Smartphone apps for improving medication adherence in hypertension: patients' perspectives

Benefits and Barriers to mHealth in Hypertension Care: Qualitative Study With German Health Care Professionals

BACKGROUND

Digital health technologies, particularly mobile health (mHealth) apps and wearable devices, have emerged as crucial assets in the battle against hypertension. By enabling lifestyle modifications, facilitating home blood pressure monitoring, and promoting treatment adherence, these technologies have significantly enhanced hypertension treatment.

OBJECTIVE

This study aims to explore the perspectives of health care professionals (HCPs) regarding the perceived benefits and barriers associated with the integration of mHealth apps into routine hypertension care. Additionally, strategies for overcoming these barriers will be identified.

METHODS

Through qualitative analysis via semistructured interviews, general practitioners (n=10), cardiologists (n=14), and nurses (n=3) were purposefully selected between October 2022 and March 2023. Verbatim transcripts were analyzed using qualitative content analysis.

RESULTS

The results unveiled 3 overarching themes highlighting the benefits of mHealth apps in hypertension care from the perspective of HCPs. First, these technologies possess the potential to enhance patient safety by facilitating continuous monitoring and early detection of abnormalities. Second, they can empower patients, fostering autonomy in managing their health conditions, thereby promoting active participation in their care. Lastly, mHealth apps may provide valuable support to medical care by offering real-time data that aids in decision-making and treatment adjustments. Despite these benefits, the study identified several barriers hindering the seamless integration of mHealth apps into hypertension care. Challenges predominantly revolved around data management, communication contexts, daily routines, and system handling. HCPs underscored the necessity for structural and procedural modifications in their daily practices to effectively address these challenges.

CONCLUSIONS

In conclusion, the effective usage of digital tools such as mHealth apps necessitates overcoming various obstacles. This entails meeting the information needs of both HCPs and patients, tackling interoperability issues to ensure seamless data exchange between different systems, clarifying uncertainties surrounding reimbursement policies, and establishing the specific clinical benefits of these technologies. Active engagement of users throughout the design and implementation phases is crucial for ensuring the usability and acceptance of mHealth apps. Moreover, enhancing knowledge accessibility through the provision of easily understandable information about mHealth apps is essential for eliminating barriers and fostering their widespread adoption in hypertension care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00029761; https://drks.de/search/de/trial/DRKS00029761.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3389/fcvm.2022.1089968.

The link between adherence to antihypertensive medications and mortality rates in patients with hypertension: a systematic review and meta-analysis of cohort studies

BACKGROUND

Hypertension (HTN) significantly contributes to cardiovascular disease (CVD) and mortality. This systematic review and meta-analysis specifically investigates how different levels of adherence to antihypertensive therapy (AHT) affect mortality rates in HTN patients. By synthesizing cohort studies, it aims to enhance understanding and inform clinical practices to improve outcomes in hypertensive populations.

METHODS

Our meta-analysis employed a comprehensive search strategy using keywords related to hypertension, medical adherence, and mortality across PubMed, Scopus, and Web of Science, up to July 2024. The eligibility criteria focused on cohort studies linking AHT adherence to mortality. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias (ROB). Quantitative analyses involved hazard ratios (HR) and confidence intervals (CI), with an 80% adherence threshold. Subgroup and meta-regression analyses were also conducted using STATA-17 to explore various outcome factors.

RESULTS

From initial 1,999 studies 12 cohort studies included in our analysis. All included studies had low ROB score. A meta-analysis of 12 studies involving 2,198,311 patient with HTN revealed that poor adherence to treatment significantly increased all-cause mortality (HR: 1.32 [1.14, 1.51], p < 0.001) with high heterogeneity (I²: 98.73%). Additionally, an analysis of four studies with 1,695,872 patients indicated that low adherence was linked to elevated cardiovascular mortality (HR: 1.61 [1.43, 1.78], p < 0.001), showing moderate heterogeneity (I²: 49.51%).

CONCLUSIONS

The study found that poor adherence to AHT significantly increases overall and cardiovascular mortality risk, underscoring the need for improved compliance strategies. Limitations like inconsistent definitions, observational biases, and varying follow-up durations necessitate further research to validate these findings.

CLINICAL TRIAL NUMBER

Not applicable.

The effect of digital therapeutics intervention on improving hypertension management in adults: a meta-analysis of randomized controlled trial

Digital therapeutics (DTx) intervention is an emerging therapy for the treatment and long-term management of hypertension. We aim to systematically evaluate the overall effect of DTx intervention on improving hypertension management. The systematic review and meta-analysis of RCTs was conducted and the PubMed, EMBASE, Web of Science, and Cochrane Library were searched to identify eligible RCTs published between Jan 1, 1982 and Sep 10, 2023. Random-effect models were utilized to pool estimates of net changes in systolic blood pressure (BP), diastolic BP, BP control rate, body mass index, weight, waist circumference, and physical activity between the DTx group and control group. 15 RCTs were included with a total of 3789 participants. Compared with the control group, DTx intervention was associated with significant changes in systolic BP, diastolic BP, and BP control rate of -3.75 mmHg(95% CI -5.74 to 1.77), -1.79 mmHg (95% CI -2.81 to -0.77) and 1.47% (95% CI 1.10 to 1.95), respectively. In addition, DTx intervention was statistically significant for improving other risk factors such as lower BMI (-0.5 kg/m2, 95% CI -0.86 to -0.15), increased physical activity (66.73 min/week, 95%CI 49.64 to 83.81), and reduced waist circumference (-2.91 cm, 95% CI -5.15 to -0.66). No difference between groups was demonstrated in weight (P = 0.30). Subgroup analyses revealed consistent effects of the change in SBP and DBP across study duration, age, sample size, patient baseline status, and intervention scenario settings(P > 0.05). DTx intervention may be useful for lowering BP and long-term management of hypertension. More large-size trials providing evidence on the same product are needed.

Perceptions of healthcare professionals and patients with cardiovascular diseases on mHealth lifestyle apps: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally and is predominantly associated with a cluster of lifestyle risk factors. Mobile health (mHealth) apps offer the potential to overcome traditional barriers by supporting healthy lifestyle behaviours. However, knowledge about perceptions of mHealth lifestyle apps among healthcare professionals and people with CVD is sparse. This study examined barriers and facilitators of using the mHealth apps for healthy lifestyle support among healthcare professionals and CVD patients.

METHODS

We conducted an in-depth qualitative study employing individual semi-structured interviews with 8 CVD healthcare professionals and 4 patients with CVD in Australia. Participants were asked open-ended questions about their perceptions and experiences with mHealth lifestyle apps. A thematic analysis approach was used to establish perceived barriers and facilitators for mHealth lifestyle apps.

RESULTS

Most participants perceived mHealth lifestyle apps as useful. The key perceptions of facilitators included features for tailoring to personal needs, low costs and wide availability of the apps and addressing barriers to use like reminders. Both healthcare professionals and patients identified the strengths and weaknesses regarding the usefulness of mHealth lifestyle apps. Healthcare professionals and patients perceived several barriers to mHealth app use including trustworthiness, scientific validity, language barriers, the capability of using an app or digital literacy, costs for some commercial apps, and accessibility of an app for low-income groups.

CONCLUSION

Lifestyle apps provide an opportunity for better patient and healthcare professional communications, however, several barriers including improving digital health literacy and scientific validations of the apps are required before being recommended in clinical practice. Findings from this study can inform potential mHealth lifestyle app design to meet the demands of users. Addressing these barriers effectively can enhance the adoption and efficacy of mHealth apps, ultimately contributing to improved CVD management and healthier lifestyle behaviours.

Intention to use mobile text message reminders for medication adherence among hypertensive patients in North West Ethiopia: a cross-sectional study

BACKGROUND

Reminders via digital technology offer a novel and efficient means to address medication forgetfulness, as they are easily accessible and user-friendly for patients. In particular mobile text message reminders are more suitable for chronic patients, as they require few technical skills, can operate without internet connectivity, and are less expensive than other technologies. This study aimed to assess the intention to use mobile text message reminders for medication adherence among hypertensive patients at the Gondar City health facilities.

METHODS

A facility-based cross-sectional study was conducted. A simple random sampling method was used to select 423 hypertensive patients. Data was collected from April 1 to May 15, 2023. Data was collected using Kobo Toolbox, and the collected data was exported to MS Excel. Subsequently, the data was imported and analyzed using the SPSS version 20. Binary and multivariable logistic regression analysis was employed to assess factors associated with the outcome variable.

RESULT

The finding indicates that 64.5% of the patients have an Intention to use mobile text message reminders for medication adherence. Perceived usefulness (AOR = 2.53: 95%CI: 1.41, 4.52), perceived ease of use (AOR = 3.28: 95% CI: 1.81, 5.95), forgetting to take medication (AOR = 2.20: 95%CI: 1.38, 3.50) and patient holds their mobile phone always (AOR = 1.96: 95%CI: 1.04, 3.68) were associated factors with outcome variable.

CONCLUSION

Forget taking medication, the patient holds their mobile phone always, Perceived ease of use and Perceived usefulness were significantly associated with the outcome variable. We recommend designing and implementing user-friendly text message reminder systems and educating hypertensive patients about the system's benefits.

Exploring patient's perspective of barriers to diabetic medication adherence in Jazan, Saudi Arabia, using the social determinants of health model

Background

Type 2 diabetes mellitus is usually associated with long-term macrovascular and microvascular complications that negatively impact the patient's quality of life and add economic burden to the healthcare system. Understanding patients' perspectives on medication nonadherence is essential for planning the appropriate methods and strategies to improve medication adherence among patients with uncontrolled diabetes.

Aim

Therefore, this study aims to explore patients' perceptions of the barriers to medication adherence through the Social Health determinants framework.

Method

After obtaining ethical approval, qualitative face-to-face interviews with a sample of patients with type 2 diabetes mellitus (uncontrolled diabetes) were conducted. Interviews were audio-recorded, and then the data were analyzed using thematic analysis to identify essential themes related to the patient's views.

Results

Fifteen patients with type 2 diabetes mellitus were interviewed. Potential barriers to antidiabetic medications were identified and categorized based on the Social Determinants of Health domains. The patient's health perceptions and behaviors were found to positively or negatively impact medication adherence. Beliefs toward antidiabetic medications, polypharmacy, medication-related problems, and the relationship between patients and their healthcare providers that related to healthcare access and quality domains were also reported as potential barriers to medications. Financial constraints, social stigma, and family support were other social health determinants factors that were found to have either positive or negative impacts on adherence. Nevertheless, using mobile health applications was suggested to facilitate medication adherence.

Conclusion

Social Determinants of Health, such as education about type 2 diabetes mellitus, quality and access to healthcare, and social stigma and support, might significantly affect medication adherence among type 2 diabetes mellitus patients. This study's findings can aid the development of suitable patient-specific tools and strategies to enhance medication adherence.

florio® HAEMO: A Longitudinal Survey of Patient Preference, Adherence and Wearable Functionality in Central Europe

INTRODUCTION

florio® HAEMO is a hemophilia treatment monitoring application (app) offering activity tracking and wearable device connectivity. Its use might support everyday activities for people with hemophilia. The aim of this study was to evaluate user satisfaction, long-term usage and the impact on data entry when pairing a wearable with a hemophilia monitoring app.

METHODS

This is a follow-up of a two-part user survey conducted in Central Europe. People with hemophilia and parents/caregivers of children with hemophilia using florio HAEMO and who completed part one were invited to complete a second online questionnaire at least 4 months later.

RESULTS

Fifty participants (83.3%) who completed part one of the survey continued to use the florio HAEMO app and completed part two. Of 14 participants who chose to use the app with a wearable, more than half (57.1%) were aged between 13 and 25 years. Overall, the results demonstrated that florio HAEMO is very easy or rather easy to use, especially for individuals pairing the app with a wearable. Most people using a wearable indicated that florio HAEMO was very or rather important in bringing certainty to daily activities (85.7%). Notably, 14 of 36 (38.9%) non-wearable users indicated that they would prefer to pair the app with a wearable in the future.

CONCLUSIONS

Adherence to the florio HAEMO app is maintained over an extended period of use. Pairing the app with a wearable might enable easier access to app features, increase data entry motivation and provide more certainty about daily activities for people with hemophilia.

Understanding Patient Perspectives on the Use of Gamification and Incentives in mHealth Apps to Improve Medication Adherence: Qualitative Study

BACKGROUND

Medication nonadherence remains a significant health and economic burden in many high-income countries. Emerging smartphone interventions have started to use features such as gamification and financial incentives with varying degrees of effectiveness on medication adherence and health outcomes. A more consistent approach to applying these features, informed by patient perspectives, may result in more predictable and beneficial results from this type of intervention.

OBJECTIVE

This qualitative study aims to identify patient perspectives on the use of gamification and financial incentives in mobile health (mHealth) apps for medication adherence in Australian patients taking medication for chronic conditions.

METHODS

A total of 19 participants were included in iterative semistructured web-based focus groups conducted between May and December 2022. The facilitator used exploratory prompts relating to mHealth apps, gamification, and financial incentives, along with concepts raised from previous focus groups. Transcriptions were independently coded to develop a set of themes.

RESULTS

Three themes were identified: purpose-driven design, trust-based standards, and personal choice. All participants acknowledged gamification and financial incentives as potentially effective features in mHealth apps for medication adherence. However, they also indicated that the effectiveness heavily depended on implementation and execution. Major concerns relating to gamification and financial incentives were perceived trivialization and potential for medication abuse, respectively.

CONCLUSIONS

The study's findings provide a foundation for developers seeking to apply these novel features in an app intervention for a general cohort of patients. However, the study highlights the need for standards for mHealth apps for medication adherence, with particular attention to the use of gamification and financial incentives. Future research with patients and stakeholders across the mHealth app ecosystem should be explored to formalize and validate a set of standards or framework.

The Attitudes of Patients with Cardiovascular Diseases towards Online Exercise with the Mobile Monitoring of Their Health-Related Vital Signs

The health care cost of cardiovascular diseases (CVD) in the EU is estimated to be today over 282 billion euros. It is well documented today that exercise training is one of the main strategies for secondary disease prevention and the follow-up integration of these patients. This study aimed to examine patients' attitudes towards online exercise with mobile monitoring of their vital signs. More specifically, the research objectives were as follows: (a) to examine patients' attitudes and expectations of online exercise, (b) cluster patients in high- and low-attitude groups and examine their intention to participate in online exercise, and (c) to examine age and gender differences in terms of their intention to exercise online. The final goal of this project was to develop a real application that could be of use to patients and professionals. Data were collected from fifty patients in the city of Thessaloniki, Greece. The results revealed that most patients were positive about exercising online if the programs were perceived as fun and, especially, safe. The use of an online monitoring application with the distant supervision of health professionals could both motivate them and strengthen their feeling of safety.

Mobile health technologies in the prevention and management of hypertension: A scoping review

Introduction

An estimated one billion people globally are currently suffering from hypertension. Prevention and management of hypertension are suboptimal especially in low- and middle-income countries leading to increased complications and deaths. With increased mobile phone coverage globally, this study aims to review mobile health technologies used for the prevention and management of hypertension.

Methods

We conducted a literature search on electronic databases using identified keywords involving "hypertension", "mobile health technology" and their synonyms. Snowballing technique was also used. Papers were screened at two levels by independent reviewers. The targets were studies published in peer-reviewed journals reporting mobile health interventions for hypertension prevention and management. Only primary research studies published in English from January 2017 to April 2024 were included. Google Forms were used to extract the data along with other characteristics, and selected articles were categorised into: mobile application, web-based solutions, and Short Message Service (SMS) and other offline solutions.

Result

The search yielded 184 articles, and 44 studies were included in the review. Most (n = 26) were randomised control trials. Twenty-two studies (22) focused only on mobile applications solutions, 12 on SMS and other offline mHealth, 5 web-based solutions, and 5 combined more than one type of mobile health technology. The United States of America had the majority of studies (n = 17), with 6 studies from other American countries, 11 from Asia and nine from Europe, while only one from Africa. A total of 36 studies reported that mobile health technology significantly improved hypertension care through reduced blood pressure, improved adherence to follow-up visits and medications, and lifestyle changes. SMS and offline mHealth strategies have also demonstrated effectiveness in promoting self-management and reducing racial disparities in hypertension care.

Conclusion

Mobile health technology has the potential to play a significant role in the prevention and management of hypertension. However, there is a need for mobile health solutions for hypertension prevention and management in African countries and other developing countries. Integrating mHealth into primary healthcare delivery would also go a long way in strengthening patient care and reducing the burden on healthcare systems.

Patients' perspectives on digital health tools

Objective

Digital technology has changed the way healthcare is delivered and accessed. However, the focus is mostly on technology and clinical aspects. This review aimed to integrate and critically analyse the available knowledge regarding patients' perspectives on digital health tools and identify facilitators and barriers to their uptake.

Methods

A narrative review was conducted using the Scopus and Google Scholar databases. Information related to facilitators and barriers to uptake was synthesised and interpreted using thematic and content analyses, respectively.

Results

Seventy-one out of 1722 articles identified were eligible for inclusion. Patient empowerment, self-management, and personalisation were identified as the main factors that contributed to patient uptake in using digital health tools. Digital literacy, health literacy, and privacy concerns were identified as barriers to the uptake of digital health technology.

Conclusion

Digital health technologies have changed the way healthcare is experienced by patients. Research highlights the disconnect between the development and implementation of digital health tools and the patients they are created for. This review may serve as the foundation for future research incorporating patients' perspectives to help increase patients' engagement with emerging technologies.

Innovation

Participatory design approaches have the potential to support the creation of patient-centred digital health tools.

A Mobile Application to Improve Diabetes Self-Management Using Rapid Prototyping: Iterative Co-Design Approach in Asian Settings

BACKGROUND

Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology.

OBJECTIVE

The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development.

METHODS

Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach.

RESULTS

Participants' ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app.

CONCLUSION

In this study, we explored users' opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.

The feasibility of smartphone-based application on cardiac rehabilitation for Chinese patients with percutaneous coronary intervention in Macau: a qualitative evaluation

BACKGROUND

To improve cardiovascular risk factors modification and effects of cardiac rehabilitation (CR), electronic applications on CR are suggested in the literature for patients after percutaneous coronary intervention (PCI).

METHODS

A sequential qualitative study, embedded in a quantitative experimental trial for mHealth application on CR (mCR) study evaluation, was conducted to understand the usability and satisfaction of mCR study. Purposive sampling were used until achieving data saturation. Individually semi-structured interviews were conducted. The textual narration from interview transcriptions were analysed by content analysis.

RESULTS

Ten participants were interviewed for qualitative evaluation. Findings presented the perceptive and experience of the mCR app users. Results were captured by four themes: 1. feasibility of mCR app, including practicality, acceptability and convenience, and barriers to use; 2. benefits from mCR app, explaining the effectiveness of mCR study; 3. advocator for better hospital care, disclosing an extension of healthcare and promoting patient-healthcarer relationship; and 4. recommendation for mCR app improvement.

CONCLUSION

Findings provided insights for cardiac healthcare providers to understand the feasibility of mHealth application on phase II CR in Macau. The mCR app facilitated CR engagement which contributed to health and well-being by promoting CHD and CR knowledge, and cardiac healthy lifestyle modification.

Needs and preferences of women with prior severe preeclampsia regarding app-based cardiovascular health promotion

BACKGROUND

Women with prior severe preeclampsia are at an increased risk for cardiovascular diseases later in life compared to women who had a normotensive pregnancy. The objective of this study was to assess their needs and preferences regarding app-based cardiovascular health promotion.

METHODS

Patients (n = 35) of the Follow-Up PreEClampsia Outpatient Clinic (FUPEC), Erasmus MC, the Netherlands, participated in an anonymous online survey. The main outcomes under study were women's needs for health behavior promotion, and their preferences with respect to intervention delivery. Descriptive statistics were used to evaluate needs, and thematic analysis was used to analyze preferences.

RESULTS

Women's primary need for health behavior promotion pertained to their fat and sugar intake and physical activity; for some, to their mental health (practices), fruit and vegetable intake, salt intake, and water intake; and for a few, to their alcohol and tobacco use. Most women preferred an app-based intervention to include, in descending order: the tracking of health-related metrics, an interactive platform, the use of behavior change strategies, the provision of information, and personalization.

CONCLUSION

Cardiovascular health promotion targeting women with prior severe preeclampsia should feel relevant to its audience. App-based interventions are likely to be well received if they target fat and sugar intake and physical activity. These interventions should preferably track health-related metrics, be interactive, contain behavior change strategies, provide information, and be personalized. Adopting these findings during intervention design could potentially increase uptake, behavior change, and behavior change maintenance in this population.

Impacts of Educational Interventions with Support of Mobile App versus Booklet for Patients with Hypertension and Metabolic Syndrome: A Secondary Data Analysis

BACKGROUND

Hypertension comorbid with metabolic syndrome could increase the development of adverse cardiovascular events. Educational interventions were effective to improve outcomes in patients.

METHODS

This was a secondary data analysis of participants with hypertension. The original randomized controlled trial aimed to examine the effect of app and booklet versus control among individuals diagnosed with metabolic syndrome living in the community. A 30-min health education was provided to each participant. In addition to the education, the app group received a mobile app while the booklet group received a booklet. Data were collected at baseline, week 4, week 12, and week 24. Intention-to-treat principle was followed, and generalized estimating equations was employed for data analysis.

RESULTS

A total of 118 participants with hypertension and metabolic syndrome were extracted from the three-arm trial data. The sample size was 36, 42, and 40 in the app group, booklet group, and control group, respectively. Compared to the control group, the app group showed a significant reduction on body weight and waist circumference at week 24, while the total exercise and self-efficacy for exercise were increased at week 12 and week 24 but no significant findings were observed in the booklet group.

CONCLUSIONS

The educational intervention supported with app was superior to the booklet support on the outcomes of body weight, waist circumference, total exercise, and self-efficacy for exercise among patients with hypertension and metabolic syndrome in the community.

Attitude and Needs Toward MTM Applications of Chronic Disease in China: A Questionnaire Survey

Objective

Chronic diseases are characterized by high incidence, long-term medication, and complex types of medication. There are also many corresponding medication therapy management (MTM) applications on the market, such as iCarea, and Medisafe. However, the existing research mainly focuses on how to choose high-quality MTM applications, and few researchers consider the expectations of MTM applications from potential users. The aims of this study were to investigate the demand, attitude, and expectations of the Chinese patients for the MTM applications to support.

Methods

From August 2019 to December 2019, we created a questionnaire to have knowledge of user needs, preferences, and expectations for MTM applications among 302 chronic patients in Hunan, Guangdong, and other provinces in China. Logistic regression analysis was performed to analyze the risk factors of affecting patients' attitudes toward MTM applications. Then, respondents' expectations and preferences for MTM applications were statistically analyzed. The survey data were merged to provide information for the design of targeted chronic disease MTM applications.

Results

A total of 260 (86.09%) out of 302 patients the respondents were willing to use the MTM applications of chronic disease. The independent influencing factors for using the MTM applications were long-term medication history (OR = 4.45, P &lt; 0.001), willing to learn about medicine knowledge (OR = 3.01, P = 0.04), and wanting to get more professional medication knowledge via Internet (OR = 2.86, P = 0.005). It was worth noting that among those willing to use MTM applications, 55.00% of respondents were willing to use the WeChat applet for MTM, while only 23.46% of respondents preferred other applications. As to the more prevalent WeChat applet for MTM, the majority of participants expected the inclusion of useful modules, such as medication log (62.81%), medication reminder (62.81%), and medication recommendations (57.79%).

Conclusion

The participants are willing to use MTM applications of chronic disease, with a preference for the WeChat applet. Patients tended to use MTM applications if they had a long-term medication history or a desire for medical knowledge, especially if they want to get more professional medication knowledge via the Internet. Participants are expected to include in the WeChat applet as medication logs, medication reminders, and medication recommendations which should be taken into serious account for the further development of MTM applications.

Rationale design and efficacy of a smartphone application for improving self-awareness of adherence to edoxaban treatment: study protocol for a randomised controlled trial (adhere app)

INTRODUCTION

High adherence to oral anticoagulants is essential for stroke prevention in patients with atrial fibrillation (AF). We developed a smartphone application (app) that pushes alarms for taking medication and measuring blood pressure (BP) and heart rate (HR) at certain times of the day. In addition to drug alarms, the habit of measuring one's BP and HR may reinforce drug adherence by improving self-awareness of the disease. This pilot study aims to test the feasibility and efficacy of the smartphone app-based intervention for improving drug adherence in patients with AF.

METHODS AND ANALYSIS

A total of 10 university hospitals in Korea will participate in this randomised control trial. Patients with AF, being treated with edoxaban for stroke prevention will be included in this study. Total of 500 patients will be included and the patients will be randomised to the conventional treatment group (250 patients) and the app conditional feedback group (250 patients). Patients in the app conditional feedback group will use the medication reminder app for medication and BP check alarms. The automatic BP machine will be linked to the smartphone via Bluetooth. The measured BP and HR will be updated automatically on the smartphone app. The primary endpoint is edoxaban adherence by pill count measurement at 3 and 6 months of follow-up. Secondary endpoints are clinical composite endpoints including stroke, systemic embolic event, major bleeding requiring hospitalisation or transfusion, or death during the 6 months. As of 24t November 2021, 80 patients were enrolled.

ETHICS AND DISSEMINATION

This study was approved by the Seoul National University Bundang Hospital Institutional Review Board and will be conducted according to the principles of the Declaration of Helsinki. The study results will be published in a reputable journal.

TRIAL REGISTRATION NUMBER

KCT0004754.

An investigation of the use of app technology to support clinical management of patients with chronic myeloid leukaemia (CML)

Introduction

The availability of healthcare apps to support patient self-management of various medical conditions, including cancer, has increased considerably in the past decade. However, there are limited published data on the role of apps in the management of chronic myeloid leukaemia (CML). The primary aim of this study was to investigate the current and future role of apps as a means of supporting patients with CML.

Methods

A 31-item questionnaire was developed and distributed to patients via three on-line CML support groups.

Results

Responses were received from 286 patients. There was an approximate 2:1 female: male split and the majority (54%, n = 155) resided in the United Kingdom. 91% (n = 260) of respondents were currently receiving drug treatment for their CML. 23.4% (n = 67) of respondents were aware that apps were available to support their CML management and 11.5% (n = 33) had experience of using such an app. 94.1% (n = 238) of those who had not used a patient support app in the past stated that they would consider using an app in the future to help manage their disease. App awareness was significantly higher amongst male patients (30.3% vs. 19.9%). Likelihood of being a current or previous app user was higher amongst younger patients (16.3% for <55 years old vs. 5.6% for ≥55 years old) whilst younger patients and those with a more recent diagnosis of CML were both more likely to be interested in using an app in the future. When asked about potential app functionality, a drug interaction checker was the feature of greatest interest to respondents.

Conclusions

We have identified both a lack of awareness of and a low uptake of patient support apps amongst CML patients. Importantly, we have demonstrated a clear interest in CML-specific apps amongst this population. Based on the functionality that study participants were most interested in, we will work with health care professionals, app developers and patients to develop a new app to deliver holistic support to CML patients.

Improving Blood Pressure Control Using Digital Communication Methods in Serbia

Background: The purpose of this study was to compare home and office BP in the adjustment of antihypertensive treatment. Methods: This study was an open, prospective, noninterventional, multicenter clinical trial that occurred between July 2019 and February 2020, in 34 cities in the territory of the Republic of Serbia, which monitored 1581 participants for 6 months. Depending on the used blood pressure monitoring method used, all patients were divided into control (office BP monitoring) and experimental (home BP telemonitoring) groups. We collected anamnestic data and data about systolic blood pressure (SP), in mmHg, diastolic blood pressure (DP), in mmHg, and heart rate (HR), in beats/minute, from all patients. Results: SP values were significantly different at baseline, and at the second, third, and fourth visits between the two tested groups. Home and office BP decreased significantly (p < 0.000) during the 6-month follow-up. We observed a statistically significant influence of the presence of diabetes mellitus and dyslipidemia on the dynamics of differences between SP monitoring values. Conclusions: Our study suggests that novel technologies in BP monitoring can be excellent alternatives for BP assessment in hypertensive patients with other cardiovascular risk factors such as diabetes and dyslipidemia.

mHealth Interventions for Self-management of Hypertension: Framework and Systematic Review on Engagement, Interactivity, and Tailoring

BACKGROUND

Engagement is essential for the effectiveness of digital behavior change interventions. Existing systematic reviews examining hypertension self-management interventions via mobile apps have primarily focused on intervention efficacy and app usability. Engagement in the prevention or management of hypertension is largely unknown.

OBJECTIVE

This systematic review explores the definition and role of engagement in hypertension-focused mobile health (mHealth) interventions, as well as how determinants of engagement (ie, tailoring and interactivity) have been implemented.

METHODS

A systematic review of mobile app interventions for hypertension self-management targeting adults, published from 2013 to 2020, was conducted. A total of 21 studies were included in this systematic review.

RESULTS

The engagement was defined or operationalized as a microlevel concept, operationalized as interaction with the interventions (ie, frequency of engagement, time or duration of engagement with the program, and intensity of engagement). For all 3 studies that tested the relationship, increased engagement was associated with better biomedical outcomes (eg, blood pressure change). Interactivity was limited in digital behavior change interventions, as only 7 studies provided 2-way communication between users and a health care professional, and 9 studies provided 1-way communication in possible critical conditions; that is, when abnormal blood pressure values were recorded, users or health care professionals were notified. The tailoring of interventions varied at different aspects, from the tailoring of intervention content (including goals, patient education, advice and feedback from health professionals, reminders, and motivational messages) to the tailoring of intervention dose and communication mode. Tailoring was carried out in a number of ways, considering patient characteristics such as goals, preferences, disease characteristics (eg, hypertension stage and medication list), disease self-management experience levels, medication adherence rate, and values and beliefs.

CONCLUSIONS

Available studies support the importance of engagement in intervention effectiveness as well as the essential roles of patient factors in tailoring, interactivity, and engagement. A patient-centered engagement framework for hypertension self-management using mHealth technology is proposed here, with the intent of facilitating intervention design and disease self-management using mHealth technology.

The Promise of Digital Self-Management: A Reflection about the Effects of Patient-Targeted e-Health Tools on Self-Management and Wellbeing

Increasingly, people have direct access to e-Health resources such as health information on the Internet, personal health portals, and wearable self-management applications, which have the potential to reinforce the simultaneously growing focus on self-management and wellbeing. To examine these relationships, we searched using keywords self-management, patient-targeting e-Health tools, and health as wellbeing. Direct access to the health information on the Internet or diagnostic apps on a smartphone can help people to self-manage health issues, but also leads to uncertainty, stress, and avoidance. Uncertainties relate to the quality of information and to use and misuse of information. Most self-management support programs focus on medical management. The relationship between self-management and wellbeing is not straightforward. While the influence of stress and negative social emotions on self-management is recognized as an important cause of the negative spiral, empirical research on this topic is limited to health literacy studies. Evidence on health apps showed positive effects on specific actions and symptoms and potential for increasing awareness and ownership by people. Effects on more complex behaviors such as participation cannot be established. This review discovers relatively unknown and understudied angles and perspectives about the relationship between e-Health, self-management, and wellbeing.

Digital Medication Adherence Support: Could Healthcare Providers Recommend Mobile Health Apps?

Adherence to prescribed medication is suboptimal in 50% of the chronic population, resulting in negative medical and economic outcomes. With the widespread use of mobile phones worldwide, medication adherence apps for mobile phones become promising medication adherence aids thanks to simplicity, user-friendliness, and accessibility for the public. Yet, until today, there is insufficient evidence in favor of using mobile health (mHealth) apps to increase medication adherence. This study aims to develop a methodology for scientific and end-user (patient) mHealth evaluation (a) to identify medication adherence apps search terms, (b) to evaluate identified apps based on scientific criteria, and (c) to report best smartphone apps evaluated by patients. Search terms were identified via literature review and expertise. Firstly, an online questionnaire was developed to identify frequently used search terms by recruited patients. Related medication adherence apps were identified and selected using predefined inclusion criteria. Secondly, identified apps were evaluated thanks to a scientific evaluation method and a created online questionnaire for patient feedback. Recruited patients were invited to test and evaluate the selected apps. Out of 1,833 free-of-charge and 307 paid apps identified, only four free-of-charge and three paid apps remained included in the study after eligibility criteria. None of the selected app reached a high score. Looking at the overall scores, Medisafe (59%), MyTherapy (56%), and Meds on time (44%) received the highest scores in the scientific app evaluation. In the patient evaluation, Dosecast (3.83 out of five points), Medisafe (3.62), and SwissMeds (3.50) received the highest scores. None of the apps in this research has undergone a process for certification, for example, CE marking, through a notified body. Security and data protection aspects of existing apps highly contribute to these low evaluation scores through little information on patient's data processing and storage. This might be corrected through the introduction of General Data Protection Regulation (GDPR) in the European Economic Area (EEA) and more scrutiny through regulatory bodies in the EU/EEA and the USA. None of the applications should be recommended by healthcare providers. In addition, clinical studies with chronic patients are necessary to measure long-term app impacts.

Integration of text messaging intervention into hypertension management among older adults: A systematic review and meta-analysis

BACKGROUND

An aging population and required hypertension control are global concerns that burden the healthcare system. Text messaging interventions have been developed to support hypertension management, but their effects on the older population are unknown.

OBJECTIVES

This review aimed to identify the effects of a text messaging intervention on hypertension management among older adults.

METHODS

Four English and two Chinese databases with randomized controlled trials published between January 2010 and December 2020 were searched. The mean age of the participants was 60 years or above. Participants were also diagnosed with hypertension. The Cochrane risk-of-bias tool was used for the critical appraisal. Data in each study were extracted, and a meta-analysis was presented in terms of mean difference (MD) and standardized mean difference (SMD).

RESULTS

A total of 1670 records were screened, of which six were included in the final review. The intervention of the included studies lasted up to 6 months, and one-way text messaging was commonly used. Meta-analysis showed that a text messaging intervention significantly reduced systolic blood pressure (MD = -6.11, p < .01) but not diastolic blood pressure. Regarding medication adherence, a moderate effect was noted with the use of text messaging among older adults with hypertension (SMD = 0.65, p = .01).

LINKING EVIDENCE TO ACTION

A text messaging intervention can improve hypertension management among older adults. The standardized content of one-way text messaging is suggested to be delivered weekly.

Comparing the Acceptance of Mobile Hypertension Apps for Disease Management Among Patients Versus Clinical Use Among Physicians: Cross-sectional Survey

Background

High blood pressure or hypertension is a vastly prevalent chronic condition among adults that can, if not appropriately treated, contribute to several life-threatening secondary diseases and events, such as stroke. In addition to first-line medication, self-management in daily life is crucial for tertiary prevention and can be supported by mobile health apps, including medication reminders. However, the prescription of medical apps is a relatively novel approach. There is limited information regarding the determinants of acceptance of such mobile health (mHealth) apps among patients as potential users and physicians as impending prescribers in direct comparison.

Objective

The present study aims to investigate the determinants of the acceptance of health apps (in terms of intention to use) among patients for personal use and physicians for clinical use in German-speaking countries. Moreover, we assessed patients’ preferences regarding different delivery modes for self-care service (face-to-face services, apps, etc).

Methods

Based on an extended model of the unified theory of acceptance and use of technology (UTAUT2), we performed a web-based cross-sectional survey to explore the acceptance of mHealth apps for self-management of hypertension among patients and physicians in Germany. In addition to UTAUT2 variables, we measured self-reported self-efficacy, eHealth literacy, previous experiences with health apps, perceived threat to privacy, and protection motivation as additional determinants of mHealth acceptance. Data from 163 patients and 46 physicians were analyzed using hierarchical regression and mediation analyses.

Results

As expected, a significant influence of the unified theory of acceptance and use of technology (UTAUT) predictors on intentions to use hypertension apps was confirmed, especially for performance expectancy. Intention to use was moderate in patients (mean 3.5; SD 1.1; range 1-5) and physicians (mean 3.4, SD 0.9), and did not differ between both groups. Among patients, a higher degree of self-reported self-efficacy and protection motivation contributed to an increased explained variance in acceptance with R²=0.09, whereas eHealth literacy was identified as exerting a positive influence on physicians (increased R²=0.10). Furthermore, our findings indicated mediating effects of performance expectancy on the acceptance among patients but not among physicians.

Conclusions

In summary, this study has identified performance expectancy as the most important determinant of the acceptance of mHealth apps for self-management of hypertension among patients and physicians. Concerning patients, we also identified mediating effects of performance expectancy on the relationships between effort expectancy and social influence and the acceptance of apps. Self-efficacy and protection motivation also contributed to an increase in the explained variance in app acceptance among patients, whereas eHealth literacy was a predictor in physicians. Our findings on additional determinants of the acceptance of health apps may help tailor educational material and self-management interventions to the needs and preferences of prospective users of hypertension apps in future research.

The SHAPES Smart Mirror Approach for Independent Living, Healthy and Active Ageing

The benefits that technology can provide in terms of health and support for independent living are in many cases not enough to break the barriers that prevent older adults from accepting and embracing technology. This work proposes a hardware and software platform based on a smart mirror, which is equipped with a set of digital solutions whose main focus is to overcome older adults’ reluctance to use technology at home and wearable devices on the move. The system has been developed in the context of two use cases: the support of independent living for older individuals with neurodegenerative diseases and the promotion of physical rehabilitation activities at home. Aspects such as reliability, usability, consumption of computational resources, performance and accuracy of the proposed platform and digital solutions have been evaluated in the initial stages of the pilots within the SHAPES project, an EU-funded innovation action. It can be concluded that the SHAPES smart mirror has the potential to contribute as a technological breakthrough to overcome the barriers that prevent older adults from engaging in the use of assistive technologies.

Identification of the Most Suitable App to Support the Self-Management of Hypertension: Systematic Selection Approach and Qualitative Study

BACKGROUND

Smartphone apps are increasingly being used to aid in hypertension self-management, and a large and ever-growing number of self-management apps have been commercially released. However, very few of these are potentially effective and secure, and researchers have yet to establish the suitability of specific hypertension apps to particular contexts.

OBJECTIVE

The aim of this study is to identify the most suitable hypertension app in the context of Saudi Arabia and its health system.

METHODS

This study used a 2-stage approach to selecting the most suitable app for hypertension self-management. First, a systematic selection approach was followed to identify a shortlist of the most suitable apps according to the criteria of potential effectiveness, theoretical underpinning, and privacy and security. Second, an exploratory qualitative study was conducted to select the most suitable from the shortlist: 12 doctors were interviewed, and 22 patients participated in 4 focus groups. These explored participants' attitudes towards self-management apps in general, and their views towards the apps identified via the systematic selection process. The qualitative data were analyzed using framework analysis.

RESULTS

In the first stage, only 5 apps were found to be potentially effective while also having a theoretical underpinning and protecting users' data. In the second stage, both doctors and patients were generally interested in using hypertension apps, but most had no experience with these apps due to a lack of awareness of their availability and suitability. Patients and doctors liked apps that combine intuitive interfaces with a pleasant and clear visual design, in-depth features (eg, color-coded feedback accompanied with textual explanations), activity-specific reminders, and educational content regarding hypertension and potential complications. When the pros and cons of the 5 apps were discussed, 3 apps were identified as being more suitable, with Cora Health rated the highest by the participants.

CONCLUSIONS

Only 5 apps were deemed potentially effective and secure. Patients' and doctors' discussions of the pros and cons of these 5 apps revealed that 3 out of the 5 are clearly more suitable, with the Cora Health app being judged most suitable overall.

Therapeutic adherence in hypertension: Current evidence and expert opinion from India

Hypertension (HTN) is a globally prevalent non-communicable disease contributing significantly to cardiovascular (CV) morbidity and mortality. In achieving control of HTN, therapeutic adherence plays a crucial role. Studies from India identify varying rates of adherence to antihypertensive medications. Multiple factors determine treatment adherence in HTN. In India, factors such as lower socioeconomic status, health literacy, asymptomatic nature of disease, forgetfulness, cost of medications, and duration of HTN determine the adherence. An excellent physician-patient relationship incorporating adequate counseling along with the use of other methods can identify poor adherence. Improving adherence necessitates incorporating a multipronged approach with strategies directed at physicians, patients, and health systems. With innovation in therapeutics, the pharmaceutical sector can contribute significantly to improve adherence. Furthermore, increasing adherence to lifestyle interventions can help achieve better HTN control and improve CV outcomes. In the Indian context, more emphasis is necessary on patient education, enhanced physician-patient relationship and communication, increased access to health care, and affordability in improving therapeutic adherence in HTN.

Effectiveness of Text Messaging Interventions on Blood Pressure Control Among Patients With Hypertension: Systematic Review of Randomized Controlled Trials

Background

Controlling blood pressure (BP) is an international health concern, and high BP is a major contributor to cardiovascular disease mortality. Evidence has shown that educational interventions directed at patients potentially improve BP control and adherence to medications and lifestyle modifications. In addition, a text messaging intervention has a potential effect on BP control; however, the dosage of a text messaging intervention has not been determined in previous reviews, resulting in difficult application in practice.

Objective

This review aimed to identify the effectiveness of a text messaging intervention on hypertension management with a specific focus on the dosage of text messaging and the type of additional interventions with text messaging.

Methods

A systematic review was conducted and reported on in accordance with PRISMA guideline. Participants were aged 18 years and older and diagnosed with primary hypertension. The included studies used text messaging as a component of the intervention. We searched for randomized controlled trials published until June 30, 2020, from the following health-related electronic databases: Embase, Medline, CINAHL Complete, PsycINFO, and Scopus. Data were extracted for qualitative synthesis and meta-analysis. The Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study, and the quality of the included studies was assessed independently by two authors.

Results

Twelve studies met the inclusion criteria. The overall methodological quality was fair (mean score 5.75). The frequency of text message delivery varied from daily to biweekly. Health education was identified in 4 studies as an additional intervention with text messaging. The overall results showed that the text messaging intervention significantly reduced systolic BP (SBP) but not diastolic BP (DBP). There was no significant difference in BP reduction between studies that lasted 6 months or less and those that lasted more than 7 months. Seven studies that lasted 6 months or less involving 1428 patients with hypertension were pooled for further meta-analysis. Text messages delivered at a lower frequency (once per week or less) had a small effect on SBP reduction (effect size 0.35, P<.01) and DBP reduction (effect size 0.28, P=.01). In addition, the use of a text messaging intervention halved the odds of uncontrolled BP among patients with hypertension in 6 months (odds ratio 0.46, P=.02).

Conclusions

This review found that a text messaging intervention was effective in BP control. One-way text messaging delivered in a weekly manner was suggested to be effective and required fewer resources. Future studies should use different forms of text message and be integrated into other interventions to improve adherence behaviors and BP control among patients with hypertension.

A Comprehensive 6A Framework for Improving Patient Self-Management of Hypertension Using mHealth Services: Qualitative Thematic Analysis

Background

Hypertension affects over 15% of the world’s population and is a significant global public health and socioeconomic challenge. Mobile health (mHealth) services have been increasingly introduced to support hypertensive patients to improve their self-management behaviors, such as adherence to pharmacotherapy and lifestyle modifications.

Objective

This study aims to explore patients’ perceptions of mHealth services and the mechanisms by which the services support them to self-manage their hypertension.

Methods

A semistructured, in-depth interview study was conducted with 22 outpatients of the General Hospital of Ningxia Medical University from March to May 2019. In 2015, the hospital introduced an mHealth service to support community-dwelling outpatients with self-management of hypertension. Content analysis was conducted by following a grounded theory approach for inductive thematic extraction. Constant comparison and categorization classified the first-level codes with similar meanings into higher-level themes.

Results

The patient-perceived mechanisms by which the mHealth service supported their self-management of hypertension were summarized as 6A: access, assessment, assistance, awareness, ability, and activation. With the portability of mobile phones and digitization of information, the mHealth service provided outpatients with easy access to assess their vital signs and self-management behaviors. The assessment results gave the patients real-time awareness of their health conditions and self-management performance, which activated their self-management behaviors. The mHealth service also gave outpatients access to assistance, which included health education and self-management reminders. Both types of assistance could also be activated by abnormal assessment results, that is, uncontrolled or deteriorating blood pressure values, discomfort symptoms, or not using the service for a long period. With its scalable use to handle any possible information and services, the mHealth service provided outpatients with educational materials to learn at their own pace. This led to an improvement in self-management awareness and ability, again activating their self-management behaviors. The patients would like to see further improvements in the service to provide more useful, personalized information and reliable services.

Conclusions

The mHealth service extended the traditional hypertension care model beyond the hospital and clinician’s office. It provided outpatients with easy access to otherwise inaccessible hypertension management services. This led to process improvement for outpatients to access health assessment and health care assistance and improved their awareness and self-management ability, which activated their hypertension self-management behaviors. Future studies can apply the 6A framework to guide the design, implementation, and evaluation of mHealth services for outpatients to self-manage chronic conditions.

Effects of Telemedicine and mHealth on Systolic Blood Pressure Management in Stroke Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Stroke is a common, harmful disease with high recurrence and mortality rates. Uncontrolled blood pressure is an important and changeable risk factor for stroke recurrence. Telemedicine and mobile health (mHealth) interventions may have the potential to facilitate the control of blood pressure among stroke survivors, but their effect has not been established.

Objective

This systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to estimate the effects of telemedicine and mHealth interventions on the control of systolic blood pressure among stroke survivors.

Methods

The research literature published up to June 28, 2020, and consisting of RCTs related to telemedicine and mHealth interventions was searched in PubMed, EMBASE, Web of Science, and the Cochrane Library. The Cochrane risk of bias tool (RoB 2.0) was used to evaluate the quality of the studies. The Cochran Q test and I² statistic were used to assess heterogeneity. Data were meta-analyzed using a random-effects model. Mean difference (MD) with 95% CI and 95% prediction interval (PI) were calculated.

Results

In total, 9 RCTs with a total sample size of 1583 stroke survivors met the inclusion criteria. Compared with the usual care, telemedicine and mHealth had a significantly greater impact on the control of systolic blood pressure (MD –5.49; 95% CI –7.87 to –3.10; P<.001; 95% PI –10.46 to –0.51). A subgroup analysis showed that the intervention mode of telephone plus SMS text messaging (MD –9.09; 95% CI –12.71 to –5.46; P<.001) or only telephone (MD –4.34; 95% CI –6.55 to –2.13; P<.001; 95% PI –7.24 to –1.45) had a greater impact on the control of systolic blood pressure than usual care. Among the stroke survivors with an intervention interval ≤1 week (MD –6.51; 95% CI –9.36 to –3.66; P<.001; 95% PI –12.91 to –0.10) or a baseline systolic blood pressure ≥140 mm Hg (MD –6.15; 95% CI –9.44 to –2.86; P<.001; 95% PI –13.55 to 1.26), the control of systolic blood pressure using telemedicine and mHealth was better than that of usual care.

Conclusions

In general, telemedicine and mHealth reduced the systolic blood pressure of stroke survivors by an average of 5.49 mm Hg compared with usual care. Telemedicine and mHealth are a relatively new intervention mode with potential applications for the control of systolic blood pressure among stroke survivors, especially those with hypertensive stroke.

Improving Medication Adherence Through Adaptive Digital Interventions (iMedA) in Patients With Hypertension: Protocol for an Interrupted Time Series Study

BACKGROUND

There is a strong need to improve medication adherence (MA) for individuals with hypertension in order to reduce long-term hospitalization costs. We believe this can be achieved through an artificial intelligence agent that helps the patient in understanding key individual adherence risk factors and designing an appropriate intervention plan. The incidence of hypertension in Sweden is estimated at approximately 27%. Although blood pressure control has increased in Sweden, barely half of the treated patients achieved adequate blood pressure levels. It is a major risk factor for coronary heart disease and stroke as well as heart failure. MA is a key factor for good clinical outcomes in persons with hypertension.

OBJECTIVE

The overall aim of this study is to design, develop, test, and evaluate an adaptive digital intervention called iMedA, delivered via a mobile app to improve MA, self-care management, and blood pressure control for persons with hypertension.

METHODS

The study design is an interrupted time series. We will collect data on a daily basis, 14 days before, during 6 months of delivering digital interventions through the mobile app, and 14 days after. The effect will be analyzed using segmented regression analysis. The participants will be recruited in Region Halland, Sweden. The design of the digital interventions follows the just-in-time adaptive intervention framework. The primary (distal) outcome is MA, and the secondary outcome is blood pressure. The design of the digital intervention is developed based on a needs assessment process including a systematic review, focus group interviews, and a pilot study, before conducting the longitudinal interrupted time series study.

RESULTS

The focus groups of persons with hypertension have been conducted to perform the needs assessment in a Swedish context. The design and development of digital interventions are in progress, and the interventions are planned to be ready in November 2020. Then, the 2-week pilot study for usability evaluation will start, and the interrupted time series study, which we plan to start in February 2021, will follow it.

CONCLUSIONS

We hypothesize that iMedA will improve medication adherence and self-care management. This study could illustrate how self-care management tools can be an additional (digital) treatment support to a clinical one without increasing burden on health care staff.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04413500; https://clinicaltrials.gov/ct2/show/NCT04413500.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24494.

Using a Commercially Available App for the Self-Management of Hypertension: Acceptance and Usability Study in Saudi Arabia

BACKGROUND

The use of smartphone apps to assist in the self-management of hypertension is becoming increasingly common, but few commercially available apps have the potential to be effective along with adequate security and privacy measures in place. In a previous study, we identified 5 apps that are potentially effective and safe, and based on the preferences of doctors and patients, one (Cora Health) was selected as the most suitable app for use in a Saudi context. However, there is currently no evidence of its usability and acceptance among potential users. Indeed, there has been little research into the usability and acceptance of hypertension apps in general, and less research considers this in the Gulf Region.

OBJECTIVE

This study aims to evaluate the acceptance and usability of the selected app in the Saudi context.

METHODS

This study used a mixed methods approach with 2 studies: a usability test involving patients in a controlled setting performing predefined tasks and a real-world usability study where patients used the app for 4 weeks. In the usability test, participants were asked to think aloud while performing the tasks, and an observer recorded the number of tasks they completed. At the end of the real-world pilot study, participants were interviewed, and the mHealth App Usability Questionnaire was completed. Descriptive statistics were used to analyze quantitative data, and thematic analysis was used to analyze qualitative data.

RESULTS

In total, 10 patients completed study 1. The study found that app usability was moderate and that participants needed some familiarization time before they could use the app proficiently. Some usability issues were revealed, related to app accessibility and navigation, and a few tasks remained uncompleted by most people. A total of 20 patients completed study 2, with a mean age of 51.6 (SD 11.7) years. Study 2 found that the app was generally acceptable and easy to use, with some similar usability issues identified. Participants stressed the importance of practice and training to use it more easily and proficiently. Participants had a good engagement level with 48% retention at the end of study 2, with most participants' engagement being classed as meaningful. The most recorded data were blood pressure, followed by stress and medication, and the most accessed feature was viewing graphs of data trends.

CONCLUSIONS

This study shows that a commercially available app can be usable and acceptable in the self-management of hypertension but also found a considerable number of possibilities for improvement, which needs to be considered in future app development. The results show that there is potential for a commercially available app to be used in large-scale studies of hypertension self-management if suggestions for improvements are addressed.

The use of mobile phones for the prevention and control of arboviral diseases: a scoping review

BACKGROUND

The rapid expansion of dengue, Zika and chikungunya with large scale outbreaks are an increasing public health concern in many countries. Additionally, the recent coronavirus pandemic urged the need to get connected for fast information transfer and exchange. As response, health programmes have -among other interventions- incorporated digital tools such as mobile phones for supporting the control and prevention of infectious diseases. However, little is known about the benefits of mobile phone technology in terms of input, process and outcome dimensions. The purpose of this scoping review is to analyse the evidence of the use of mobile phones as an intervention tool regarding the performance, acceptance, usability, feasibility, cost and effectiveness in dengue, Zika and chikungunya control programmes.

METHODS

We conducted a scoping review of studies and reports by systematically searching: i) electronic databases (PubMed, PLOS ONE, PLOS Neglected Tropical Disease, LILACS, WHOLIS, ScienceDirect and Google scholar), ii) grey literature, using Google web and iii) documents in the list of references of the selected papers. Selected studies were categorized using a pre-determined data extraction form. Finally, a narrative summary of the evidence related to general characteristics of available mobile health tools and outcomes was produced.

RESULTS

The systematic literature search identified 1289 records, 32 of which met the inclusion criteria and 4 records from the reference lists. A total of 36 studies were included coming from twenty different countries. Five mobile phone services were identified in this review: mobile applications (n = 18), short message services (n=7), camera phone (n = 6), mobile phone tracking data (n = 4), and simple mobile communication (n = 1). Mobile phones were used for surveillance, prevention, diagnosis, and communication demonstrating good performance, acceptance and usability by users, as well as feasibility of mobile phone under real life conditions and effectiveness in terms of contributing to a reduction of vectors/ disease and improving users-oriented behaviour changes. It can be concluded that there are benefits for using mobile phones in the fight against arboviral diseases as well as other epidemic diseases. Further studies particularly on acceptance, cost and effectiveness at scale are recommended.

Patients' Experiences of Using Smartphone Apps to Support Self-Management and Improve Medication Adherence in Hypertension: Qualitative Study

BACKGROUND

Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support.

OBJECTIVE

The aim of this study is to explore patients' experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension.

METHODS

A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data.

RESULTS

Participants' age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients' experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence.

CONCLUSIONS

The study's findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study's findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients.

Increasing and Evolving Role of Smart Devices in Modern Medicine

Today is an age of rapid digital integration, yet the capabilities of modern-day smartphones and smartwatches are underappreciated in daily clinical practice. Smartphones are ubiquitous, and smartwatches are very common and on the rise. This creates a wealth of information simply waiting to be accessed, studied and applied clinically, ranging from activity level to various heart rate metrics. This review considers commonly used devices, the validity and accuracy of the data they obtain and potential clinical application of the data.

Using mHealth for the management of hypertension in UK primary care: an embedded qualitative study of the TASMINH4 randomised controlled trial

BACKGROUND

Self-monitoring of blood pressure is common but how telemonitoring with a mobile healthcare (mHealth) solution in the management of hypertension can be implemented by patients and healthcare professionals (HCPs) is currently unclear.

AIM

Evaluation of facilitators and barriers to self- and telemonitoring interventions for hypertension within the Telemonitoring and Self-monitoring in Hypertension (TASMINH4) trial.

DESIGN AND SETTING

An embedded process evaluation of the TASMINH4 randomised controlled trial (RCT), in the West Midlands, in UK primary care, conducted between March 2015 and September 2016.

METHOD

A total of 40 participants comprising 23 patients were randomised to one of two arms: mHealth (self-monitoring by free text/short message service [SMS]) and self-monitoring without mHealth (self-monitoring using paper diaries). There were also15 healthcare professionals (HCPs) and two patient caregivers.

RESULTS

Four key implementation priority areas concerned: acceptability of self- and telemonitoring to patients and HCPs; managing data; communication; and integrating self-monitoring into hypertension management (structured care). Structured home monitoring engaged and empowered patients to self-monitor regardless of the use of mHealth, whereas telemonitoring potentially facilitated more rapid communication between HCPs and patients. Paper-based recording integrated better into current workflows but required additional staff input.

CONCLUSION

Although telemonitoring by mHealth facilitates easier communication and convenience, the realities of current UK general practice meant that a paper-based approach to self-monitoring could be integrated into existing workflows with greater ease. Self-monitoring should be offered to all patients with hypertension. Telemonitoring appears to give additional benefits to practices over and above self-monitoring but both need to be offered to ensure generalisability.

Interactive Mobile Health Intervention and Blood Pressure Management in Adults

Despite the availability of effective drugs, blood pressure (BP) control remains poor among most populations. To explore the effects of interactive mobile health (mhealth) intervention on BP management and find out the optimal target population, we performed a systematic review and meta-analysis of randomized controlled trials to estimate the pooled effects of mhealth intervention on BP control. PubMed, EMBASE, Cochrane Library, and CNKI were searched to identify eligible randomized controlled trials published between January 15, 2007 and April 28, 2019, and bibliographies of eligible articles were further reviewed. Random-effect models were utilized to pool estimates of net changes in systolic BP and diastolic BP between mhealth intervention group and control group. Eleven randomized controlled trials met the inclusion criteria, with a total sample size of 4271 participants. Compared with the control group, mhealth intervention was associated with significant changes in systolic BP and diastolic BP of -3.85 mm Hg; 95% CI, -4.74 to -2.96 and -2.19 mm Hg; 95% CI, -3.16 to -1.23, respectively. Subgroup analyses revealed consistent effects across study duration and intervention intensity subgroups. In addition, participants with inadequate BP control at recruitment might gain more benefits with mhealth intervention. Therefore, interactive mhealth intervention may be a useful tool for improving BP control among adults, especially among those with inadequate BP control.

Patients' Perceptions of mHealth Apps: Meta-Ethnographic Review of Qualitative Studies

BACKGROUND

Mobile phones and tablets are being increasingly integrated into the daily lives of many people worldwide. Mobile health (mHealth) apps have promising possibilities for optimizing health systems, improving care and health, and reducing health disparities. However, health care apps often seem to be underused after being downloaded.

OBJECTIVE

The aim of this paper is to reach a better understanding of people's perceptions, beliefs, and experience of mHealth apps as well as to determine how highly they appreciate these tools.

METHODS

A systematic review was carried out on qualitative studies published in English, on patients' perception of mHealth apps between January 2013 and June 2018. Data extracted from these articles were synthesized using a meta-ethnographic approach and an interpretative method.

RESULTS

A total of 356 articles were selected for screening, and 43 of them met the inclusion criteria. Most of the articles included populations inhabiting developed countries and were published during the last 2 years, and most of the apps on which they focused were designed to help patients with chronic diseases. In this review, we present the strengths and weaknesses of using mHealth apps from the patients' point of view. The strengths can be categorized into two main aspects: engaging patients in their own health care and increasing patient empowerment. The weaknesses pointed out by the participants focus on four main topics: trustworthiness, appropriateness, personalization, and accessibility of these tools.

CONCLUSIONS

Although many of the patients included in the studies reviewed considered mHealth apps as a useful complementary tool, some major problems arise in their optimal use, including the need for more closely tailored designs, the cost of these apps, the validity of the information delivered, and security and privacy issues. Many of these issues could be resolved with more support from health providers. In addition, it would be worth developing standards to ensure that these apps provide patients accurate evidence-based information.

Exploring the perspectives of stroke survivors and healthcare professionals on the use of mobile health to promote physical activity: A qualitative study protocol

Background: Physical inactivity is both the second-highest population attributable risk factor for and a common consequence of stroke. Despite well-documented health benefits associated with physical activity, its levels typically remain below recommended guidelines in stroke survivors. Consequently, calls have been made for novel interventions targeting the promotion of physical activity in stroke survivors. Mobile health is an emerging field which can offer personalised health interventions through mobile and wireless technology. However, a paucity of research has focused on mobile health to promote physical activity in stroke survivors and, more broadly, this field has been criticised for not incorporating the views of stakeholders. This study aims to explore the perspectives of stroke survivors and healthcare professionals on the development of a mobile health intervention for the promotion of physical activity. Methods: The current study will employ a qualitative descriptive approach using separate, semi-structured focus groups for two key stakeholder groups. Community-dwelling stroke survivors will be recruited through an early supported discharge service for acute stroke and stroke support groups. Healthcare professionals will be recruited through the same early supported discharge service, relevant professional bodies and Twitter. The final number of focus groups will depend on data saturation. Thematic analysis will be conducted using NVivo 12 and findings will be reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies. Conclusion: This study was granted ethical approval from the HSE Mid-Western Regional Hospital Research Ethics Committee and the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick. Output will consist of recommendations for the development of a mobile health intervention aimed at the promotion of physical activity in stroke survivors. Findings will be disseminated locally through presentations at stroke support groups, as well as internationally through academic conferences and peer-reviewed journals.

A qualitative comparison of high and low adherers with apparent treatment-resistant hypertension

Poor adherence is a leading cause of apparent resistance to antihypertensive treatment. Recent empirical research has investigated predictors of adherence for primary care patients who are apparently resistant to treatment; however, questions remain regarding the variability in adherence behaviour among this group. This study aimed to investigate factors that may elucidate medication adherence among patients with apparent treatment-resistant hypertension (aTRH) using qualitative methods. Fourteen semi-structured interviews were conducted with patients undergoing treatment for aTRH in primary care in the West of Ireland. Patients who self-reported both high and low adherence in a previous quantitative study were purposively sampled. Data were analysed using thematic analysis. A public and patient involvement research group were active partners in developing the study protocol and interview topic guide. Three major themes were identified: beliefs about treatment, habits and routine, and health and health systems. High adherers reported favourable beliefs about antihypertensive treatment that had been validated by experience with taking the treatment over time, described strong medication-taking habits and stable routines, and positive relations with their GP. Low adherers expressed less coherence in their beliefs and used less effective strategies to support their medication-taking in daily life. The current findings are consistent with qualitative studies of adherence in other chronic conditions. Results reflect the difficulty for healthcare practitioners in identifying adherent versus non-adherent patients via conversation, and highlight the importance of accurate adherence assessment. Inception studies may provide an opportunity to better understand adherence behaviour across the illness trajectory.

Specific hypertension smartphone application to improve medication adherence in hypertension: a cluster-randomized trial

Introduction: Digital interventions, such as smartphone applications (apps), are becoming an increasingly common way to support medication adherence and self-management in chronic illness.Aim: To evaluate the effectiveness of the intervention in pharmacological therapeutic adherence in mild to moderate arterial hypertension (AHT), through an app installed on a mobile phone, as well as the degree of control reached by the patient with this tool.Methods: Prospective, randomized controlled trial, full study and multicenter study. Four primary care centers participated. One hundred and fifty-four hypertensive patients under antihypertensive treatment were included. Two groups were established: a control group (CG) with usual intervention (n = 77) and an intervention group (n = 77) (IG), targeting hypertensive people who owned and regularly used a mobile smartphone, specifically using the app called AlerHTA to promote health education and reminder of appointments. There were three visits: initial, 6 and 12 months. Drug adherence was measured by electronic monitors (MEMSs). The primary outcomes were average daily percentage adherence between 80 and 100%, and AHT control.Results: A total of 148 patients finished the study. Mean age was 57.5 ± 9.9. Global adherence was 77.02% (CI = 70.25-83.79) and daily adherence was 74.32% (CI = 67.29-81.35%). Daily adherence was 93.15% and 86.3% in IG, and 70.66% and 62.66% in CG after 6 and 12 months respectively (p < .05). The percentage of uncontrolled patients was 28.3% (CI = 21.05-35.55%). The control of high blood pressure at 12 months was 17.8% and 38.6% for IG and CG respectively (p < .05). The number of patients needed to treat to avoid non-adherence (NNT) was 4.23 patients.Conclusions: The intervention with an app installed on the mobile phones of hypertensive patients favors pharmacological therapeutic adherence and improves the percentage of hypertensive patient control.Trial registration: Spanish Agency of Medicine: EPA-SP UN-HTA-2015-01.