Development and Usability Testing of an mHealth Tool for Trauma-Informed Prevention of Substance Use, HIV Acquisition, and Risky Sexual Behaviors Among Adolescents: Mixed Methods Study

BACKGROUND

Youth who experience traumatic events are at a substantially higher risk of engaging in substance use and sexual risk behaviors and problems (eg, HIV acquisition) than their non-trauma-exposed counterparts. Evidence-based substance use and risky sexual behavior prevention may reduce the risk of these outcomes. Trauma-focused mental health treatment provides a window of opportunity for the implementation of such preventive work with these youth. However, overburdened clinicians face challenges in adding prevention content while implementing evidence-based treatments. Mobile health (mHealth) tools can help reduce this burden in delivering prevention curricula. Trauma-Informed Prevention for Substance Use and Risky Sexual Behavior (TIPS) is an mHealth app that was developed to aid trauma-focused cognitive behavioral therapy (TF-CBT) clinicians in the implementation of an evidence-based risk behavior prevention curriculum.

OBJECTIVE

The goal of this paper is to describe the rationale for and development of the TIPS app and present the results of a mixed methods approach for the initial evaluation of its usability.

METHODS

Participants included clinicians (n=11), adolescents (n=11), and caregivers (n=10) who completed qualitative interviews and an adapted version of the Website Analysis and Measurement Inventory.

RESULTS

In total, 4 overarching themes emerged from the participants' answers to the qualitative interview questions, demonstrating a generally positive response to the app. The themes were (1) strength of app content, (2) suggestions about app content, (3) esthetics and usability, and (4) benefits to the patient and session implementation. Clinicians, adolescents, and caregivers all agreed that the content was very relevant to adolescents and used examples and language that adolescents could relate to. All 3 groups also discussed that the content was comprehensive and addressed issues often faced by adolescents. All 3 groups of users made suggestions about the esthetics, which mostly comprised suggestions to change the font, color, or pictures within the app. Of all the groups, adolescents were most positive about the esthetics and usability of the app. Results from the Website Analysis and Measurement Inventory further illustrated the users' favorable reaction to the TIPS app, with 100% (11/11) of clinicians, 100% (10/10) of caregivers, and most adolescents (7/11, 64%) selecting strongly agree or somewhat agree to the following statement: "This app has much that is of interest to me." Adolescents generally found the app easier to use than did caregivers and clinicians.

CONCLUSIONS

The TIPS app shows promise as an mHealth tool for TF-CBT clinicians to integrate evidence-based substance use, risky sexual behavior, and HIV prevention during treatment. Future research, including a randomized controlled trial comparing TF-CBT implementation with and without the inclusion of the app, is necessary to evaluate the feasibility and efficacy of the app in reducing the risk of substance use and risky sexual behavior among trauma-exposed adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03710720; https://clinicaltrials.gov/study/NCT03710720.

Understanding User Acceptance of Clinical Decision Support Systems to Promote Increased Cancer Screening Rates in a Primary Care Practice

OBJECTIVE

Clinical decision support systems (CDDSs) in the electronic medical record (EMR) have been implemented in primary care settings to identify patients due for cancer screening tests, while functioning as a real time reminder system. There is little known about primary care providers (PCPs) perspective or user acceptance of CDSS. The purpose of this study was to investigate primary care provider perceptions of utilizing CDSS alerts in the EMR to promote increased screening rates for breast cancer, cervical cancer, and colorectal cancer.

METHODS

An electronic survey was administered to PCPs in a Midwest Health Institution community internal medicine practice from September 25, 2019 through November 27, 2019.

RESULTS

Among 37 participants (9 NP/Pas and 28 MD/DOs), the NP/PA group was more likely to agree that alerts were helpful (50%; P-value = .0335) and the number of alerts (89%; P = .0227) in the EMR was appropriate. The NP/PA group also was more likely to find alerts straightforward to use (78%, P = .0239). Both groups agreed about feeling comfortable using the health maintenance alerts (MD/DO = 79%; NP/PA = 100%).

CONCLUSION

CDSSs can promote and facilitate ordering of cancer screening tests. The use of technology can promptly identify patients due for a test and act as a reminder to the PCP. PCPs identify these alerts to be a beneficial tool in the EMR when they do not interrupt workflow and provide value to patient care. More work is needed to identify factors that could optimize alerts to be even more helpful, particularly to MD/DO groups.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

Background

Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective.

Objective

This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]).

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features.

Results

We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods.

Conclusions

There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders.

'Help for trauma from the app stores?' A systematic review and standardised rating of apps for Post-Traumatic Stress Disorder (PTSD)

Background: Mobile health applications (apps) are considered to complement traditional psychological treatments for Post-Traumatic Stress Disorder (PTSD). However, the use for clinical practice and quality of available apps is unknown. Objective: To assess the general characteristics, therapeutic background, content, and quality of apps for PTSD and to examine their concordance with established PTSD treatment and self-help methods. Method: A web crawler systematically searched for apps targeting PTSD in the British Google Play and Apple iTunes stores. Two independent researchers rated the apps using the Mobile App Rating Scale (MARS). The content of high-quality apps was checked for concordance with psychological treatment and self-help methods extracted from current literature on PTSD treatment. Results: Out of 555 identified apps, 69 met the inclusion criteria. The overall app quality based on the MARS was medium (M = 3.36, SD = 0.65). Most apps (50.7%) were based on cognitive behavioural therapy and offered a wide range of content, including established psychological PTSD treatment methods such as processing of trauma-related emotions and beliefs, relaxation exercises, and psychoeducation. Notably, data protection and privacy standards were poor in most apps and only one app (1.4%) was scientifically evaluated in a randomized controlled trial. Conclusions: High-quality apps based on established psychological treatment techniques for PTSD are available in commercial app stores. However, users are confronted with great difficulties in identifying useful high-quality apps and most apps lack an evidence-base. Commercial distribution channels do not exploit the potential of apps to complement the psychological treatment of PTSD.

Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App

Objective: Clinicians' perceptions of CBT-I Coach, a patient-facing mobile app for cognitive-behavioral therapy for insomnia (CBT-I), are critical to its adoption and integration into practice. Diffusion of innovations theory emphasizes the influence of perceptions, including the relative advantage to current practice, the compatibility to clinicians' needs, the complexity, the innovation's trialability, and observability. This study intended to evaluate the use and perceptions of CBT-I Coach among Veterans Affairs (VA)-trained CBT-I clinicians. Participants and Methods: Clinicians (N = 108) were surveyed about their use, feedback, and perceptions of CBT-I Coach a year after the app became available. Results: Overall perceptions of CBT-I Coach were favorable. Fifty percent of clinicians reported using CBT-I Coach, with 98% intending to continue use. The app was perceived to increase sleep diary completion and homework compliance. Clinicians viewed the app as providing accessibility to helpful tools and improving patient engagement. Of those not using the app, 83% endorsed intention to use it. Reasons for nonuse were lack of patient access to smart phones, not being aware of the app, not having time to learn it, and inability to directly access app data. Those who reported using CBT-I Coach had more favorable perceptions across all constructs (p < .01 - p < .001), except relative advantage, compared to nonusers. Users perceived it as less complex and more compatible with their practice than nonusers. Conclusions: Continued efforts are needed to increase adoption and enhance use of CBT-I Coach, as well as study if reported benefits can be evidenced more directly.

The influence of mobile health applications on patient - healthcare provider relationships: A systematic, narrative review

OBJECTIVE

To explore the influence of mobile health applications on various dimensions of patient and healthcare provider relationships.

METHODS

A systematic, narrative review of English literature reporting experiences and outcomes of using mobile health applications was performed, evaluating communication and relationships between patients and healthcare professionals. Findings were framed thematically within the four dimensions of relationship-centred care. The methodological quality of included articles was appraised.

RESULTS

Thirty-seven articles were included, all of them meeting tenets of relationship-centred care. After adopting mobile health applications patients perceived an overall positive impact on their relationship with healthcare providers, indicating they are ready to transition from traditional clinical ecounters to a different modality. Use of the applications supported patients in assuming active roles in the management of their health in collaboration with health professionals. Reluctance of providers to using mobile health needs to be acknowledged and addressed when encouraging wider use of applications in clinical practice.

CONCLUSION

The use of mobile health applications can influence communication and relationships between patients and providers positively, facilitating relationship-centered healthcare.

PRACTICE IMPLICATION

Implementation of mobile health can support patients' self-efficacy, improve access to healthcare services and improve relationships between patients and providers in ambulatory and hospital settings.

Theories Predicting End-User Acceptance of Telemedicine Use: Systematic Review

Background

Only a few telemedicine applications have made their way into regular care. One reason is the lack of acceptance of telemedicine by potential end users.

Objective

The aim of this systematic review was to identify theoretical predictors that influence the acceptance of telemedicine.

Methods

An electronic search was conducted in PubMed and PsycINFO in June 2018 and supplemented by a hand search. Articles were identified using predefined inclusion and exclusion criteria. In total, two reviewers independently assessed the title, abstract, and full-text screening and then individually performed a quality assessment of all included studies.

Results

Out of 5917 potentially relevant titles (duplicates excluded), 24 studies were included. The Axis Tool for quality assessment of cross-sectional studies revealed a high risk of bias for all studies except for one study. The most commonly used models were the Technology Acceptance Model (n=11) and the Unified Theory of Acceptance and Use of Technology (n=9). The main significant predictors of acceptance were perceived usefulness (n=11), social influences (n=6), and attitude (n=6). The results show a superiority of technology acceptance versus original behavioral models.

Conclusions

The main finding of this review is the applicability of technology acceptance models and theories on telemedicine adoption. Characteristics of the technology, such as its usefulness, as well as attributes of the individual, such as his or her need for social support, inform end-user acceptance. Therefore, in the future, requirements of the target group and the group’s social environment should already be taken into account when planning telemedicine applications. The results support the importance of theory-guided user-centered design approaches to telemedicine development.

Proposing a standardized, step-by-step model for creating post-traumatic stress disorder (PTSD) related mobile mental health apps in a framework based on technical and medical norms

Background: Prevalence of post-traumatic stress disorder (PTSD) is a problem all over the world. There are high barriers for entry into formal psychotherapy, which results in a lack of mental health care for a significant part of the population. Mobile mental Health (mMHealth) applications (apps) seem to be a promising new development for countering this lack of care, building on the success of mHealth (Mobile Health) apps in general. Unfortunately, the overall quality of such apps stands in high contrast to their number. The aim of this manuscript is to propose a standard for creating PTSD-related mMHealth apps incorporating a process for evaluation and assessment of their usability and impact. Methods: This is done by first defining each step of the process and its relation to the other steps. The steps themselves, divided into those concerned with development, evaluation and implementation, are bound to the established medical and technical norms pertaining to them. Existing protocols from recent literature have been integrated into these steps. Results: As a result, a comprehensive model covering the process of creating, assessing and implementing an mMHealth app from start to finish was developed. The model may be adapted to other disorders or specialized for certain symptoms of PTSD. Conclusion: Adopting such a model could result in a 'blueprint' for creating mMHealth apps in a standardized way, thereby facilitating the testing and comparing of such apps.

Clinical decision support systems in hospital care using ubiquitous devices: Current issues and challenges

Supporting clinicians in decision making using advanced technologies has been an active research area in biomedical engineering during the past years. Among a wide range of ubiquitous systems, smartphone applications have been increasingly developed in healthcare settings to help clinicians as well as patients. Today, many smartphone applications, from basic data analysis to advanced patient monitoring, are available to clinicians and patients. Such applications are now increasingly integrating into healthcare for clinical decision support, and therefore, concerns around accuracy, stability, and dependency of these applications are rising. In addition, lack of attention to the clinicians’ acceptability, as well as the low impact on the medical professionals’ decision making, are posing more serious issues on the acceptability of smartphone applications. This article reviews smartphone-based decision support applications, focusing on hospital care settings and their overall impact of these applications on the wider clinical workflow. Additionally, key challenges and barriers of the current ubiquitous device-based healthcare applications are identified. Finally, this article addresses current challenges, future directions, and the adoption of mobile healthcare applications.

Posttraumatic Stress Disorder and Mobile Health: App Investigation and Scoping Literature Review

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent mental health issue among veterans. Access to PTSD treatment is influenced by geographic (ie, travel distance to facilities), temporal (ie, time delay between services), financial (ie, eligibility and cost of services), and cultural (ie, social stigma) barriers.

OBJECTIVE

The emergence of mobile health (mHealth) apps has the potential to bridge many of these access gaps by providing remote resources and monitoring that can offer discrete assistance to trauma survivors with PTSD and enhance patient-clinician relationships. In this study, we investigate the current mHealth capabilities relevant to PTSD.

METHODS

This study consists of two parts: (1) a review of publicly available PTSD apps designed to determine the availability of PTSD apps, which includes more detailed information about three dominant apps and (2) a scoping literature review performed using a systematic method to determine app usage and efforts toward validation of such mHealth apps. App usage relates to how the end users (eg, clinicians and patients) are interacting with the app, whereas validation is testing performed to ensure the app's purpose and specifications are met.

RESULTS

The results suggest that though numerous apps have been developed to aid in the diagnosis and treatment of PTSD symptoms, few apps were designed to be integrated with clinical PTSD treatment, and minimal efforts have been made toward enhancing the usability and validation of PTSD apps.

CONCLUSIONS

These findings expose the need for studies relating to the human factors evaluation of such tools, with the ultimate goal of increasing access to treatment and widening the app adoption rate for patients with PTSD.

Usability Assessment of a Post-Traumatic Stress Disorder (PTSD) mHealth App

Post-traumatic stress disorder (PTSD) is a common mental health disorder that can affect those who have experienced a traumatic event. Despite the availability of different treatment options for PTSD, there are several barriers that prevent some patients from receiving treatment. To overcome these barriers, mobile health (mHealth) apps have been developed to allow access to therapeutic and self-assessment tools outside the clinic. Our review of literature shows that the three mostly used apps (PTSD Coach, PE Coach, and CPT Coach) are not empirically evaluated and very little information is available for the process used in design and development of these tools. This paper documents a usability study of the most popular PTSD mHealth app; PTSD Coach. Findings indicate that the learning component of the app provides useful information, the assessment is effective in keeping track of the symptoms, and that some of the tools provided can help mitigate some of the symptoms. However, the color scheme, lack of personalization options, and lack of clarity on the mitigation techniques was deemed to affect usability.

EPA guidance on eMental health interventions in the treatment of posttraumatic stress disorder (PTSD)

The aim of this EPA guidance was to develop recommendations on eMental health interventions in the treatment of posttraumatic stress disorder (PTSD). A systematic literature search was performed and 40 articles were retrieved and assessed with regard to study characteristics, applied technologies, therapeutic approaches, diagnostic ascertainment, efficacy, sustainability of clinical effects, practicability and acceptance, attrition rates, safety, clinician-supported vs. non-supported interventions and active vs. waiting-list controls. The reviewed studies showed a great heterogeneity concerning study type, study samples, interventions and outcome measures. Based on these findings, five graded recommendations dealing with symptom reduction, acceptability, type of administration, clinician support, self-efficacy and coping were developed.