Usability of Commercially Available Mobile Applications for Diverse Patients

Exploring the digital divide: results of a survey informing mobile application development

Introduction

Mobile health apps risk widening health disparities if they overlook digital inclusion. The digital divide, encompassing access, familiarity, and readiness, poses a significant barrier to medical interventions. Existing literature lacks exploration of the digital divide's contributing factors. Hence, data are needed to comprehend the challenges in developing inclusive health apps.

Methods

We created a survey to gauge internet and smartphone access, smartphone familiarity, and readiness for using mobile health apps among caregivers of pediatric patients in tertiary care. Open-ended questions solicited feedback and suggestions on mobile health applications. Responses were categorized by similarity and compared. Developed with patient partners, the survey underwent cognitive testing and piloting for accuracy.

Results

Data from 209 respondents showed that 23% were affected by the digital divide, mainly due to unfamiliarity with digital skills. Among 49 short text responses about health app concerns, 31 mentioned security and confidentiality, with 7 mentioning the impersonal nature of such apps. Desired features included messaging healthcare providers, scheduling, task reminders, and simplicity.

Conclusions

This study underscores a digital divide among caregivers of pediatric patients, with nearly a quarter affected primarily due to a lack of digital comfort. Respondents emphasized user-friendliness and online security for health apps. Future apps should prioritize digital inclusion by addressing the significant barriers and carefully considering patient and family concerns.

Electronic maternal and child health application usability, feasibility and acceptability among healthcare providers in Amhara region, Ethiopia

An innovative electronic Maternal and Child Health (eMCH) application was developed to support operational and clinical decision-making in maternal and child health services. End-user-based evaluation of eHealth application is a critical step to ascertain how successfully users can learn and use it, and improve the technology. Therefore, this study aimed to evaluate the eMCH tool usability, feasibility, and acceptability among healthcare providers (HCPs) in the Amhara region, Ethiopia. A cross-sectional study was conducted among HCPs working in six public healthcare facilities. The usability evaluation was done on 24 HCPs across three professional categories using the ISO 9241-11 usability guideline. One hundred nine HCPs were participated in the feasibility and acceptability study. Data were collected using a standard usability tool, think-aloud protocol, a self-administered approach, and Open Broadcaster Software Studio version 26.1.1 video recorder. Descriptive statistics were used to describe the data. A Kruskal-Wallis test was used to measure the association between mean scores and categories of HCPs. The recorded videos were used for the log file analysis method. None of the HCP categories were able to complete all the tasks without errors. The average number of errors and restarts were 7.5 and 2.8, respectively. The average number of restarts was directly proportional to the average number of errors. The participants successfully completed more than 70% of the tasks without requiring any assistance or guidance. Forty-seven comments or errors were identified from the think-aloud analysis and 22 comments from the usability metrics analysis. Overall, statistically significant performance differences were observed among the three HCP groups across the majority of the usability evaluation metrics. Fifty-seven percent of HCPs scored higher than the mean on the feasibility study. Slightly higher than half, 56 (51.4%), of the HCPs scored higher than the mean score on the acceptability study. The usability evaluation identified vital comments and usability flaws that were essential for the eMCH tool to be upgraded. The tool was feasible and acceptable as reported by end-users. Therefore, the errors and usability flaws of the tool should be fixed before deployment to other healthcare settings.

Symptom Reduction and Engagement in a Cognitive-Behavioral Mobile Phone App: A Study of User Profiling to Determine Prognostic Indicators

OBJECTIVE

We investigated the presence of latent transition profiles in a sample of users of a cognitive-behavioral mental health app for the general population. Users' baseline characteristics were used as predictors of the profiles. The role of engagement with the app in the transition profiles was examined.

METHOD

A total of 541 users completed the Patient Health Questionnaire-9 and the General Anxiety Disorder-7 when started using the app and 30 days after. Random-Intercept Latent Transition Analysis was implemented to identify users' profiles and transition patterns as classes. The age of the users and the Emotional Self-Awareness Scale-Revised (ESAS-R) were used as predictors of class membership at baseline. The Homework Rating Scale-Mobile Application (HRS-MA; as a measure of engagement) was used as a predictor of class membership at 30 days of app use.

RESULTS

A 3-class solution was obtained according to the severity of symptoms (from mild to moderately severe). Age and ESAS-R predicted class membership initially; the higher the age and ESAS-R, the higher the probability of starting using the app with lower distress levels. The HRS-MA predicted class membership at 30 days of app use; the higher the engagement for more symptomatic and younger users, the higher the probability of improvement. However, older users tended to engage less.

CONCLUSION

Our findings underpin the relevance of easily accessible digital interventions for young adults with mild to moderate mental health problems. Further studies and developments are required to enhance these apps for older cohorts.

Administrative burden for patients in U.S. health care settings Post-Affordable Care Act: A scoping review

Administrative burdens are the costs associated with receiving a service or accessing a program. Based on the Herd & Moynihan framework, they occur in three subcategories: learning costs, compliance costs, and psychological costs. Administrative burdens manifest inequitably, more significantly impacting vulnerable populations. Administrative burdens may impact the health of those trying to access services, and in some cases block access to health-promoting services entirely. This scoping review examined studies focused on the impact on patients of administrative burden administrative burden in health care settings in the U.S. following the passage of the Affordable Care Act. We queried databases for empirical literature capturing patient administrative burden, retrieving 1578 records, with 31 articles ultimately eligible for inclusion. Of the 31 included studies, 18 used quantitative methods, nine used qualitative methods, three used mixed methods, and one was a case study. In terms of administrative burden subcategories, most patient outcomes reported were learning (22 studies) and compliance costs (26 studies). Psychological costs were the most rarely reported; all four studies describing psychological costs were qualitative in nature. Only twelve studies connected patient demographic data with administrative burden data, despite previous research suggesting an inequitable burden impact. Additionally, twenty-eight studies assessed administrative burden and only three attempted to reduce it via an intervention, resulting in a lack of data on intervention design and efficacy.

Enhancing tuberculosis treatment adherence and motivation through gamified real-time mobile app utilization: a single-arm intervention study

BACKGROUND

Finding innovative methods to enhance Tuberculosis treatment adherence in Malaysia is imperative, given the rising trend of non-adhere TB patients. Direct Observed Therapy (DOTS) has been used to ensure Tuberculosis (TB) drug compliance worldwide. However, due to its inconvenience, digitalizing this system into a virtual monitoring system via a mobile app can help deliver a more efficient tuberculosis management system. A gamified video-observed therapy is developed that connects three users the patient, supervisor, and administrator, allowing drug monitoring and patient loss to follow up with the patient tracking system. Thus, the objective of this study is to determine the impact of Gamified Real-time Video Observed Therapy (GRVOTS) mobile apps on patient medication adherence rates and motivation.

METHODS

71 patients from 18 facilities participated in the 8-week single-arm intervention study. GRVOTS mobile apps were installed in their mobile apps, and patients were expected to fulfill tasks such as providing Video Direct Observe Therapy (VDOTS) daily as well as side effect reporting. At 3-time intervals of baseline,1-month, and 2-month intervals, the number of VDOT taken, the Malaysian Medication Adherence Assessment Tool (MyMAAT), and the Intrinsic Motivation Inventory (IMI) questionnaire were collected. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals.

RESULTS

This study involved 71 numbers of patients from 18 healthcare facilities who showed a significantly higher treatment adherence score of 90.87% than a standard score of 80% with a mean difference of 10.87(95% CI: 7.29,14.46; p < 0.001). The participants' MyMAAT and IMI scores significantly increased over 3-time intervals with the IMI Interest domain showing the highest mean difference 19.76 (95% CI: 16.37, 21.152: p < 0.001).

CONCLUSIONS

By utilizing GRVOTS, a mobile application based on gamification and real-time features, we can enhance motivation and medication adherence among TB patients, while also addressing the limitations of physical DOTS.

TRIAL REGISTRATION

IRCT20230308057657N1, Registered on (15/03/23).

Examining and Addressing Telemedicine Disparities Through the Lens of the Social Determinants of Health: A Qualitative Study of Patient and Provider During the COVID-19 Pandemic

Accelerated use of telemedicine during the COVID-19 pandemic enabled uninterrupted healthcare delivery while unmasking care disparities for several vulnerable communities. The social determinants of health (SDOH) serve as a critical model for understanding how the circumstances in which people are born, work, and live impact health outcomes. We performed semi-structured interviews to understand patients and providers' experiences with telemedicine encounters during the COVID-19 pandemic. Through a deductive approach, we applied the SDOH to determine telemedicine's role and impact within this framework. Overall, patient and provider interviews supported the use of existing SDOH domains to describe disparities in Internet access and telemedicine use, rather than reframing technology as a sixth SDOH. In order to mitigate the digital divide, we identify and propose solutions that address SDOH-related barriers that shape the use of health information technologies.

User-Centered Design of a Diabetes Self-Management Tool for Underserved Populations

BACKGROUND

User-centered design (UCD) or user experience design (UXD) methods have gained recent popularity for the design of mobile health (mHealth) interventions. However, there is a gap in application of these methods for diabetes self-management. This study aims to document the UCD process for a self-management mobile application aimed for patients with diabetes in underserved communities.

METHODS

A UCD mixed-methods approach including interviews with patients and providers, a review of literature, and a technology landscape analysis were used to define the app functional information requirements that informed the user experience/user interface design process. Usability studies with the app designers and developers, intended users, and a focus group of nurse educators and dieticians were used to test and improve the design.

RESULTS

An mHealth app was developed with health-tracking features for stress, blood sugar, food, exercise, medications, weight, and blood pressure. We tackled a range of usability and user experience challenges, which encompassed addressing issues like low health literacy by employing a combination of user interface design principles, intuitive visualizations, customizable icons, seamless database integration, and automated data input features. Special attention was given to the design of educational content accounting for the intended users' cultural background and literacy levels.

CONCLUSIONS

User-centered design approach contributed to a better understanding of the intended users' needs, limitations, mental models, and expectations, facilitating the design of a comprehensive mobile app for patients with diabetes in underserved communities that includes essential features for self-management while providing a strong educational component, addressing an important gap in the literature.

Effect of a Medication Adherence Mobile Phone App on Medically Underserved Patients with Chronic Illness: Preliminary Efficacy Study

BACKGROUND

Medication adherence is vital in the treatment of patients with chronic illness who require long-term medication therapies to maintain optimal health. Medication adherence, a complex and widespread problem, has been difficult to solve. Additionally, lower-income, medically underserved communities have been found to have higher rates of inadequate adherence to oral medications. Even so, this population has been underrepresented in studies using mobile medication adherence app interventions. Federally qualified health centers provide care for medically underserved populations, defined as communities and populations where there is a demonstrable unmet need for health services. These centers have been reporting an increase in a more complex chronic disease population. Including medically underserved individuals in mobile health studies provides opportunities to support this disproportionately affected group, work toward reducing health disparities in access to health care, and understand barriers to mobile health uptake.

OBJECTIVE

The aim of this preliminary efficacy study was to evaluate the effects and feasibility of a commercially available medication adherence app, Medisafe, in a medically underserved adult population with various chronic illnesses seeking care in a federally qualified health center.

METHODS

Participants in this single-arm pre-post intervention preliminary efficacy study (N=10) completed a baseline survey, used the app for 2 weeks, and completed an end-of-study survey. The primary outcome measures were medication adherence and medication self-efficacy. Feedback on the use of the app was also gathered.

RESULTS

A statistically significant median increase of 8 points on the self-efficacy for adherence to medications scale was observed (P=.03, Cohen d=0.69). Though not significant, the adherence to refills and medications scale demonstrated a median change of 2.5 points in the direction of increased medication adherence (P=.21, Cohen d=0.41). Feedback about the app was positive.

CONCLUSIONS

Use of the Medisafe app is a viable option to improve medication self-efficacy and medication adherence in medically underserved patients in an outpatient setting with a variety of chronic illnesses.

The Effect of Mobile eHealth Education to Improve Knowledge, Skills, Self-Care, and Mobile eHealth Literacies Among Patients With Diabetes: Development and Evaluation Study

BACKGROUND

The promotion of mobile health (mHealth) and eHealth technologies as tools for managing chronic diseases, particularly diabetes mellitus, is on the rise. Nevertheless, individuals with diabetes frequently face a literacy gap that hinders their ability to fully leverage the benefits offered by these resources. Enhancing technology literacy to facilitate the adoption of mobile eHealth services poses a significant challenge in numerous countries.

OBJECTIVE

This study aims to develop an educational mobile eHealth literacy (eHL) program for patients with diabetes and to evaluate its effect on patients' outcomes.

METHODS

This study designed a mobile eHL education program comprising 2 modules specifically tailored for individuals with type 2 diabetes (T2D). These modules focused on guiding participants through the process of effectively navigating reliable health websites and utilizing diabetes-related apps. Using a pre- and posttest experimental design, the study featured an intervention group and a control group. Participants were recruited from 3 outpatient departments in hospitals, and assessments were conducted both before and after the intervention, along with a follow-up measure at the 3-month mark. The evaluation encompassed sociodemographic characteristics, computer and internet proficiency, mobile app usage, mobile eHL, and patient outcomes such as self-care behaviors and glycated hemoglobin (HbA1c) levels.

RESULTS

The analysis included a total of 132 eligible participants. Significant differences were observed in the mean scores of knowledge (P<.001) and skills (P<.001) related to computers, the web, and mobile devices at the initiation of the study and after the intervention. During the 3-month follow-up, the findings indicated a significant improvement in mobile eHL (t114=3.391, P=.001) and mHealth literacy (mHL, a subconcept of mobile eHL; t114=3.801, P<.001) within the intervention group, whereas no such improvement was observed in the control group. The chi-square values from the McNemar test underscored that individuals with uncontrolled diabetes (HbA1c≥7%) in the intervention group exhibited more improvement compared with the control group. The generalized estimating equations model unveiled a significant difference in the change of general mHL in the intervention group (β=1.91, P=.047) and self-care behavior in the control group from T0 to T2 (β=-8.21, P=.015). Despite being small, the effect sizes for mobile eHL (d=0.49) and HbA1c (d=0.33) in the intervention group were greater than those in the control group (d=0.14 and d=0.16, respectively).

CONCLUSIONS

The implementation of a mobile eHL education intervention demonstrates a positive influence on the familiarity of patients with T2D regarding health technology, leading to favorable glycemic outcomes. While additional studies are warranted for a more comprehensive understanding, this program emerges as a promising solution for enhancing patients' uptake of digital health technology.

Health Disparities, Clinical Trials, and the Digital Divide

In the past few years, there have been rapid advances in technology and the use of digital tools in health care and clinical research. Although these innovations have immense potential to improve health care delivery and outcomes, there are genuine concerns related to inadvertent widening of the digital gap consequentially exacerbating health disparities. As such, it is important that we critically evaluate the impact of expansive digital transformation in medicine and clinical research on health equity. For digital solutions to truly improve the landscape of health care and clinical trial participation for all persons in an equitable way, targeted interventions to address historic injustices, structural racism, and social and digital determinants of health are essential. The urgent need to focus on interventions to promote health equity was made abundantly clear with the coronavirus disease 2019 pandemic, which magnified long-standing social and racial health disparities. Novel digital technologies present a unique opportunity to embed equity ideals into the ecosystem of health care and clinical research. In this review, we examine racial and ethnic diversity in clinical trials, historic instances of unethical research practices in biomedical research and its impact on clinical trial participation, and the digital divide in health care and clinical research, and we propose suggestions to achieve digital health equity in clinical trials. We also highlight key digital health opportunities in cardiovascular medicine and dermatology as exemplars, and we offer future directions for development and adoption of patient-centric interventions aimed at narrowing the digital divide and mitigating health inequities.

Artificial intelligence in diabetes management: Advancements, opportunities, and challenges

The increasing prevalence of diabetes, high avoidable morbidity and mortality due to diabetes and diabetic complications, and related substantial economic burden make diabetes a significant health challenge worldwide. A shortage of diabetes specialists, uneven distribution of medical resources, low adherence to medications, and improper self-management contribute to poor glycemic control in patients with diabetes. Recent advancements in digital health technologies, especially artificial intelligence (AI), provide a significant opportunity to achieve better efficiency in diabetes care, which may diminish the increase in diabetes-related health-care expenditures. Here, we review the recent progress in the application of AI in the management of diabetes and then discuss the opportunities and challenges of AI application in clinical practice. Furthermore, we explore the possibility of combining and expanding upon existing digital health technologies to develop an AI-assisted digital health-care ecosystem that includes the prevention and management of diabetes.

Cultural Responsivity in Technology-Enabled Services: Integrating Culture Into Technology and Service Components

Technology-enabled services (TESs) are clinical interventions that combine technological and human components to provide health services. TESs for mental health are efficacious in the treatment of anxiety and depression and are currently being offered as frontline treatments around the world. It is hoped that these interventions will be able to reach diverse populations across a range of identities and ultimately decrease disparities in mental health treatment. However, this hope is largely unrealized. TESs include both technology and human service components, and we argue that cultural responsivity must be considered in each of these components to help address existing treatment disparities. To date, there is limited guidance on how to consider cultural responsivity within these interventions, including specific targets for the development, tailoring, or design of the technologies and services within TESs. In response, we propose a framework that provides specific recommendations for targets based on existing models, both at the technological component level (informed by the Behavioral Intervention Technology Model) and the human support level (informed by the Efficiency Model of Support). We hope that integrating culturally responsive considerations into these existing models will facilitate increased attention to cultural responsivity within TESs to ensure they are ethical and responsive for everyone.

Design and development of a mobile-based self-care application for patients with depression and anxiety disorders

BACKGROUND AND AIM

Depression and anxiety can cause social, behavioral, occupational, and functional impairments if not controlled and managed. Mobile-based self-care applications can play an essential and effective role in controlling and reducing the effects of anxiety disorders and depression. The aim of this study was to design and develop a mobile-based self-care application for patients with depression and anxiety disorders with the goal of enhancing their mental health and overall well-being.

MATERIALS AND METHODS

In this study we designed a mobile-based application for self -management of depression and anxiety disorders. In order to design this application, first the education- informational needs and capabilities were identified through a systematic review. Then, according to 20 patients with depression and anxiety, this education-informational needs and application capabilities were approved. In the next step, the application was designed.

RESULTS

In the first step, 80 education-information needs and capabilities were identified. Finally, in the second step, of 80 education- informational needs and capabilities, 68 needs and capabilities with a mean greater than and equal to 3.75 (75%) were considered in application design. Disease control and management, drug management, nutrition and diet management, recording clinical records, communicating with physicians and other patients, reminding appointments, how to improve lifestyle, quitting smoking and reducing alcohol consumption, educational content, sedation instructions, introducing health care centers for depression and anxiety treatment and recording activities, personal goals and habits in a diary were the most important features of this application.

CONCLUSION

The designed application can encourage patients with depression and stress to perform self-care processes and access necessary information without searching the Internet.

Prostate cancer patients' experiences and preferences for web-based physical activity applications: A qualitative meta-synthesis

BACKGROUND

The incidence of prostate cancer increases with age. Physical activity can improve the prognosis and quality of life of patients. However, studies have observed lower levels of physical activity in men with prostate cancer, and most do not meet physical activity guidelines. Web-based physical activity is a promising form of exercise that will play an important role in prostate cancer patients.

AIMS

To synthesise the experiences and preferences of prostate cancer patients for web-based PA applications, thereby providing a basis for the construction of intervention programs tailored to the needs of patients.

METHODS

We systematically searched PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and three Chinese databases. This review includes qualitative empirical reports from the date of establishment of the respective databases until April 2023. Data extraction was performed by two independent reviewers and study quality was assessed.

RESULTS

A total of nine studies were included. The experiences and preferences of prostate cancer patients with web-based physical activity apps were synthesised into the following three analysis themes: (1) Pursuing individualised management strategies; (2) Perceiving and seeking social support and (3) Moving forwards in the struggle.

CONCLUSION

Our study found that men with prostate cancer experienced greater challenges in engaging in physical activity. Because of individual differences between patients, health care providers need to provide care that is tailored to each patient. Future studies should further explore the specific effects of web-based PA applications in promoting the physical function of prostate cancer patients to increase their flexibility.

RELEVANCE TO CLINICAL PRACTICE

This article synthesises prostate cancer patients' experiences with web-based physical activity applications, highlighting their specific information needs. The results suggest several implications for the application of individualised management strategies, the perception and search for social support, and health- literacy. The results of this study will inform future research and program design that recognises the importance of patient-centred efforts to better self-manage physical function.

PATIENT OR PUBLIC CONTRIBUTION

In the early stages of the study, objectives and subsequent findings were presented and discussed in a meeting with a reference group that represented patients, health professionals and the public.

Usability and acceptability of virtual reality for chronic pain management among diverse patients in a safety-net setting: a qualitative analysis

Objective

The aim of this study was to understand the usability and acceptability of virtual reality (VR) among a racially and ethnically diverse group of patients who experience chronic pain.

Materials and Methods

Using the Technology Acceptance Model theory, we conducted semistructured interviews and direct observation of VR use with English-speaking patients who experience chronic pain treated in a public healthcare system (n = 15), using a commercially available VR technology platform. Interviews included questions about current pain management strategies, technology use, experiences and opinions with VR, and motivators for future use.

Results

Before the study, none of the 15 participants had heard about or used VR for pain management. Common motivators for VR use included a previous history of substance use and having exhausted many other options to manage their pain and curiosity. Most participants had a positive experience with VR and 47% found that the VR modules distracted them from their pain. When attempting the navigation-based usability tasks, most participants (73%-92%) were able to complete them independently.

Discussion

VR is a usable tool for diverse patients with chronic pain. Our findings suggest that the usability of VR is not a barrier and perhaps a focus on improving the accessibility of VR in safety-net settings is needed to reduce disparities in health technology use.

Conclusions

The usability and acceptability of VR are rarely studied in diverse patient populations. We found that participants had a positive experience using VR, showed interest in future use, and would recommend VR to family and friends.

Outcomes of End-User Testing of a Care Coordination Mobile App With Families of Children With Special Health Care Needs: Simulation Study

BACKGROUND

Care for children with special health care needs relies on a network of providers who work to address the medical, behavioral, developmental, educational, social, and economic needs of the child and their family. Family-directed, manually created visual depictions of care team composition (ie, care mapping) and detailed note-taking curated by caregivers (eg, care binders) have been shown to enhance care coordination for families of these children, but they are difficult to implement in clinical settings owing to a lack of integration with electronic health records and limited visibility of family-generated insights for care providers. Caremap is an electronic health record-integrated digital personal health record mobile app designed to integrate the benefits of care mapping and care binders. Currently, there is sparse literature describing end-user participation in the co-design of digital health tools. In this paper, we describe a project that evaluated the usability and proof of concept of the Caremap app through end-user simulation.

OBJECTIVE

This study aimed to conduct proof-of-concept testing of the Caremap app to coordinate care for children with special health care needs and explore early end-user engagement in simulation testing. The specific aims included engaging end users in app co-design via app simulation, evaluating the usability of the app using validated measures, and exploring user perspectives on how to make further improvements to the app.

METHODS

Caregivers of children with special health care needs were recruited to participate in a simulation exercise using Caremap to coordinate care for a simulated case of a child with complex medical and behavioral needs. Participants completed a postsimulation questionnaire adapted from 2 validated surveys: the Pediatric Integrated Care Survey (PICS) and the user version of the Mobile Application Rating Scale (uMARS). A key informant interview was also conducted with a liaison to Spanish-speaking families regarding app accessibility for non-English-speaking users.

RESULTS

A Caremap simulation was successfully developed in partnership with families of children with special health care needs. Overall, 38 families recruited from 19 different US states participated in the simulation exercise and completed the survey. The average rating for the survey adapted from the PICS was 4.1 (SD 0.82) out of 5, and the average rating for the adapted uMARS survey was 4 (SD 0.83) out of 5. The highest-rated app feature was the ability to track progress toward short-term, patient- and family-defined care goals.

CONCLUSIONS

Internet-based simulation successfully facilitated end-user engagement and feedback for a digital health care coordination app for families of children with special health care needs. The families who completed simulation with Caremap rated it highly across several domains related to care coordination. The simulation study results elucidated key areas for improvement that translated into actionable next steps in app development.

Web- and app-based tools for remote hearing assessment: a scoping review

OBJECTIVE

Remote hearing screening and assessment may improve access to, and uptake of, hearing care. This review, the most comprehensive to date, aimed to (i) identify and assess functionality of remote hearing assessment tools on smartphones and online platforms, (ii) determine if assessed tools were also evaluated in peer-reviewed publications and (iii) report accuracy of existing validation data.

DESIGN

Protocol was registered in INPLASY and reported according to PRISMA-Extension for Scoping Reviews.

STUDY SAMPLE

In total, 187 remote hearing assessment tools (using tones, speech, self-report or a combination) and 101 validation studies met the inclusion criteria. Quality, functionality, bias and applicability of each app were assessed by at least two authors.

RESULTS

Assessed tools showed considerable variability in functionality. Twenty-two (12%) tools were peer-reviewed and 14 had acceptable functionality. The validation results and their quality varied greatly, largely depending on the category of the tool.

CONCLUSION

The accuracy and reliability of most tools are unknown. Tone-producing tools provide approximate hearing thresholds but have calibration and background noise issues. Speech and self-report tools are less affected by these issues but mostly do not provide an estimated pure tone audiogram. Predicting audiograms using filtered language-independent materials could be a universal solution.

Achieving Digital Health Equity by Personalizing the Patient Experience

Background

COVID saw a significant increase in the use of virtual care, supporting its utility and its benefits. It also revealed that unfortunately there are limitations and gaps we still need to address, including inequitable access to digitally enabled health care tools.

Methods

On November 8, 2022, the Mass General Brigham held the Third Annual Virtual Care Symposium: Demystifying Clinical Appropriateness in Virtual Care and What's Ahead for Pay Parity. One panel addressed digital health equity and key points are summarized here.

Results

Four experts discussed the key domains of digital equity and inclusion in the session titled "Achieving Digital Health Equity: Is it a One-Size-Fits-All Approach or Personalized Patient Experience?" These included lessons from strategies and tactics being used by hospitals and health systems to address digital equity issues; and opportunities to achieve digital health equity for specific populations (e.g., Medicaid).

Conclusions

Understanding the drivers of digital health disparities can help organizations and health care systems develop and test strategies to reduce them and improve access to quality health care through digitally enabled technologies and delivery channels.

Personal Health Libraries for People Returning From Incarceration: Protocol for a Qualitative Study

BACKGROUND

Individuals released from carceral facilities have high rates of hospitalization and death, especially in the weeks immediately after their return to community settings. During this transitional process, individuals leaving incarceration are expected to engage with multiple providers working in separate, complex systems, including health care clinics, social service agencies, community-based organizations, and probation and parole services. This navigation is often complicated by individuals' physical and mental health, literacy and fluency, and socioeconomic status. Personal health information technology, which can help people access and organize their health information, could improve the transition from carceral systems to the community and mitigate health risks upon release. Yet, personal health information technologies have not been designed to meet the needs and preferences of this population nor tested for acceptability or use.

OBJECTIVE

The objective of our study is to develop a mobile app to create personal health libraries for individuals returning from incarceration to help bridge the transition from carceral settings to community living.

METHODS

Participants were recruited through Transitions Clinic Network clinic encounters and professional networking with justice-involved organizations. We used qualitative research methods to assess the facilitators and barriers to developing and using personal health information technology for individuals returning from incarceration. We conducted individual interviews with people just released from carceral facilities (n=~20) and providers (n=~10) from the local community and carceral facilities involved with the transition for returning community members. We used rigorous rapid qualitative analysis to generate thematic output characterizing the unique circumstances impacting the development and use of personal health information technology for individuals returning from incarceration and to identify content and features for the mobile app based on the preferences and needs of our participants.

RESULTS

As of February 2023, we have completed 27 qualitative interviews with individuals recently released from carceral systems (n=20) and stakeholders (n=7) who support justice-involved individuals from various organizations in the community.

CONCLUSIONS

We anticipate that the study will characterize the experiences of people transitioning from prison and jails to community settings; describe the information, technology resources, and needs upon reentry to the community; and create potential pathways for fostering engagement with personal health information technology.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44748.

Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field

Current digital health approaches have not engaged diverse end users or reduced health or health care inequities, despite their promise to deliver more tailored and personalized support to individuals at the right time and the right place. To achieve digital health equity, we must refocus our attention on the current state of digital health uptake and use across the policy, system, community, individual, and intervention levels. We focus here on (a) outlining a multilevel framework underlying digital health equity; (b) summarizingfive types of interventions/programs (with example studies) that hold promise for advancing digital health equity; and (c) recommending future steps for improving policy, practice, and research in this space.

Impact of omicron wave and associated control measures in Shanghai on health management and psychosocial well-being of patients with chronic conditions

The objective of this cross-sectional study was to investigate health management, well-being, and pandemic-related perspectives of chronic disease patients in the context of stringent measures, and associated correlates. A self-report survey was administered during the Omicron wave lockdown in Shanghai, China. Items from the Somatic Symptom Scale (SSS) and Symptom Checklist-90 were administered, as well as pandemic-related items. Overall, 1,775 patients (mostly married females with hypertension) were recruited through a community family physician group. Mean SSS scores were 36.1 ± 10.5/80, with 41.5% scoring in the elevated range (i.e., >36). In an adjusted model, being female, diagnosis of coronary artery disease and arrhythmia, perceived impact of pandemic on life, health condition, change to exercise routine, tolerance of control measures, as well as perception of future and control measures were significantly associated with greater distress. One-quarter perceived the pandemic had a permanent impact on their life, and 44.1% perceived at least a minor impact. One-third discontinued exercise due to the pandemic. While 47.6% stocked up on their medications before the lockdown, their supply was only enough for two weeks; 17.5% of participants discontinued use. Chief among their fears were inability to access healthcare (83.2%), and what they stated they most needed to manage their condition was medication access (65.6%). Since 2020 when we assessed a similar cohort, distress and perceived impact of the pandemic have worsened. Greater access to cardiac rehabilitation in China could address these issues.

The Use of Robotic Technology in the Healthcare of People above the Age of 65-A Systematic Review

AIM

The integration of robots can help provide solutions in regards to the need for an increase in resources in healthcare. The aim of this review was to identify how robots are utilized in the healthcare of people who are over the age of 65 and how this population experiences interacting with healthcare robots.

DESIGN

A systematic literature review with an integrated design was conducted.

METHODS

A literature search was performed in the electronic databases CINAHL via EBSCO, EMBASE, and Medline via Ovid. Content analysis was performed to assess the studies that were included in this review.

RESULTS

A total of 14 articles were included. Participants in the studies included 453 older people ranging from 65 to 108 years of age. Nine of the studies focused on people with dementia or cognitive impairment. Seven studies included different types of socially assistive human-like robots, six of the studies included two different types of animal-like robots, and one study focused on a robotic rollator. The robots mainly served as social assistive- or engagement robots.

Design Features Associated With Engagement in Mobile Health Physical Activity Interventions Among Youth: Systematic Review of Qualitative and Quantitative Studies

BACKGROUND

Globally, 81% of youth do not meet the physical activity (PA) guidelines. Youth of families with a low socioeconomic position are less likely to meet the recommended PA guidelines. Mobile health (mHealth) interventions are preferred by youth over traditional in-person approaches and are in line with their media preferences. Despite the promise of mHealth interventions in promoting PA, a common challenge is to engage users in the long term or effectively. Earlier reviews highlighted the association of different design features (eg, notifications and rewards) with engagement among adults. However, little is known about which design features are important for increasing engagement among youth.

OBJECTIVE

To inform the design process of future mHealth tools, it is important to investigate the design features that can yield effective user engagement. This systematic review aimed to identify which design features are associated with engagement in mHealth PA interventions among youth who were aged between 4 and 18 years.

METHODS

A systematic search was conducted in EBSCOhost (MEDLINE, APA PsycINFO, and Psychology & Behavioral Sciences Collection) and Scopus. Qualitative and quantitative studies were included if they documented design features associated with engagement. Design features and related behavior change techniques and engagement measures were extracted. Study quality was assessed according to the Mixed Method Assessment Tool, and one-third of all screening and data extraction were double coded by a second reviewer.

RESULTS

Studies (n=21) showed that various features were associated with engagement, such as a clear interface, rewards, multiplayer game mode, social interaction, variety of challenges with personalized difficulty level, self-monitoring, and variety of customization options among others, including self-set goals, personalized feedback, progress, and a narrative. In contrast, various features need to be carefully considered while designing mHealth PA interventions, such as sounds, competition, instructions, notifications, virtual maps, or self-monitoring, facilitated by manual input. In addition, technical functionality can be considered as a prerequisite for engagement. Research addressing youth from low socioeconomic position families is very limited with regard to engagement in mHealth apps.

CONCLUSIONS

Mismatches between different design features in terms of target group, study design, and content translation from behavior change techniques to design features are highlighted and set up in a design guideline and future research agenda.

TRIAL REGISTRATION

PROSPERO CRD42021254989; https://tinyurl.com/5n6ppz24.

Randomized trial protocol for remote monitoring for equity in advancing the control of hypertension in safety net systems (REACH-SNS) study

BACKGROUND

Self-measured blood pressure monitoring (SMBP) is essential to effective management of hypertension. This study aims to evaluate effectiveness and implementation of SMBP that leverages: cellular-enabled home BP monitors without a need for Wi-Fi or Bluetooth; simple communication modalities such as text messaging to support patient engagement; and integration into existing team-based workflows in safety-net clinics.

METHODS

This study will be conducted with patients in San Francisco who are treated within a network of safety-net clinics. English and Spanish-speaking patients with diagnosed hypertension will be eligible for the trial if they have recent BP readings ≥140/90 mmHg and do not have co-morbid conditions that make home BP monitoring more complex to manage. This study will implement a three-arm randomized controlled trial to compare varying levels of implementation support: 1) cellular-enabled BP monitors (with minimal implementation support), 2) cellular-enabled BP monitors with protocol-based implementation support (text reminders for patients; aggregated BP summaries sent to primary care providers), and 3) cellular-enabled BP monitors and pharmacist-led support (pharmacist coaching and independent medication adjustments).

RESULTS

For the main analysis, we will use mixed effects linear regression to compare the change in primary outcome of systolic BP. Secondary outcomes include BP control (<140/90 mmHg), medication intensification, patient-reported outcomes, and implementation processes (i.e., engagement with the intervention).

DISCUSSION

This study will design and test a digital health intervention for use in marginalized populations treated within safety net settings, evaluating both effectiveness and implementation to advance more equitable health outcomes.

Ethical considerations for developing pediatric mhealth interventions for teens with socially complex needs

TOPIC

Mobile Health (mHealth) stands as a potential means to better reach, assess, and intervene with teens with socially complex needs. These youth often face overlapping adversities including medical illness and a history of experiencing adverse childhood experiences (ACEs). Clinicians are faced with navigating ethical decisions when developing mHealth tools for teens who have socially complex needs. Many tools have been developed for adults from the general population. However, despite the development of thousands of mHealth interventions, developers tend to focus on designing for usability, engagement, and efficacy, with less attention on the ethical considerations of making such tools.

PURPOSE

To safely move mHealth interventions from research into clinical practice, ethical standards must be met during the design phase. In this paper we adapt the Four Box Model (i.e., medical indications, preferences of patients, quality of life, and contextual features) to guide mHealth developers through ethical considerations when designing mHealth interventions for teens who present with a medical diagnosis and a history of ACEs.

SOURCES

A review of language, inclusive features, data sharing, and usability is presented using both the Four Box Model and potential scenarios to guide each consideration.

CONCLUSIONS

To better support designers of mHealth tools we present a framework for evaluating applications to determine overlap with ethical design and are well suited for use in clinical practice with underserved pediatric patients.

Examining Equity in Access and Utilization of a Freely Available Meditation App

Digital interventions have the potential to alleviate mental health disparities for marginalized and minoritized communities. The current study examined whether disparities in access and utilization of meditation in the United States (US) were reduced for a freely available meditation app. We analyzed demographic and usage data from US-based users of the Healthy Minds Program (HMP; N = 66,482) between October 2019 and July 2022. College education was associated with a greater likelihood of accessing (65.0% of users vs. 32.9% of the US population) and continuing to utilize the app (β = .11-.17). Conversely, identifying as African American was associated lower likelihood of accessing (5.3% vs. 13.4% of US population) and continuing to utilize the app (β = -.02-.03). African Americans were more likely to access content from an African American meditation teacher, but this did not appear to increase utilization. Additional efforts are warranted to identify factors which might reduce disparities.

Application of artificial intelligence in medical technologies: A systematic review of main trends

Objective

Artificial intelligence (AI) has been increasingly applied in various fields of science and technology. In line with the current research, medicine involves an increasing number of artificial intelligence technologies. The introduction of rapid AI can lead to positive and negative effects. This is a multilateral analytical literature review aimed at identifying the main branches and trends in the use of using artificial intelligence in medical technologies.

Methods

The total number of literature sources reviewed is n = 89, and they are analyzed based on the literature reporting evidence-based guideline PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for a systematic review.

Results

As a result, from the initially selected 198 references, 155 references were obtained from the databases and the remaining 43 sources were found on open internet as direct links to publications. Finally, 89 literature sources were evaluated after exclusion of unsuitable references based on the duplicated and generalized information without focusing on the users.

Conclusions

This article is identifying the current state of artificial intelligence in medicine and prospects for future use. The findings of this review will be useful for healthcare and AI professionals for improving the circulation and use of medical AI from design to implementation stage.

Recommendations for design of a mobile application to support management of anxiety and depression among Black American women

Black American women experience adverse health outcomes due to anxiety and depression. They face systemic barriers to accessing culturally appropriate mental health care leading to the underutilization of mental health services and resources. Mobile technology can be leveraged to increase access to culturally relevant resources, however, the specific needs and preferences that Black women feel are useful in an app to support management of anxiety and depression are rarely reflected in existing digital health tools. This study aims to assess what types of content, features, and important considerations should be included in the design of a mobile app tailored to support management of anxiety and depression among Black women. Focus groups were conducted with 20 women (mean age 36.6 years, SD 17.8 years), with 5 participants per group. Focus groups were led by a moderator, with notetaker present, using an interview guide to discuss topics, such as participants' attitudes and perceptions towards mental health and use of mental health services, and content, features, and concerns for design of a mobile app to support management of anxiety and depression. Descriptive qualitative content analysis was conducted. Recommendations for content were either informational (e.g., information to find a Black woman therapist) or inspirational (e.g., encouraging stories about overcoming adversity). Suggested features allow users to monitor their progress, practice healthy coping techniques, and connect with others. The importance of feeling "a sense of community" was emphasized. Transparency about who created and owns the app, and how users' data will be used and protected was recommended to establish trust. The findings from this study were consistent with previous literature which highlighted the need for educational, psychotherapy, and personal development components for mental health apps. There has been exponential growth in the digital mental health space due to the COVID-19 pandemic; however, a one-size-fits-all approach may lead to more options but continued disparity in receiving mental health care. Designing a mental health app for and with Black women may help to advance digital health equity by providing a tool that addresses their specific needs and preferences, and increase engagement.

Perspectives of Kidney Transplant Recipients on eHealth: Semistructured Interviews

The acceptability and impact of eHealth on patient outcomes may be limited if their concerns and priorities are not addressed. This study aimed to describe the perspectives and experiences of eHealth among kidney transplant recipients.

METHODS

Face-to-face semistructured interviews were conducted with 30 adult kidney transplant recipients from New South Wales, Australia (urban and regional), in ambulatory clinics. We used purposive sampling to obtain a wide range of demographic and clinical characteristics. Transcripts were analyzed thematically. Ethics was approved by the Western Sydney Local Health District (6054-2019/ETH08718).

FINDINGS

Six themes were identified: seeking access to quality care (prioritizing and trusting clinician advice, better safety and timeliness, enabled by user-friendly content); supporting self-management (responsive to individualized informational need, empowerment through practical knowledge, encouraging connectedness); assessing reliability and trustworthiness (discerning information integrity, applying to own context, apprehensive about privacy and confidentiality); enhancing health system capabilities (synergy with routine consultations, essential to coordination, achieving goals by real-time monitoring); technology burden and limitation (uncertainty with navigation and comprehension, challenged by technical difficulties, requiring additional preparation, confrontation and distress); and lacking applicable value (diminished assurance of medical services, existing practice and procedures, hampered by low expectations and disinterest).

CONCLUSION

Recipients felt eHealth could support healthcare delivery and self-management activities. However, they encountered challenges in navigating technology and were concerned about privacy, confidentiality, and misinformation. eHealth that is accessible, individualized, and secure may improve patient satisfaction and outcomes.

Perceptions on wearable sensor-based interventions for monitoring of opioid therapy: A qualitative study

Prescription opioid use is a risk factor for the development of opioid use disorder. Digital solutions, including wearable sensors, represent a promising opportunity for health monitoring, risk stratification and harm reduction in this treatment space. However, data on their usability and acceptability in individuals using opioids is limited. To address this gap, factors that impact usability and acceptability of wearable sensor-based opioid detection were qualitatively studied in participants enrolled in a wearable sensor-based opioid monitoring research study. At the conclusion of the monitoring period, participants were invited to take part in semi-structured interviews developed based on the technology acceptance model. Thematic analysis was conducted first using deductive, then inductive coding strategies. Forty-four participants completed the interview; approximately half were female. Major emergent themes include sensor usability, change in behavior and thought process related to sensor use, perceived usefulness in sensor-based monitoring, and willingness to have opioid use patterns monitored. Overall acceptance for sensor-based monitoring was high. Aesthetics, simplicity, and seamless functioning were all reported as key to usability. Perceived behavior changes related to monitoring were infrequent while perceived usefulness in monitoring was frequently projected onto others, requiring careful consideration regarding intervention development and targeting. Specifically, care must be taken to avoid stigma associated with opioid use and implied misuse. The design of sensor systems targeted for opioid use must also consider the physical, social, and cognitive alterations inherent in the respective disease processes compared to routine daily life.

Comparing Professional and Consumer Ratings of Mental Health Apps: Mixed Methods Study

Background

As the number of mental health apps has grown, increasing efforts have been focused on establishing quality tailored reviews. These reviews prioritize clinician and academic views rather than the views of those who use them, particularly those with lived experiences of mental health problems. Given that the COVID-19 pandemic has increased reliance on web-based and mobile mental health support, understanding the views of those with mental health conditions is of increasing importance.

Objective

This study aimed to understand the opinions of people with mental health problems on mental health apps and how they differ from established ratings by professionals.

Methods

A mixed methods study was conducted using a web-based survey administered between December 2020 and April 2021, assessing 11 mental health apps. We recruited individuals who had experienced mental health problems to download and use 3 apps for 3 days and complete a survey. The survey consisted of the One Mind PsyberGuide Consumer Review Questionnaire and 2 items from the Mobile App Rating Scale (star and recommendation ratings from 1 to 5). The consumer review questionnaire contained a series of open-ended questions, which were thematically analyzed and using a predefined protocol, converted into binary (positive or negative) ratings, and compared with app ratings by professionals and star ratings from app stores.

Results

We found low agreement between the participants’ and professionals’ ratings. More than half of the app ratings showed disagreement between participants and professionals (198/372, 53.2%). Compared with participants, professionals gave the apps higher star ratings (3.58 vs 4.56) and were more likely to recommend the apps to others (3.44 vs 4.39). Participants’ star ratings were weakly positively correlated with app store ratings (r=0.32, P=.01). Thematic analysis found 11 themes, including issues of user experience, ease of use and interactivity, privacy concerns, customization, and integration with daily life. Participants particularly valued certain aspects of mental health apps, which appear to be overlooked by professional reviewers. These included functions such as the ability to track and measure mental health and providing general mental health education. The cost of apps was among the most important factors for participants. Although this is already considered by professionals, this information is not always easily accessible.

Conclusions

As reviews on app stores and by professionals differ from those by people with lived experiences of mental health problems, these alone are not sufficient to provide people with mental health problems with the information they desire when choosing a mental health app. App rating measures must include the perspectives of mental health service users to ensure ratings represent their priorities. Additional work should be done to incorporate the features most important to mental health service users into mental health apps.

Preliminary User Evaluation of a Physical Activity Smartphone App for Older Adults

Objectives

Mobile health (mHealth) delivered through smartphone apps is a viable means of improving health behaviors. Technologies can be strengthened and made more age-inclusive by involving older adults as co-designers, resulting in more accessible and effective products. This study's purpose is to describe preliminary acceptability and feasibility of a physical activity (PA) app tailored to underactive older people.

Methods

Moving Up is a multi-feature app designed to increase PA and reduce sedentary behaviors in underactive older adults. The suite houses a core activity tracker and three add-on features that target correlates of inactivity: sedentary behavior, stereotypes about aging, and PA knowledge and routines. Three groups of 4-5 older adult smartphone owners were provided with and oriented to the Moving Up app activity tracker and one add-on feature. Participants beta-tested the app for two weeks, after which each cohort reconvened to discuss experiences, make recommendations for app improvements, and complete a usability questionnaire on their assigned feature.

Results

Thirteen participants (median age, 71 years; iOS users, n=8; females, n=12) completed the beta-testing period and returned for follow-up. Reported usability was moderate across the features. Sentiments about app content and general impressions were mainly positive, although users made several recommendations for app improvements such as more individualized messaging and timely notifications.

Conclusions

A PA app for older adults demonstrated generally good usability and acceptability. Integrating the impressions and recommendations from older adults into the design of mHealth tools will enhance overall usability and likelihood to positively influence PA behaviors long-term.

Perspectives on adapting a mobile application for pain self-management in neurofibromatosis type 1: results of online focus group discussions with individuals living with neurofibromatosis type 1 and pain management experts

OBJECTIVE

Neurofibromatosis type 1 (NF1) is a genetic disorder in which chronic pain commonly occurs. The study sought to understand the needs of individuals with NF1 and pain management experts when adapting a pain self-management mobile health application (app) for individuals with NF1.

DESIGN

We conducted a series of online, audio-recorded focus groups that were then thematically analysed.

SETTING

Online focus groups with adults currently residing in the USA.

PARTICIPANTS

Two types of participants were included: individuals with NF1 (n=32 across six focus groups) and pain management experts (n=10 across three focus groups).

RESULTS

Six themes across two levels were identified. The individual level included lifestyle, reasons for using the mobile app and concerns regarding its use. The app level included desired content, desired features and format considerations. Findings included recommendations to grant free access to the app and include a community support feature for individuals to relate and validate one another's experience with pain from NF1. In addition, participants noted the importance of providing clear instructions on navigating the app, the use of an upbeat, hopeful tone and appropriate visuals.

CONCLUSIONS

Both participant groups endorsed the use of iCanCope (iCC) as an NF1 pain self-management mobile app. Differences between groups were noted, however. The NF1 group appeared interested in detailed and nuanced pain tracking capabilities; the expert group prioritised tracking information such as mood, nutrition and activity to identify potential associations with pain. In tailoring the existing iCC app for individuals with NF1, attention should be paid to creating a community support group feature and to tailoring content, features and format to potential users' specific needs.

High engagement in mobile peer support is associated with better glycemic control in type 1 diabetes: a real-world study

AIMS

Peer support for diabetes has become convenient and interactive following the emergence of mobile health (mHealth). We aimed to evaluate the association between engagement in peer support via mHealth app and glycemic control in type 1 diabetes (T1D).

METHODS

This retrospective study included adults with T1D who had joined the mobile community "TangTangQuan (TTQ)" since May 2018 for at least one year. "Like", "comment" and "share" were the major interaction indicators of mobile community and were used to assess engagement in peer support. The patients were divided into four engagement groups by quartile. The primary outcome was the change in HbA_1c , mean fasting blood glucose (FBG) and postprandial blood glucose (PBG) from baseline to the 12th month. Other outcomes included the change of self-monitoring of blood glucose frequency, hypoglycemia frequency, and the proportion of reaching optimal glycemic control.

RESULTS

Among the 693 individuals, the HbA_1c , mean FBG and PBG improved in the 12th month. Multiple regression analysis showed that higher engagement in peer support was associated with a greater reduction of HbA_1c (β=-0.45, P<0.001) and mean FBG (β=-0.82, P<0.001). In the subgroup of poor glycemic control, the association between engagement in peer support and glycemic improvement still remained (HbA_1c : β=-0.86, P=0.002; FBG: β=-1.36, P=0.001). The engagement in mobile peer support was positively correlated with educational level (OR=1.42, P=0.042), household income (OR=1.43, P=0.013), and the use of continuous subcutaneous insulin infusion (OR=1.73, P=0.009).

CONCLUSION

High engagement in mobile peer support was associated with better glycemic control in adults with T1D.

Telemedicine and Telehealth in Urology-What Do the 'Patients' Think About It?

Telemedicine is the delivery of healthcare to patients who are not in the same location as the physician. The practice of telemedicine has a large number of advantages, including cost savings, low chances of nosocomial infection, and fewer hospital visits. Teleclinics have been reported to be successful in the post-surgery and post-cancer therapy follow-up, and in offering consulting services for urolithiasis patients. This review focuses on identifying the outcomes of the recent studies related to the usage of video consulting in urology centers for hematuria referrals and follow-up appointments for a variety of illnesses, including benign prostatic hyperplasia (BPH), kidney stone disease (KSD), and urinary tract infections (UTIs) and found that they are highly acceptable and satisfied. Certain medical disorders can cause embarrassment, social exclusion, and also poor self-esteem, all of which can negatively impair health-related quality-of-life. Telemedicine has proven beneficial in such patients and is a reliable, cost-effective patient-care tool, and it has been successfully implemented in various healthcare settings and specialties.

Beyond instrumental support: Mobile application use by family caregivers of persons living with dementia

In recent years, there has been a rapid increase in technology use in dementia caregiving, particularly the use of mobile applications (apps) which are highly accessible, cost-effective and intuitive. Yet, little is known about the experiences of family caregivers of persons living with dementia who use apps to support caregiving activities. This is of particular concern given that limited understandings of the user experience in designing technology have often led to end-users experiencing barriers in technology adoption and use. Using a qualitative descriptive approach, the purpose of the study was to explore the experiences of family caregivers of persons living with dementia on using apps in their caregiving roles. A purposive sample of five family caregivers in Ontario, Canada participated in two interviews each, with the second interview informed by photo-elicitation methods. Thematic analysis of the collected data revealed a central overarching theme, Connecting to support through apps in my, your and our lives, which explicated how apps played an important role in the lives of the caregiver, the care recipient and both together as a dyad. Three core themes also emerged: Adapting apps to meet individual needs of the dyad, Minimising the impact of the condition on the person and the family and Determining the effectiveness of apps. The findings highlighted that the value of apps extends beyond their mere functionality and their ability to help with care provision as they are also able to promote richer interpersonal connections, enhance personhood and sustain family routines. This research advances our understanding of the impact of app use in caregiving and provides direction for future research, policy, education, practice and app development.

Informing the Future of Integrated Digital and Clinical Mental Health Care: Synthesis of the Outcomes From Project Synergy

BACKGROUND

Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users' needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care.

OBJECTIVE

Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms.

METHODS

Participating health care organizations included the following: Open Arms-Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation's National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention.

RESULTS

Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted.

CONCLUSIONS

Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care.

Implementing patient-reported outcomes in routine clinical care for diverse and underrepresented patients in the United States

BACKGROUND

Patient-reported outcomes (PROs) are used increasingly in routine clinical care and inform policies, reimbursements, and quality improvement. Less is known regarding PRO implementation in routine clinical care for diverse and underrepresented patient populations.

OBJECTIVE

This review aims to identify studies of PRO implementation in diverse and underrepresented patient populations, elucidate representation of clinical specialties, assess implementation outcomes, and synthesize patient needs, concerns, and preferences.

METHODS

MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO were searched September 2021 for studies aiming to study PRO implementation in diverse and underrepresented patient populations within the United States. Studies were screened and data extracted by three independent reviewers. Implementation outcomes were assessed according to Proctor et al. taxonomy. A descriptive analysis of data was conducted.

RESULTS

The search yielded 8,687 records, and 28 studies met inclusion criteria. The majority were observational cohort studies (n = 21, 75%) and conducted in primary care (n = 10, 36%). Most studies included majority female (n = 19, 68%) and non-White populations (n = 15, 54%), while fewer reported socioeconomic (n = 11, 39%) or insurance status (n = 9, 32.1%). Most studies assessed implementation outcomes of feasibility (n = 27, 96%) and acceptability (n = 19, 68%); costs (n = 3, 11%), penetration (n = 1, 4%), and sustainability (n = 1, 4%) were infrequently assessed.

CONCLUSION

PRO implementation in routine clinical care for diverse and underrepresented patient populations is generally feasible and acceptable. Research is lacking in key clinical specialties. Further work is needed to understand how health disparities drive PRO implementation outcomes.

Applying the Digital Health Social Justice Guide

Introduction

Digital health, the use of apps, text-messaging, and online interventions, can revolutionize healthcare and make care more equitable. Currently, digital health interventions are often not designed for those who could benefit most and may have unintended consequences. In this paper, we explain how privacy vulnerabilities and power imbalances, including racism and sexism, continue to influence health app design and research. We provide guidelines for researchers to design, report and evaluate digital health studies to maximize social justice in health.

Methods

From September 2020 to April 2021, we held five discussion and brainstorming sessions with researchers, students, and community partners to develop the guide and the key questions. We additionally conducted an informal literature review, invited experts to review our guide, and identified examples from our own digital health study and other studies.

Results

We identified five overarching topics with key questions and subquestions to guide researchers in designing or evaluating a digital health research study. The overarching topics are: 1. Equitable distribution; 2. Equitable design; 3. Privacy and data return; 4. Stereotype and bias; 5. Structural racism.

Conclusion

We provide a guide with five key topics and questions for social justice digital health research. Encouraging researchers and practitioners to ask these questions will help to spark a transformation in digital health toward more equitable and ethical research. Future work needs to determine if the quality of studies can improve when researchers use this guide.

Enhancing Patient-Centered Surgical Care With Mobile Health Technology

From smartphones or wearables to portable physiologic sensors and apps, healthcare is witnessing an exponential growth in mHealth-digital health tools used to support medical and surgical care, as well as public health. In surgery, there is interest in harnessing the capabilities of mHealth to improve the quality of patient-centered care delivery. Digitally delivered surveys have enhanced patient-reported outcome measurement and patient engagement throughout care. Wearable devices and sensors have allowed for the assessment of physical fitness before surgery and during recovery. Smartphone-based digital phenotyping has introduced novel methods of integrating multiple data streams (accelerometer, global positioning system, call and text logs) to create multidimensional digital health footprints for patients following surgery. Yet, with all the technological sophistication and 'big data' mHealth provides, widespread implementation has been elusive. Do clinicians and patients find these data valuable or clinically actionable? How can mHealth become integrated into the day-to-day workflows of surgical systems? Do these data represent opportunities to address disparities of care or worsen them? In this review, we discuss experiences and future opportunities to use mHealth to enhance patient-centered surgical care.

Evaluation of mHealth Apps for Diverse, Low-Income Patient Populations: Framework Development and Application Study

Background

The use of mobile technology or smartphones has grown exponentially in the United States, allowing more individuals than ever internet access. This access has been especially critical to households earning less than US $30,000, the majority of whom indicate that smartphones are their main source of internet access. The increasing ubiquity of smartphones and virtual care promises to offset some of the health disparities that cut through the United States. However, disparities cannot be addressed if the medical information offered though smartphones is not accessible or reliable.

Objective

This study seeks to create a framework to review the strengths and weaknesses of mobile Health (mHealth) apps for diverse, low-income populations.

Methods

Focusing on smoking cessation, diabetes management, and medication adherence as models of disease management, we describe the process for selecting, evaluating, and obtaining patient feedback on mHealth apps.

Results

The top 2 scoring apps in each category were QuitNow! and Smoke Free-Quit Smoking Now for smoking cessation, Glucosio and MyNetDiary for diabetes management, and Medisafe and MyMeds for medication adherence.

Conclusions

We believe that this framework will prove useful for future mHealth app development, and clinicians and patient advisory groups in connecting culturally, educationally, and socioeconomically appropriate mHealth apps with low-income, diverse communities and thus work to bridge health disparities.

Telemedicine and Health Disparities

Content available: Author Audio Recording.

Exploring Usability Issues of a Smartphone-Based Physician-to-Physician Teleconsultation App in an Orthopedic Clinic: Mixed Methods Study

Background

Physician-to-physician teleconsultation has increasingly played an essential role in delivering optimum health care services, particularly in orthopedic practice. In this study, the usability of a smartphone app for teleconsultation among orthopedic specialists was investigated to explore issues informing further recommendations for improvement in the following iterations.

Objective

This study aimed to explore usability issues emerging from users’ interactions with MEDIC app, a smartphone-based patient-centered physician-to-physician teleconsultation system.

Methods

Five attending physicians in the Department of Orthopedics in a large medical school in Bangkok, Thailand, were recruited and asked to perform 5 evaluation tasks, namely, group formation, patient registration, clinical data capturing, case record form creation, and teleconsultation. In addition, one expert user was recruited as the control participant. Think aloud was adopted while performing the tasks. Semistructured interviews were conducted after each task and prior to the exit. Quantitative and qualitative measures were used to identify usability issues in 7 domains based on the People At the Centre of Mobile Application Development model: effectiveness, efficiency, satisfaction, learnability, memorability, error, and cognitive load.

Results

Several measures indicate various aspects of usability of the app, including completion rates, time to completion, number of clicks, number of screens, errors, incidents where participants were unable to perform tasks, which had previously been completed, and perceived task difficulty. Major and critical usability issues based on participant feedback were rooted from the limitation of screen size and resolution. Errors in data input (eg, typing errors, miscalculation), action failures, and misinterpretation of data (ie, radiography) were the most critical and common issues found in this study. A few participants did not complete the assigned tasks mostly owing to the navigation design and misreading/misunderstanding icons. However, the novice users were quite positive that they would be able to become familiar with the app in a short period of time.

Conclusions

The usability issues in physician-to-physician teleconsultation systems in smartphones, in general, are derived from the limitations of smartphones and their operating systems. Although some recommendations were devised to handle these usability issues, usability evaluation for additional development should still be further investigated.

Smartphone-Delivered Ecological Momentary Interventions Based on Ecological Momentary Assessments to Promote Health Behaviors: Systematic Review and Adapted Checklist for Reporting Ecological Momentary Assessment and Intervention Studies

Background

Healthy behaviors are crucial for maintaining a person’s health and well-being. The effects of health behavior interventions are mediated by individual and contextual factors that vary over time. Recently emerging smartphone-based ecological momentary interventions (EMIs) can use real-time user reports (ecological momentary assessments [EMAs]) to trigger appropriate support when needed in daily life.

Objective

This systematic review aims to assess the characteristics of smartphone-delivered EMIs using self-reported EMAs in relation to their effects on health behaviors, user engagement, and user perspectives.

Methods

We searched MEDLINE, Embase, PsycINFO, and CINAHL in June 2019 and updated the search in March 2020. We included experimental studies that incorporated EMIs based on EMAs delivered through smartphone apps to promote health behaviors in any health domain. Studies were independently screened. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. We performed a narrative synthesis of intervention effects, user perspectives and engagement, and intervention design and characteristics. Quality appraisal was conducted for all included studies.

Results

We included 19 papers describing 17 unique studies and comprising 652 participants. Most studies were quasi-experimental (13/17, 76%), had small sample sizes, and great heterogeneity in intervention designs and measurements. EMIs were most popular in the mental health domain (8/17, 47%), followed by substance abuse (3/17, 18%), diet, weight loss, physical activity (4/17, 24%), and smoking (2/17, 12%). Of the 17 studies, the 4 (24%) included randomized controlled trials reported nonstatistically significant effects on health behaviors, and 4 (24%) quasi-experimental studies reported statistically significant pre-post improvements in self-reported primary outcomes, namely depressive (P<.001) and psychotic symptoms (P=.03), drinking frequency (P<.001), and eating patterns (P=.01). EMA was commonly used to capture subjective experiences as well as behaviors, whereas sensors were rarely used. Generally, users perceived EMIs to be helpful. Common suggestions for improvement included enhancing personalization, multimedia and interactive capabilities (eg, voice recording), and lowering the EMA reporting burden. EMI and EMA components were rarely reported and were not described in a standardized manner across studies, hampering progress in this field. A reporting checklist was developed to facilitate the interpretation and comparison of findings and enhance the transparency and replicability of future studies using EMAs and EMIs.

Conclusions

The use of smartphone-delivered EMIs using self-reported EMAs to promote behavior change is an emerging area of research, with few studies evaluating efficacy. Such interventions could present an opportunity to enhance health but need further assessment in larger participant cohorts and well-designed evaluations following reporting checklists. Future research should explore combining self-reported EMAs of subjective experiences with objective data passively collected via sensors to promote personalization while minimizing user burden, as well as explore different EMA data collection methods (eg, chatbots).

Trial Registration

PROSPERO CRD42019138739; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=138739

Teledermatology: How It Is Impacting the Underserved

The rapid mobilization of telemedicine during the COVID-19 pandemic has brought about renewed concern about the digital divide. Understanding the benefits and limitations of remote medical care is an ongoing process. Access to telemedicine appointments, as well as the experience of the virtual appointment itself, varies across demographic groups. Telemedicine has promise in dermatology. However, if it continues to expand beyond the pandemic, federal changes may be necessary to improve access to remote care for all patients moving forward. This involves creating mandates for increased broadband access, deploying digital health tools and portals usable by underserved populations, and increasing access to interpreters. Information technology personnel may also become necessary members of the clinical care team. Parity between video and phone visit reimbursement for providers is also necessary.

Accessibility and Digital Mental Health: Considerations for More Accessible and Equitable Mental Health Apps

Digital mental health is often touted as a solution to issues of access to mental health care. However, there has been little research done to understand the accessibility of digital mental health, especially for those with disabilities. In this piece, we define accessibility as it relates to mental health apps, describe the current state of accessibility in the digital world broadly and in mental health apps more specifically, outline why accessibility matters in mental health apps, and identify future steps to better incorporate accessibility into research and development of mental health apps.

Non-use of telemedicine: A scoping review

Many telemedicine interventions fail to be implemented in medical care with non-use and discontinued use by patients being among the major reasons. The aim of this scoping review was to provide an overview of barriers associated with non-use and discontinued use of telemedicine. An electronic search was conducted in Pubmed in October 2019 and updated in November 2020, followed by a hand search in the beginning of 2021. All potential articles were screened by two independent reviewers based on predefined inclusion and exclusion criteria. A qualitative content analysis according to Mayring was carried out. The topics 'intervention', 'context of use' and 'user' were chosen as overarching themes. Out of 1377 potentially relevant articles, 73 were included. User-related barriers were mentioned in most of the analysed studies, followed by barriers related to the intervention. The analysis provides the basis for overcoming non-use issues in telemedicine.

Characteristics of Acute Childhood Illness Apps for Parents: Environmental Scan

Background

Providing parents with resources that aid in the identification and management of acute childhood illnesses helps those parents feel better equipped to assess their children’s health and significantly changes parental health-seeking behaviors. Some of these resources are limited by accessibility and scalability. Remote locations and staffing limitations create challenges for parents aiming to access their child’s health information. Mobile health apps offer a scalable, accessible solution for improving health literacy by enabling access to health information through mobile devices. 

Objective

The aim of our study is to create an inventory of acute childhood illness apps that are available to North American parents and caregivers, assess their quality, and identify the areas in which future apps can be improved.

Methods

We conducted an environmental scan to identify and summarize app information for parents and digital health researchers. The Google and Apple app marketplaces were used as search platforms. We built a list of search terms and searched the platforms for apps targeted at parents and related to acute pediatric illnesses in the United States and Canada. We assessed apps meeting the inclusion criteria using the Mobile App Rating Scale (MARS), a validated tool for assessing the quality of health apps. The MARS examines apps on 5 subscales: engagement, functionality, aesthetics, information quality, and subjective quality. Data were analyzed by MARS subscale averages and individual item scores.

Results

Overall, 650 unique apps were screened, and 53 (8.2%) were included. On a scale of 1-5, apps had an average engagement score of 2.82/5 (SD 0.86), functionality score of 3.98/5 (SD 0.72), aesthetics score of 3.09/5 (SD 0.87), information quality score of 2.73/5 (SD 1.32), and subjective quality score of 2.20/5 (SD 0.79). On the same scale of 1-5, app scores ranged from 2.2/5 to 4.5/5 (mean 3.2, SD 0.6). The top 3 MARS-scored apps were Baby and Child First Aid (4.5/5), Ada (4.5/5), and HANDi Paediatric (4.2/5). Taken together, the top 3 apps covered topics of emergency pediatric first aid, identification of (and appropriate response to) common childhood illnesses, a means of checking symptoms, and a means of responding to emergency situations. There was a lack of Canadian-based app content available to parents in both marketplaces; this space was filled with content originating primarily in the United Kingdom and the United States. In addition, published evidence of the impact of the included apps was poor: of 53 apps, only 5 (9%) had an evidence base showing that the app had been trialed for usability or efficacy.

Conclusions

There is a need for evidence-based acute childhood illness apps of Canadian origin. This environmental scan offers a comprehensive picture of the health app landscape by examining trends in acute childhood illness apps that are readily available to parents and by identifying gaps in app design.