interactions.

RESULTS

There were seven fundamental characteristics of physical activity monitoring and promotion that were identified, which were then used as a foundation to develop the application. There were fourteen participants that enrolled in the application evaluation. The age range was from 24 to 45; body mass index ranged from 18.5 to 42.98, with 4 of the subjects falling into the category "obese". Half of them were experienced with smartphones, and all were familiar with a social network system. There were thirteen participants that completed the study; one was excluded. Overall, participants gave high scores to almost all of the usability factors examined, with averages of 4.52 out of a 5.00 maximum. Over 29 days, participants used the application for a total of 119,380 minutes (average=7.57 hours/day/participant; SD 1.56).

CONCLUSIONS

Based on the fundamental characteristics, the application was successfully developed. The usability results suggest that the system is usable and user satisfaction was high. Deploying the application was shown to be feasible for the promotion of daily physical activity.

mHealth interventions for weight loss: a guide for achieving treatment fidelity

mHealth interventions have shown promise for helping people sustain healthy behaviors such as weight loss. However, few have assessed treatment fidelity, that is, the accurate delivery, receipt, and enactment of the intervention. Treatment fidelity is critical because the valid interpretation and translation of intervention studies depend on treatment fidelity assessments. We describe strategies used to assess treatment fidelity in mobile health (mHealth) interventions aimed at sustaining healthy behaviors in weight loss. We reviewed treatment fidelity recommendations for mHealth-based behavioral interventions and described how these recommendations were applied in three recent weight loss studies. We illustrate how treatment fidelity can be supported during study design, training of providers, treatment delivery, receipt of treatment, and enactment of treatment skills. Pre-planned strategies to ensure the treatment fidelity of mHealth interventions will help counter doubts concerning valid conclusions about their effectiveness and allow investigators and clinicians to implement robustly efficacious mobile health programs.

TRIAL REGISTRATION NUMBER

1F31 NR012599.

mHealth 2.0: Experiences, Possibilities, and Perspectives

With more than 1 billion users having access to mobile broadband Internet and a rapidly growing mobile app market, all stakeholders involved have high hopes that this technology may improve health care. Expectations range from overcoming structural barriers to access in low-income countries to more effective, interactive treatment of chronic conditions. Before medical health practice supported by mobile devices ("mHealth") can scale up, a number of challenges need to be adequately addressed. From a psychological perspective, high attrition rates, digital divide of society, and intellectual capabilities of the users are key issues when implementing such technologies. Furthermore, apps addressing behavior change often lack a comprehensive concept, which is essential for an ongoing impact. From a clinical point of view, there is insufficient evidence to allow scaling up of mHealth interventions. In addition, new concepts are required to assess the efficacy and efficiency of interventions. Regarding technology interoperability, open standards and low-energy wireless protocols appear to be vital for successful implementation. There is an ongoing discussion in how far health care-related apps require a conformity assessment and how to best communicate quality standards to consumers. "Apps Peer-Review" and standard reporting via an "App synopsis" appear to be promising approaches to increase transparency for end users. With respect to development, more emphasis must be placed on context analysis to identify what generic functions of mobile information technology best meet the needs of stakeholders involved. Hence, interdisciplinary alliances and collaborative strategies are vital to achieve sustainable growth for "mHealth 2.0," the next generation mobile technology to support patient care.

Commentary: pediatric eHealth interventions: common challenges during development, implementation, and dissemination

OBJECTIVE

To provide an overview of common challenges that pediatric eHealth researchers may encounter when planning, developing, testing, and disseminating eHealth interventions along with proposed solutions for addressing these challenges.

METHODS

The article draws on the existing eHealth literature and the authors' collective experience in pediatric eHealth research.

RESULTS AND CONCLUSIONS

The challenges associated with eHealth interventions and their proposed solutions are multifaceted and cut across a number of areas from eHealth program development through dissemination. Collaboration with a range of individuals (e.g., multidisciplinary colleagues, commercial entities, primary stakeholders) is the key to eHealth intervention success. To ensure adequate resources for design, development, and planning for sustainability, a number of public and private sources of funding are available. A study design that addresses ethical concerns and security issues is critical to ensure scientific integrity and intervention dissemination. Table I summarizes key issues to consider during eHealth intervention development, testing, and dissemination.

Is health literacy related to health behaviors and cell phone usage patterns among the text4baby target population?

BACKGROUND

Text4baby provides educational text messages to pregnant and postpartum women and targets underserved women. The primary purpose of this study is to examine the health behaviors and cell phone usage patterns of a text4baby target population and the associations with health literacy.

METHODS

Pregnant and postpartum women were recruited from two Women, Infant and Children clinics in Atlanta. Women were asked about their demographics, selected pregnancy or postpartum health behaviors, and cell phone usage patterns. Health literacy skills were measured with the English version of the Newest Vital Sign. Multivariable logistic regression was used to examine health behaviors and cell usage patterns by health literacy classification, controlling for commonly accepted confounders.

RESULTS

Four hundred sixty-eight women were recruited, and 445 completed the Newest Vital Sign. Of these, 22% had inadequate health literacy, 50% had intermediate health literacy, and 28% had adequate health literacy skills. Compared to adequate health literacy, limited literacy was independently associated with not taking a daily vitamin during pregnancy (OR 3.6, 95% CI: 1.6, 8.5) and never breastfeeding their infant (OR 1.4, 95% CI: 1.1, 1.8). The majority (69.4%) of respondents received nine or more text messages a day prior to enrollment, one in four participants (24.6%) had changed their number within the last six months, and 7.0% of study participants shared a cell phone. Controlling for potentially confounding factors, those with limited health literacy were more likely to share a cell phone than those with adequate health literacy (OR 2.57, 95% CI: 1.79, 3.69).

CONCLUSIONS

Text4baby messages should be appropriate for low health literacy levels, especially as this population may have higher prevalence of targeted unhealthy behaviors. Text4baby and other mhealth programs targetting low health literacy populations should also be aware of the different ways that these populations use their cell phones, including: sharing cell phones, which may mean participants will not receive messages or have special privacy concerns; frequently changing cell phone numbers which could lead to higher drop-off rates; and the penetrance of text messages in a population that receives many messages daily.

Mobile health (mHealth) based medication adherence measurement - a pilot trial using electronic blisters in diabetes patients

AIMS

The aim of the present study was to evaluate a mobile health (mHealth) based remote medication adherence measurement system (mAMS) in elderly patients with increased cardiovascular risk treated for diabetes, high cholesterol and hypertension. Cardiovascular risk was defined as the presence of at least two out of the three risk factors: type 2 diabetes, hypercholesterolaemia and hypertension.

METHODS

For treatment of diabetes, hypercholesterolaemia and hypertension, four predefined routinely used drugs were selected. Drug adherence was investigated in a controlled randomized doctor blinded study with crossover design. The mAMS was used to measure and improve objectively the adherence by means of closed-loop interactions.

RESULTS

The mean age of the 53 patients (30 female) was 69.4 ± 4.8 years. A total of 1654 electronic blisters were handed out. A statistically significant difference (P = 0.04) between the monitoring and the control phase was observed for the diabetes medication only. In a post-study questionnaire twenty-nine patients appreciated that their physician knew if and when they had taken their medications and 13 asked for more or automated communication with their physicians. Only one subject withdrew from the study because of technical complexity.

CONCLUSIONS

The results indicate that mHealth based adherence management is feasible and well accepted by patients with increased cardiovascular risk. It may help to increase adherence, even in patients with high baseline adherence and, subsequently, lead to improved control of indicators including blood pressure and cholesterol concentrations. Electronic blisters can be used in a multi-medication regimen but need to be carefully designed for day-to-day application.

Mobile applications for diabetics: a systematic review and expert-based usability evaluation considering the special requirements of diabetes patients age 50 years or older

BACKGROUND

A multitude of mhealth (mobile health) apps have been developed in recent years to support effective self-management of patients with diabetes mellitus type 1 or 2.

OBJECTIVE

We carried out a systematic review of all currently available diabetes apps for the operating systems iOS and Android. We considered the number of newly released diabetes apps, range of functions, target user groups, languages, acquisition costs, user ratings, available interfaces, and the connection between acquisition costs and user ratings. Additionally, we examined whether the available applications serve the special needs of diabetes patients aged 50 or older by performing an expert-based usability evaluation.

METHODS

We identified relevant keywords, comparative categories, and their specifications. Subsequently, we performed the app review based on the information given in the Google Play Store, the Apple App Store, and the apps themselves. In addition, we carried out an expert-based usability evaluation based on a representative 10% sample of diabetes apps.

RESULTS

In total, we analyzed 656 apps finding that 355 (54.1%) offered just one function and 348 (53.0%) provided a documentation function. The dominating app language was English (85.4%, 560/656), patients represented the main user group (96.0%, 630/656), and the analysis of the costs revealed a trend toward free apps (53.7%, 352/656). The median price of paid apps was €1.90. The average user rating was 3.6 stars (maximum 5). Our analyses indicated no clear differences in the user rating between free and paid apps. Only 30 (4.6%) of the 656 available diabetes apps offered an interface to a measurement device. We evaluated 66 apps within the usability evaluation. On average, apps were rated best regarding the criterion "comprehensibility" (4.0 out of 5.0), while showing a lack of "fault tolerance" (2.8 out of 5.0). Of the 66 apps, 48 (72.7%) offered the ability to read the screen content aloud. The number of functions was significantly negative correlated with usability. The presence of documentation and analysis functions reduced the usability score significantly by 0.36 and 0.21 points.

CONCLUSIONS

A vast number of diabetes apps already exist, but the majority offer similar functionalities and combine only one to two functions in one app. Patients and physicians alike should be involved in the app development process to a greater extent. We expect that the data transmission of health parameters to physicians will gain more importance in future applications. The usability of diabetes apps for patients aged 50 or older was moderate to good. But this result applied mainly to apps offering a small range of functions. Multifunctional apps performed considerably worse in terms of usability. Moreover, the presence of a documentation or analysis function resulted in significantly lower usability scores. The operability of accessibility features for diabetes apps was quite limited, except for the feature "screen reader".

Incorporating guidelines for use of mobile technologies in health research and practice

This commentary aims to create initial recommendations to guide researchers' decisions on the development and use of mobile technologies for public health research. We recommend that mobile technologies for public health research should be scalable and sustainable; draw on social, psychological and/or behavioral theoretical models; be able to be integrated with multiple communication devices; incorporate social network and/or geographic metrics and take a community-based participatory approach to development and implementation. All of these approaches are discussed.

Preventing postpartum smoking relapse among inner city women: development of a theory-based and evidence-guided text messaging intervention

Background

Underserved women are at high risk for smoking relapse after childbirth due to their unique socioeconomic and postpartum stressors and barriers. Mobile text messaging technology allows delivery of relapse prevention programs targeted to their personal needs over time.

Objective

To describe the development of a social-cognitive theory-based and evidence-guided text messaging intervention for preventing postpartum smoking relapse among inner city women.

Methods

Guided by the cognitive-social health information processing framework, user-centered design, and health communication best practices, the intervention was developed through a systematic process that included needs assessment, followed by an iterative cycling through message drafting, health literacy evaluation and rewriting, review by target community members and a scientific advisory panel, and message revision, concluding with usability testing.

Results

All message content was theory-grounded, derived by needs assessment analysis and evidence-based materials, reviewed and revised by the target population, health literacy experts, and scientific advisors. The final program, “Txt2Commit,” was developed as a fully automated system, designed to deliver 3 proactive messages per day for a 1-month postpartum smoking relapse intervention, with crave and lapse user-initiated message functions available when needed.

Conclusions

The developmental process suggests that the application of theory and best practices in the design of text messaging smoking cessation interventions is not only feasible but necessary for ensuring that the interventions are evidence based and user-centered.

Using the iPod Touch for Patient Health Behavior Assessment and Health Promotion in Primary Care

BACKGROUND

There is a growing recognition of the importance of lifestyle behavior change for health promotion and disease prevention, as well as the concomitant influence of patient-physician communication on effective behavior change. Mobile technology is increasingly being recognized as an important and efficient tool to collect patients' health behavior data and facilitate patient-physician communication.

OBJECTIVE

The aim of this study was to assess the feasibility of an iPod touch-based health behavior assessment (HBA) tool in enhancing patient-physician collaborative goal-setting for health promotion in primary care.

METHODS

A total of 109 patients from three primary care clinics in central Texas completed a brief HBA, which was programmed on an iPod touch device. An instant feedback report was generated for the patient and their physician simultaneously to facilitate collaborative goal-setting. Within approximately 7 days of the HBA, the patients were phoned for a follow-up survey for their feedback on the iPod touch-based HBA and resultant patient-physician communication.

RESULTS

Patients were able to complete an HBA on the iPod touch with ease. Among those who completed the follow-up survey (n=83), 30% (25/83) reported that their physicians discussed the HBA report with them, while 29% (24/83) established behavior change goals with them. More than 90% (75/83) of the patients reported positive experiences with the iPod touch-based HBA.

CONCLUSIONS

It is feasible to use mobile tools for HBA in the primary care setting. The HBA also facilitated patient-physician communication on behavior change. However, more research is needed on the effectiveness of large scale dissemination of mobile-based HBA technology on health communication and behavior change for preventing or managing lifestyle-related chronic conditions, such as obesity, diabetes, cancer, or heart diseases.

Knowledge and skill retention of a mobile phone data collection protocol in rural Liberia

INTRODUCTION

With a large number of births occurring outside the formal health system, it is difficult to determine the number of pregnant women in rural regions of Liberia. The exponential growth of mobile phone use in developing countries provides a potential avenue for data collection on maternal and child health in such rural, remote regions.

METHODS

A pre-, post-, and one-year posttest design was used to collect data on knowledge and skill retention for 7 essential items required for mobile phone use among traditional birth attendants (TBAs) trained in a short message service (SMS) texting data collection protocol (N = 99) in rural Liberia.

RESULTS

Sixty-three participants (63.6% retention) completed the one-year posttest and displayed evidence of statistically significant knowledge and skill retention in 6 of the 7 tasks (P < .005), including the ability to: 1) turn on the phone, 2) use the mobile phone to make a call, 3) recognize that they have coverage, 4) recognize that the mobile phone is charged, 5) create a SMS text message without help, and 6) send a SMS text message without help. The TBAs continued to have difficulty with more complex tasks such as adding minutes to a phone.

DISCUSSION

The mobile phone data-collection protocol proved feasible with TBAs demonstrating knowledge retention in a one-year posttest; however, clinical significance needs further investigation. The protocol increased communication and collaboration among TBAs, certified midwives, and clinic staff.

Evaluating user perceptions of mobile medication management applications with older adults: a usability study

BACKGROUND

Medication nonadherence has a significant impact on the health and wellbeing of individuals with chronic disease. Several mobile medication management applications are available to help users track, remember, and read about their medication therapy.

OBJECTIVE

The objective of this study was to explore the usability and usefulness of existing medication management applications for older adults.

METHODS

We recruited 35 participants aged 50 and over to participate in a 2-hour usability session. The average age ranged from 52-78 years (mean 67 years) and 71% (25/35) of participants were female. Each participant was provided with an iPad loaded with four medication management applications: MyMedRec, DrugHub, Pillboxie, and PocketPharmacist. These applications were evaluated using the 10 item System Usability Scale (SUS) and visual analog scale. An investigator-moderated 30-minute discussion followed, and was recorded. We used a grounded theory (GT) approach to analyze qualitative data.

RESULTS

When assessing mobile medication management applications, participants struggled to think of a need for the applications in their own lives. Many were satisfied with their current management system and proposed future use only if cognition and health declined. Most participants felt capable of using the applications after a period of time and training, but were frustrated by their initial experiences with the applications. The early experiences of participants highlighted the benefits of linear navigation and clear wording (eg, "undo" vs "cancel") when designing for older users. While there was no order effect, participants attributed their poor performance to the order in which they tried the applications. They also described being a part of a technology generation that did not encounter the computer until adulthood. Of the four applications, PocketPharmacist was found to be the least usable with a score of 42/100 (P<.0001) though it offered a drug interaction feature that was among the favorite features of participants. The usability scores for MyMedRec (56/100), DrugHub (57/100), and Pillboxie (52/100) were not significantly different and participants preferred MyMedRec and DrugHub for their simple, linear interfaces.

CONCLUSIONS

With training, adults aged 50 and over can be capable and interested in using mHealth applications for their medication management. However, in order to adopt such technology, they must find a need that their current medication management system cannot fill. Interface diversity and multimodal reminder methods should be considered to increase usability for older adults. Lastly, regulation or the involvement of older adults in development may help to alleviate generation bias and mistrust for applications.

Measuring the lifespace of people with Parkinson's disease using smartphones: proof of principle

BACKGROUND

Lifespace is a multidimensional construct that describes the geographic area in which a person lives and conducts their activities, and reflects mobility, health, and well-being. Traditionally, it has been measured by asking older people to self-report the length and frequency of trips taken and assistance required. Global Positioning System (GPS) sensors on smartphones have been used to measure Lifespace of older people, but not with people with Parkinson's disease (PD).

OBJECTIVE

The objective of this study was to investigate whether GPS data collected via smartphones could be used to indicate the Lifespace of people with PD.

METHODS

The dataset was supplied via the Michael J Fox Foundation Data Challenge and included 9 people with PD and 7 approximately matched controls. Participants carried smartphones with GPS sensors over two months. Data analysis compared the PD group and the control group. The impact of symptom severity on Lifespace was also investigated.

RESULTS

Visualization methods for comparing Lifespace were developed including scatterplots and heatmaps. Lifespace metrics for comparison included average daily distance, percentage of time spent at home, and number of trips into the community. There were no significant differences between the PD and the control groups on Lifespace metrics. Visual representations of Lifespace were organized based on the self-reported severity of symptoms, suggesting a trend of decreasing Lifespace with increasing PD symptoms.

CONCLUSIONS

Lifespace measured by GPS-enabled smartphones may be a useful concept to measure the progression of PD and the impact of various therapies and rehabilitation programs. Directions for future use of GPS-based Lifespace are provided.

Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers

There has been a spike in interest and use of telehealth, catalyzed recently by the anticipated implementation of the Affordable Care Act, which rewards efficiency in healthcare delivery. Advances in telehealth services are in many areas, including gap service coverage (eg, night-time radiology coverage), urgent services (eg, telestroke services and teleburn services), mandated services (eg, the delivery of health care services to prison inmates), and the proliferation of video-enabled multisite group chart rounds (eg, Extension for Community Healthcare Outcomes programs). Progress has been made in confronting traditional barriers to the proliferation of telehealth. Reimbursement by third-party payers has been addressed in 19 states that passed parity legislation to guarantee payment for telehealth services. Medicare lags behind Medicaid, in some states, in reimbursement. Interstate medical licensure rules remain problematic. Mobile health is currently undergoing explosive growth and could be a disruptive innovation that will change the face of healthcare in the future.

Diabetes self-management support using mHealth and enhanced informal caregiving

OBJECTIVE

To characterize diabetes patient engagement and clinician notifications for an mHealth interactive voice response (IVR) service.

DESIGN

Observational study.

METHODS

For three to six months, VA patients with diabetes received weekly IVR calls assessing health status and self-care along with tailored education. Patients could enroll with an informal caregiver who received suggestions on self-management support. Notifications were issued to clinicians when patients reported significant problems.

RESULTS

Patients (n = 303) participated for a total of 5684 patient-weeks, during which 84% of calls were completed. The odds of call completion decreased over time (AOR = 0.96, p < 0.001), and were lower among unmarried patients (AOR = 0.67, p = 0.038) and those who had difficulties with health literacy (AOR = 0.67, p = 0.039), diabetes-related distress (AOR = 0.30, p = 0.018), or medication nonadherence (AOR = 0.57, p = 0.002). Twenty-one clinician notifications were triggered per 100 patient-weeks. The odds of notification were higher during the early weeks of the program (AOR = 0.95, p < 0.001) and among patients who were older (AOR = 1.03, p = 0.004) or more physically impaired (AOR = 0.97, p < 0.001).

CONCLUSIONS

By providing information that is reliable, valid, and actionable, IVR-based mHealth services may increase access to between-visit monitoring and diabetes self-management support. The system detects abnormal glycemia and blood pressure levels that might otherwise go unreported, although thresholds for clinician notifications might require adjustment to avoid overloading clinicians. Patient engagement might be enhanced by addressing health literacy and psychological distress.

A classification scheme for analyzing mobile apps used to prevent and manage disease in late life

Background

There are several mobile apps that offer tools for disease prevention and management among older adults, and promote health behaviors that could potentially reduce or delay the onset of disease. A classification scheme that categorizes apps could be useful to both older adult app users and app developers.

Objective

The objective of our study was to build and evaluate the effectiveness of a classification scheme that classifies mobile apps available for older adults in the “Health & Fitness” category of the iTunes App Store.

Methods

We constructed a classification scheme for mobile apps according to three dimensions: (1) the Precede-Proceed Model (PPM), which classifies mobile apps in terms of predisposing, enabling, and reinforcing factors for behavior change; (2) health care process, specifically prevention versus management of disease; and (3) health conditions, including physical health and mental health. Content analysis was conducted by the research team on health and fitness apps designed specifically for older adults, as well as those applicable to older adults, released during the months of June and August 2011 and August 2012. Face validity was assessed by a different group of individuals, who were not related to the study. A reliability analysis was conducted to confirm the accuracy of the coding scheme of the sample apps in this study.

Results

After applying sample inclusion and exclusion criteria, a total of 119 apps were included in the study sample, of which 26/119 (21.8%) were released in June 2011, 45/119 (37.8%) in August 2011, and 48/119 (40.3%) in August 2012. Face validity was determined by interviewing 11 people, who agreed that this scheme accurately reflected the nature of this application. The entire study sample was successfully coded, demonstrating satisfactory inter-rater reliability by two independent coders (95.8% initial concordance and 100% concordance after consensus was reached). The apps included in the study sample were more likely to be used for the management of disease than prevention of disease (109/119, 91.6% vs 15/119, 12.6%). More apps contributed to physical health rather than mental health (81/119, 68.1% vs 47/119, 39.5%). Enabling apps (114/119, 95.8%) were more common than reinforcing (20/119, 16.8%) or predisposing apps (10/119, 8.4%).

Conclusions

The findings, including face validity and inter-rater reliability, support the integrity of the proposed classification scheme for categorizing mobile apps for older adults in the “Health and Fitness” category available in the iTunes App Store. Using the proposed classification system, older adult app users would be better positioned to identify apps appropriate for their needs, and app developers would be able to obtain the distributions of available mobile apps for health-related concerns of older adults more easily.

Integrating mobile phones into medical abortion provision: intervention development, use, and lessons learned from a randomized controlled trial

Background

Medical abortion is legal in South Africa but access and acceptability are hampered by the current protocol requiring a follow-up visit to assess abortion completion.

Objective

To assess the feasibility and efficacy of information and follow-up provided via mobile phone after medical abortion in a randomized controlled trial (RCT).

Methods

Mobile phones were used in three ways in the study: (1) coaching women through medical abortion using short message service (SMS; text messages); (2) a questionnaire to assess abortion completion via unstructured supplementary service data (USSD, a protocol used by GSM mobile telephones that allows the user to interact with a server via text-based menus) and the South African mobile instant message and social networking application Mxit; and (3) family planning information via SMS, mobisite and Mxit. A needs and context assessment was done to learn about women’s experiences undergoing medical abortion and their use of mobile phones. After development, the mobile interventions were piloted. Recruitment was done by field workers at the clinics. In the RCT, women were interviewed at baseline and exit. Computer logs were also analyzed. All study participants received standard of care at the clinics.

Results

In the RCT, 234 women were randomized to the intervention group. Eight did not receive the intervention due to invalid numbers, mis-registration, system failure, or opt-out, leaving 226 participants receiving the full intervention. Of the 226, 190 returned and were interviewed at their clinic follow-up visit. The SMSs were highly acceptable, with 97.9% (186/190) saying that the SMSs helped them through the medical abortion. In terms of mobile phone privacy, 86.3% (202/234) said that it was not likely or possible that someone would see SMSs on their phone, although at exit, 20% (38/190) indicated that they had worried about phone privacy. Having been given training at baseline and subsequently asked via SMS to complete the self-assessment questionnaire, 90.3% (204/226) attempted it, and of those, 86.3% (176/204) reached an endpoint of the questionnaire. For the family planning information, a preference for SMS was indicated by study clients, although the publicly available Mxit/mobisite was heavily used (813,375 pages were viewed) over the study duration.

Conclusions

SMS provided a good medium for timed, "push" information that guided and supported women through medical abortion. Women were able to perform a self-assessment questionnaire via mobile phones if provided training and prompted by SMS. Phone privacy needs to be protected in similar settings. This study may contribute to the successful expansion of medical abortion provision aided by mobile phones.

Trial Registration

Pan African Clinical Trials Registry (PACTR): PACTR201302000427144; http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201302000427144 (Archived by WebCite at http://www.webcitation.org/6N0fnZfzm).

Understanding messaging preferences to inform development of mobile goal-directed behavioral interventions

Background

Mobile messaging interventions have been shown to improve outcomes across a number of mental health and health-related conditions, but there are still significant gaps in our knowledge of how to construct and deliver the most effective brief messaging interventions. Little is known about the ways in which subtle linguistic variations in message content can affect user receptivity and preferences.

Objective

The aim of this study was to determine whether any global messaging preferences existed for different types of language content, and how certain characteristics moderate those preferences, in an effort to inform the development of mobile messaging interventions.

Methods

This study examined user preferences for messages within 22 content groupings. Groupings were presented online in dyads of short messages that were identical in their subject matter, but structurally or linguistically varied. Participants were 277 individuals residing in the United States who were recruited and compensated through Amazon’s Mechanical Turk (MTurk) system. Participants were instructed to select the message in each dyad that they would prefer to receive to help them achieve a personal goal of their choosing.

Results

Results indicate global preferences of more than 75% of subjects for certain types of messages, such as those that were grammatically correct, free of textese, benefit-oriented, polite, nonaggressive, and directive as opposed to passive, among others. For several classes of messages, few or no clear global preferences were found. There were few personality- and trait-based moderators of message preferences, but subtle manipulations of message structure, such as changing “Try to…” to “You might want to try to…” affected message choice.

Conclusions

The results indicate that individuals are sensitive to variations in the linguistic content of text messages designed to help them achieve a personal goal and, in some cases, have clear preferences for one type of message over another. Global preferences were indicated for messages that contained accurate spelling and grammar, as well as messages that emphasize the positive over the negative. Research implications and a guide for developing short messages for goal-directed behaviors are presented in this paper.

A 21st century approach to tackling dengue: Crowdsourced surveillance, predictive mapping and tailored communication

This paper describes a social media system to prevent dengue in Sri Lanka and potentially in the rest of the South and Southeast Asia regions. The system integrates three concepts of public health prevention that have thus far been implemented only in silos. First, the predictive surveillance component uses a computer simulation to forewarn health authorities and the general public about impending disease outbreaks. The civic engagement component allows the general public to use social media tools to interact and engage with health authorities by aiding them in surveillance efforts by reporting symptoms, mosquito bites and breeding sites using smartphone technologies. The health communication component utilizes citizen data gathered from the first two components to disseminate customized health awareness messages to enhance knowledge and increase preventive behaviors among citizens. The system, known as "Mo-Buzz," will be made available on a host of digital platforms like simple mobile phones, smart phones and a website. We present challenges and lessons learnt including content validation, stakeholder collaborations and applied trans-disciplinary research.

A usability study of a mobile health application for rural Ghanaian midwives

INTRODUCTION

Midwives in rural Ghana work at the frontline of the health care system, where they have access to essential data about the patient population. However, current methods of data capture, primarily pen and paper, make the data neither accessible nor usable for monitoring patient care or program evaluation. Electronic health (eHealth) systems present a potential mechanism for enhancing the roles of midwives by providing tools for collecting, exchanging, and viewing patient data as well as offering midwives the possibility for receiving information and decision support. Introducing such technology in low-resource settings has been challenging because of low levels of user acceptance, software design that does not match the end-user environment, and/or unforeseen challenges such as irregular power availability. These challenges are often attributable to a lack of understanding by the software developers of the end users' needs and work environment.

METHODS

A mobile health (mHealth) application known as mClinic was designed to support midwife access to the Millennium Village-Global Network, an eHealth delivery platform that captures data for managing patient care as well as program evaluation and monitoring, decision making, and management. We conducted a descriptive usability study composed of 3 phases to evaluate an mClinic prototype: 1) hybrid lab-live software evaluation of mClinic to identify usability issues; 2) completion of a usability questionnaire; and 3) interviews that included low-fidelity prototyping of new functionality proposed by midwives.

RESULTS

The heuristic evaluation identified usability problems related to 4 of 8 usability categories. Analysis of usability questionnaire data indicated that the midwives perceived mClinic as useful but were more neutral about the ease of use. Analysis of midwives' reactions to low-fidelity prototypes during the interview process supported the applicability of mClinic to midwives' work and identified the need for additional functionality.

DISCUSSION

User acceptance is essential for the success of any mHealth implementation. Usability testing identified mClinic development flaws and needed software enhancements.

Can mHealth Improve Risk Assessment in Underserved Populations? Acceptability of a Breast Health Questionnaire App in Ethnically Diverse, Older, Low-Income Women

BACKGROUND

Use of mobile health (mHealth) tools has expanded rapidly but little research has been done on its acceptability by low-income, diverse, older patient populations.

OBJECTIVE

To assess the attitudes of a diverse group of underserved women on the acceptability and usability of mHealth tools in a clinical setting using a breast health questionnaire application (app) at a public hospital mammography clinic.

METHODS

Semi-structured interviews were conducted in a breast-imaging center of an urban safety net institution from July-August 2012. Interviews included pre- and post-questions. Women completed the Athena breast health questionnaire app on an iPad and were asked about their experience and ways to improve the tool.

RESULTS

Fifteen women age 45-79 years from diverse ethnic and educational backgrounds were interviewed. The majority of women, 11 of 15, preferred the Athena app over a paper version and all the women thought the app was easy to use. Two Spanish-speaking Latinas preferred paper; and two women, with limited mobile phone use, did not have a preference. Many women indicated that it would be necessary to have staff available for instruction and assistance if the app were to be implemented.

CONCLUSIONS

mHealth tools are an acceptable, if not preferred, method of collecting health information for diverse, older, low-income women. Further studies are required to evaluate the reliability and accuracy of data collection using mHealth tools in underserved populations. mHealth tools should be explored as a novel way to engage diverse populations to improve clinical care and bridge gaps in health disparities.

Achieving HIV risk reduction through HealthMpowerment.org, a user-driven eHealth intervention for young Black men who have sex with men and transgender women who have sex with men

Young, Black men who have sex with men and transgender women who have sex with men (YBMSM/TW) are at disproportionate risk for HIV and other sexually transmitted infections (HIV/STI). HealthMpowerment.org (HMP) is a mobile phone optimised online intervention that utilises behaviour change and gaming theories to reduce risky sexual behaviours and build community among HIV-positive and negative YBMSM/TW. The intervention is user-driven, provides social support, and utilises a point reward system. A four-week pilot trial was conducted with a diverse group of 15 YBMSM/TW. During exit interviews, participants described how HMP components led to behaviour changes such as asking partners' sexual history, increased condom use, and HIV/STI testing. The user-driven structure, interactivity, and rewards appeared to facilitate sustained user engagement and the mobile platform provided relevant information in real-time. Participants described the reward elements of exceeding their previous scores and earning points toward prizes as highly motivating. HMP showed promise for being able to deliver a sufficient intervention dose and we found a trend toward higher dose received and more advanced stages of behaviour change. In this pilot trial, HMP was well accepted and demonstrates promise for translating virtual intervention engagement into actual behaviour change to reduce HIV risk behaviours.

Bridging the Human Resource Gap in Primary Health Care Delivery Systems of Developing Countries With mHealth: Narrative Literature Review

BACKGROUND

Mobile health (mHealth) has the potential to solve human resource issues in the health care sector. mHealth is of particular interest in developing countries, where widespread mobile networks and access to devices are connecting people like never before.

OBJECTIVE

The aim of this paper was to review published and unpublished literature, field projects, and pilot studies on mHealth usage in overcoming shortage of human health resources in developing countries.

METHODS

A narrative literature review was undertaken using an iterative approach in extracting literature focused on mHealth and human health resources of low-income countries, especially India. The present review has undertaken comprehensive coverage of the work on related field projects that have been either published, accepted for publication, or pilot tested.

RESULTS

This review presented the use of mHealth across various dimensions of primary health care, including data collection, disease surveillance, health education, supervision, monitoring, and feedback. Field studies of fast, error-free data collection and transmission using mHealth were also documented. New apps for supervision, monitoring, and utilization of innovative health education tools were documented in the current review. Practical limitations of mHealth and challenges set forth in developing countries included issues of data security, cost constraints, health provider privacy, and technical barriers.

CONCLUSIONS

In the present review, we have documented a few mHealth projects that contribute to the proficient use of human resources. These projects pave the path for the efficient utilization of mHealth, offering solutions to emerging human resource challenges and simultaneously revamping the health care delivery in resource-limited settings.

Dynamic Integration of Mobile JXTA with Cloud Computing for Emergency Rural Public Health Care

Objectives

The existing processes of health care systems where data collection requires a great deal of labor with high-end tasks to retrieve and analyze information, are usually slow, tedious, and error prone, which restrains their clinical diagnostic and monitoring capabilities. Research is now focused on integrating cloud services with P2P JXTA to identify systematic dynamic process for emergency health care systems. The proposal is based on the concepts of a community cloud for preventative medicine, to help promote a healthy rural community. We investigate the approaches of patient health monitoring, emergency care, and an ambulance alert alarm (AAA) under mobile cloud-based telecare or community cloud controller systems.

Methods

Considering permanent mobile users, an efficient health promotion method is proposed. Experiments were conducted to verify the effectiveness of the method. The performance was evaluated from September 2011 to July 2012. A total of 1,856,454 cases were transported and referred to hospital, identified with health problems, and were monitored. We selected all the peer groups and the control server N₀ which controls N₁, N₂, and N₃ proxied peer groups. The hospital cloud controller maintains the database of the patients through a JXTA network.

Results

Among 1,856,454 transported cases with beneficiaries of 1,712,877 cases there were 1,662,834 lives saved and 8,500 cases transported per day with 104,530 transported cases found to be registered in a JXTA network.

Conclusion

The registered case histories were referred from the Hospital community cloud (HCC). SMS messages were sent from node N₀ to the relay peers which connected to the N₁, N₂, and N₃ nodes, controlled by the cloud controller through a JXTA network.

HCI and mobile health interventions: How human-computer interaction can contribute to successful mobile health interventions

Advances in mobile computing offer the potential to change when, where, and how health interventions are delivered. Rather than relying on occasional in-clinic interactions, mobile health (mHealth) interventions may overcome constraints due to limited clinician time, poor patient adherence, and inability to provide meaningful interventions at the most appropriate time. Technological capability, however, does not equate with user acceptance and adoption. How then can we ensure that mobile technologies for behavior change meet the needs of their target audience? In this paper, we argue that overcoming acceptance and adoption barriers requires interdisciplinary collaborations, bringing together not only technologists and health researchers but also human-computer interaction (HCI) experts. We discuss the value of human-computer interaction research to the nascent field of mHealth and demonstrate how research from HCI can offer complementary insights on the creation of mobile health interventions. We conclude with a discussion of barriers to interdisciplinary collaborations in mobile health and suggest ways to overcome them.

mHealth approaches to child obesity prevention: successes, unique challenges, and next directions

Childhood obesity continues to be a significant public health issue. mHealth systems offer state-of-the-art approaches to intervention design, delivery, and diffusion of treatment and prevention efforts. Benefits include cost effectiveness, potential for real-time data collection, feedback capability, minimized participant burden, relevance to multiple types of populations, and increased dissemination capability. However, these advantages are coupled with unique challenges. This commentary discusses challenges with using mHealth strategies for child obesity prevention, such as lack of scientific evidence base describing effectiveness of commercially available applications; relatively slower speed of technology development in academic research settings as compared with industry; data security, and patient privacy; potentially adverse consequences of increased sedentary screen time, and decreased focused attention due to technology use. Implications for researchers include development of more nuanced measures of screen time and other technology-related activities, and partnering with industry for developing healthier technologies. Implications for health practitioners include monitoring, assessing, and providing feedback to child obesity program designers about users' data transfer issues, perceived security and privacy, sedentary behavior, focused attention, and maintenance of behavior change. Implications for policy makers include regulation of claims and quality of apps (especially those aimed at children), supporting standardized data encryption and secure open architecture, and resources for research-industry partnerships that improve the look and feel of technology. Partnerships between academia and industry may promote solutions, as discussed in this commentary.