User Preferences and Design Recommendations for an mHealth App to Promote Cystic Fibrosis Self-Management

Barriers and enablers of digital health use in managing chronic suppurative lung diseases in children and adolescents: Perspectives from healthcare professionals and parents

BACKGROUND

Digital health sources (DHSs) become increasingly integral in healthcare of chronic respiratory diseases. Identifying barriers and facilitators of using DHSs for the care of children and adolescents with chronic suppurative lung diseases (CSLDs) is key for their successful implementation and potential improvements in disease management. The objective of this study was to identify the perceived barriers and facilitators of healthcare professionals (HCPs) and parents of children and adolescents with CSLDs for the use of DHSs.

METHODS

Two focus groups, one with seven HCPs and one with six parents, run through Microsoft Teams. An experienced moderator led both sessions with the assistance of two facilitators, using a semi-structured topic guide. Audiovisual recording was verbatim transcribed, and followed by thematic analysis.

RESULTS

Overall, eleven main themes were yield. Technical complexities, psychological aversions, socioeconomic challenges, privacy concerns, and therapy-related issues were identified as barriers to the adoption of DHSs. Attractive content, improved accessibility, technical support, familiarity with technology, training for users, and shared decision-making with the family, were reported as core facilitators. Technical complexities and psychological aversions were common barriers in both focus groups, whereas content, accessibility, and technical support were common facilitators.

CONCLUSIONS

DHSs for children and adolescents with CSLDs need to consider attractive content layout, technical assistance, cost-free accessibility, and broad compatibility, since these are important issues reported by HCPs and parents.

A scoping review of the types and features of technology used to deliver exercise prescription and improve exercise adherence

OBJECTIVE

Exercise adherence and motivation can benefit from technology, but the specific factors influencing these improvements remain unclear. This scoping review aimed to outline the types and features of technology used in exercise prescription within healthcare, focusing on enhancing users' adherence to exercise.

METHODS

A comprehensive systematic literature search was conducted from January 2000 to February 2023 across Web of Science, Google Scholar, and MEDLINE via PubMed. The review sought studies on technology-based exercise prescriptions for adults ≥ 18 years, evaluating features that enhance motivation or adherence.

RESULTS

Out of 1724 articles reviewed, 45 met the criteria, demonstrating that mobile applications, exercise gaming, wearable trackers, and websites are commonly used technologies for prescribing exercise in healthcare setting. Common features, special features, and motivating features were found to be important in all technology-based exercise tools to enhance users' adherence and motivation.

CONCLUSION

This review provides a comprehensive overview of the technological types and approaches that can support and improve exercise adherence among health service users. The findings also emphasize on specific features that can address current gaps in technology-driven fitness interventions.

PRACTICE IMPLICATIONS

Healthcare professionals should make informed decisions when recommending these tools to health service users, since technology does play a significant role in promoting long-term adherence to exercise programs.

Requirements and Key Features of a Mobile Application for Adolescent Self-Care From a Stakeholders Perspective: A Qualitative Study

Adolescence is characterized by many changes and these changes differentiate adolescents' self-care needs. The use of smartphones and tablets to provide healthcare services has expanded, and the user-centered design could help to create mobile applications based on users' needs. Therefore, the present study aimed to identify the data requirements and key features of mobile application for adolescent self-care from a stakeholder perspective. This study was conducted with a qualitative approach to identify the key features of mobile application for adolescent's self-care as well as educational content axes for five component of self-care using conventional and directed content analysis respectively. From 3 sub-groups 30 participants were selected based on purposive sampling with maximum variety and sampling was performed until data saturation. Data were collected through in-depth semi-structured interviews. Participants' informed consent was obtained before the interview. The interview lasted 20-40 min and MAXQDA software version 10 was used for data analysis. In this study, four criteria of acceptability, reliability, transferability, and validity proposed by Guba and Lincoln were used to evaluate and validate the data. After conducting the interviews, 789 initial codes, 12 sub-categories, and 3 categories (app view, app content architecture, app self-care content) were emerged, which reflects the key features of a mobile application and the necessary educational content. The research findings could provide a guide for future mobile application development considering the viewpoints of health professionals, content, and software experts. Addressing the features and requirements in practice could lead to designing efficient and effective mobile applications.

Discovering what young adults want in electronic interventions aimed at reducing alcohol-related consequences

BACKGROUND

Despite intervention efforts, negative alcohol-related consequences continue to impact young adults. Most alcohol interventions focus on reducing alcohol consumption; however, previous research indicates that focusing solely on alcohol use may not decrease consequences. Additionally, many alcohol interventions have diminishing engagement, and few are designed with young adults involved in the development process. Drawing on user-centered design, this study sought to understand young adult perceptions, preferences, and needs for electronic interventions specifically aimed at reducing alcohol consequences.

METHODS

Using semi-structured qualitative interviews, 21 young adult drinkers (ages 18-24; 57.1% female) shared their opinions regarding the need for electronic interventions (i.e., mobile or web-delivered) to reduce alcohol consequences as well as their preferences for content, features, and ways to increase engagement. Interviews were coded and analyzed using a multi-step thematic analysis approach.

RESULTS

As part of our discovery phase of intervention development, content coding revealed four main themes. Participants perceived several benefits of interventions focused on alcohol consequences, such as promoting mindful alcohol use and reducing alcohol-related harms. Participants also discussed perceived limitations of such programs, including believing consequences from drinking are unavoidable, necessary for learning, and associated with peer pressure. Preferences for features included real-time tracking, personalized feedback, and psychoeducation along with preferences for design including non-judgmental framing, interactive content, and a user-friendly platform.

CONCLUSIONS

Engaging end users early in the development process is a valuable approach to increase intervention relevancy with the target population. This can also inform intervention content and design to maximize engagement and satisfaction (e.g., framing, features, and interactivity) while also reducing barriers identified early on (e.g., peer pressure).

Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework

BACKGROUND

Digital serious games (SGs) have rapidly become a promising strategy for entertainment-based health education; however, developing SGs for children with chronic diseases remains a challenge.

OBJECTIVE

In this study, we attempted to provide an updated scope of understanding of the development and evaluation of SG educational tools and develop a framework for SG education development to promote self-management activities and behavior change in children with chronic diseases.

METHODS

This study consists of a knowledge base and an analytical base. This study followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. To build the knowledge base, 5 stages of research were developed, including refining the review question (stage 1), searching for studies (stage 2), selecting relevant studies (stage 3), charting the information (stage 4), and collating the results (stage 5). Eligible studies that developed SG prototypes and evaluated SG education for children with chronic diseases were searched for in PubMed, Embase, Google Scholar, and peer-reviewed journals. In the analytical base, the context-mechanism-output approach and game taxonomy were used to analyze relevant behavioral theories and essential game elements. Game taxonomy included social features, presentation, narrative and identity, rewards and punishment, and manipulation and control. A total of 2 researchers selected the domains for the included behavioral theories and game elements. The intended SG framework was finalized by assembling SG fragments. Those SG fragments were appropriately reintegrated to visualize a new SG framework.

RESULTS

This scoping review summarized data from 16 randomized controlled trials that evaluated SG education for children with chronic diseases and 14 studies on SG frameworks. It showed that self-determination theory was the most commonly used behavioral theory (9/30, 30%). Game elements included feedback, visual and audio designs, characters, narratives, rewards, challenges, competitions, goals, levels, rules, and tasks. In total, 3 phases of a digital SG framework are proposed in this review: requirements (phase 1), design and development (phase 2), and evaluation (phase 3). A total of 6 steps are described: exploring SG requirements (step 1), identifying target users (step 2), designing an SG prototype (step 3), building the SG prototype (step 4), evaluating the SG prototype (step 5), and marketing and monitoring the use of the SG prototype (step 6). Safety recommendations to use digital SG-based education for children in the post-COVID-19 era were also made.

CONCLUSIONS

This review summarizes the fundamental behavioral theories and game elements of the available literature to establish a new theory-driven step-by-step framework. It can support game designers, clinicians, and educators in designing, developing, and evaluating digital, SG-based educational tools to increase self-management activities and promote behavior change in children with chronic diseases.

Cross-Cutting mHealth Behavior Change Techniques to Support Treatment Adherence and Self-Management of Complex Medical Conditions: Systematic Review

Background

Mobile health (mHealth) interventions have immense potential to support disease self-management for people with complex medical conditions following treatment regimens that involve taking medicine and other self-management activities. However, there is no consensus on what discrete behavior change techniques (BCTs) should be used in an effective adherence and self-management-promoting mHealth solution for any chronic illness. Reviewing the extant literature to identify effective, cross-cutting BCTs in mHealth interventions for adherence and self-management promotion could help accelerate the development, evaluation, and dissemination of behavior change interventions with potential generalizability across complex medical conditions.

Objective

This study aimed to identify cross-cutting, mHealth-based BCTs to incorporate into effective mHealth adherence and self-management interventions for people with complex medical conditions, by systematically reviewing the literature across chronic medical conditions with similar adherence and self-management demands.

Methods

A registered systematic review was conducted to identify published evaluations of mHealth adherence and self-management interventions for chronic medical conditions with complex adherence and self-management demands. The methodological characteristics and BCTs in each study were extracted using a standard data collection form.

Results

A total of 122 studies were reviewed; the majority involved people with type 2 diabetes (28/122, 23%), asthma (27/122, 22%), and type 1 diabetes (19/122, 16%). mHealth interventions rated as having a positive outcome on adherence and self-management used more BCTs (mean 4.95, SD 2.56) than interventions with no impact on outcomes (mean 3.57, SD 1.95) or those that used >1 outcome measure or analytic approach (mean 3.90, SD 1.93; P=.02). The following BCTs were associated with positive outcomes: self-monitoring outcomes of behavior (39/59, 66%), feedback on outcomes of behavior (34/59, 58%), self-monitoring of behavior (34/59, 58%), feedback on behavior (29/59, 49%), credible source (24/59, 41%), and goal setting (behavior; 14/59, 24%). In adult-only samples, prompts and cues were associated with positive outcomes (34/45, 76%). In adolescent and young adult samples, information about health consequences (1/4, 25%), problem-solving (1/4, 25%), and material reward (behavior; 2/4, 50%) were associated with positive outcomes. In interventions explicitly targeting medicine taking, prompts and cues (25/33, 76%) and credible source (13/33, 39%) were associated with positive outcomes. In interventions focused on self-management and other adherence targets, instruction on how to perform the behavior (8/26, 31%), goal setting (behavior; 8/26, 31%), and action planning (5/26, 19%) were associated with positive outcomes.

Conclusions

To support adherence and self-management in people with complex medical conditions, mHealth tools should purposefully incorporate effective and developmentally appropriate BCTs. A cross-cutting approach to BCT selection could accelerate the development of much-needed mHealth interventions for target populations, although mHealth intervention developers should continue to consider the unique needs of the target population when designing these tools.

Understanding Physical Activity Determinants in an HIV Self-Management Intervention: Qualitative Analysis Guided by the Theory of Planned Behavior

BACKGROUND

People living with HIV have long life expectancy and are experiencing more comorbid conditions, being at an increased risk for developing cardiovascular disease (CVD) and diabetes, further exacerbated due to the HIV or inflammatory process. One effective intervention shown to decrease mortality and improve health outcomes related to CVD and diabetes in people living with HIV is increased regular physical activity. However, people living with HIV often fall short of the daily recommended physical activity levels. While studies show that mobile health (mHealth) can potentially help improve people's daily activity levels and reduce mortality rates due to comorbid conditions, these studies do not specifically focus on people living with HIV. As such, it is essential to understand how mHealth interventions, such as wearables, can improve the physical activity of people living with HIV.

OBJECTIVE

This study aimed to understand participants' experiences wearing a fitness tracker and an app to improve their physical activity.

METHODS

In total, 6 focus groups were conducted with participants who completed the control arm of a 6-month randomized controlled trial (ClinicalTrials.gov NCT03205982). The control arm received daily walk step reminders to walk at least 5000 steps per day and focused on the overall wellness of the individual. The analysis of the qualitative focus groups used inductive content analysis using the theory of planned behavior as a framework to guide and organize the analysis.

RESULTS

In total, 41 people living with HIV participated in the focus groups. The majority (n=26, 63%) of participants reported their race as Black or African American, and 32% (n=13) of them identified their ethnicity as Hispanic or Latino. In total, 9 major themes were identified and organized following the theory of planned behavior constructs. Overall, 2 major themes (positive attitude toward tracking steps and tracking steps is motivating) related to attitudes toward the behavior, 2 major themes (social support or motivation from the fitness tracker and app and encouragement from family and friends) related to participant's subjective norms, 1 theme (you can adjust your daily habits with time) related to perceived behavioral control, 2 themes (reach their step goal and have a healthier lifestyle) related to participant's intention, and 2 themes (continuing to walk actively and regularly wearing the fitness tracker) related to participant's changed behavior. Participants highlighted how the mHealth interface with the avatar and daily step tracking motivated them to both begin and continue to engage in physical activity by adjusting their daily routines.

CONCLUSIONS

Findings from this study illustrate how features of mHealth apps may motivate people living with HIV to start and continue sustained engagement in physical activities. This sustained increase in physical activity is crucial for reducing the risk of comorbid conditions such as diabetes or CVD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03205982; https://classic.clinicaltrials.gov/ct2/show/NCT03205982.

Mobile health platform for self-management of pediatric cystic fibrosis: Impact on patient-centered care outcomes

BACKGROUND

Previously, we adapted a mobile health platform (Genia) to the needs of patients and families in a pediatric CF center in the United States. In this feasibility study, we tested the impact of Genia on measures of patient-centered care.

METHODS

In a one-group pre-post study with adolescents with CF and caregivers of children with CF, we tested Genia's effect over 6 months on patient satisfaction with chronic illness care (PACIC) and shared decision-making (CollaboRate). Feasibility and acceptability were assessed with exit interviews and app analytics.

RESULTS

The intervention included 40 participants: 30 caregivers of children with CF age ≤14 years and 10 patients with CF age ≥15 years. The use of Genia was associated with increased satisfaction with care (p = 0.024), including delivery system and decision support (p = 0.017), goal setting (p = 0.006), and shared decision-making (p<0.001). The use of Genia was associated with nominal improvements in all QOL domains and symptom scales. The platform was feasible, with participants recording more than 4,400 observations (mean 84.2) and submitting 496 weekly reports (mean 13.8) and 70 quarterly reports (mean 1.8), and acceptable (95% retention rate). For participants, the most useful app feature was pre-visit reports (66.7%), and the top symptom trackers were those for cough (23.7%), appetite (21.1%), energy (18.4%), and medicines (18.4%).

CONCLUSION

The use of Genia over 6 months was feasible, acceptable, and associated with improved measures of patient-centered care. Study results support wider use of Genia in clinical settings. Efficacy for clinical outcomes should be assessed in a randomized clinical trial.

Guidelines to Establish an Equitable Mobile Health Ecosystem

Mobile health (mHealth)-that is, use of mobile devices, such as mobile phones, monitoring devices, personal digital assistants, and other wireless devices, in medical care-is a promising approach to the provision of support services. mHealth may aid in facilitating monitoring of mental health conditions, offering peer support, providing psychoeducation (i.e., information about mental health conditions), and delivering evidence-based practices. However, some groups may fail to benefit from mHealth despite a high need for mental health services, including people from racially and ethnically disadvantaged groups, rural residents, individuals who are socioeconomically disadvantaged, and people with disabilities. A well-designed mHealth ecosystem that considers multiple elements of design, development, and implementation can afford disadvantaged populations the opportunity to address inequities and facilitate access to and uptake of mHealth. This article proposes inclusion of the following principles and standards in the development of an mHealth ecosystem of equity: use a human-centered design, reduce bias in machine-learning analytical techniques, promote inclusivity via mHealth design features, facilitate informed decision making in technology selection, embrace adaptive technology, promote digital literacy through mHealth by teaching patients how to use the technology, and facilitate access to mHealth to improve health outcomes.

Addressing and evaluating health literacy in mHealth: a scoping review

Background

Recent surveys have revealed many adults have basic or below basic health literacy, which is linked to medical errors, increased illness, and compromised public health. Health literacy as a concept is multi-faceted extending beyond the individual to include social structures and the context in which health information is being accessed. Delivering health information via mobile devices (mHealth) expands the amount of information available while presenting challenges to ensuring these materials are suitable for a variety of literacy needs. The aims of this study are to discover how health literacy is addressed and evaluated in mHealth app development.

Methods

A scoping review of 5 peer-reviewed databases was conducted. Eligible articles were written in English, addressed general literacy or mHealth/digital/eHealth literacy, and collected literacy information in order to incorporate literacy into the design and/or modification of an app or collected literacy information to describe the population being studied. The "Health Literacy Online" (HLO) United States (U.S.) government guide was used as a framework.

Results

Thirty-two articles were reviewed. Articles included health literacy recommendations for all HLO categories and some recommendations not aligned with these categories. Most articles addressed health literacy using specific HLO categories though none incorporated every HLO category. The most common categories addressed engagement and testing of mHealth content. Though several studies addressed health literacy through a formal assessment tool, most did not. Evaluation of health literacy in mHealth was end-user focused and did not extensively evaluate content for fit to a variety of individuals with limited health literacy.

Conclusions

The recommendations seen consistently in our results in conjunction with formal HLO categories can act as beginning steps towards development of a health literacy evaluation tool for mHealth apps themselves. It is clear efforts are being made to reduce barriers to using mHealth for those with literacy deficits, however, it was also clear that this space has room to be more pragmatic in evaluation of mHealth tools for literacy. End user engagement in design and testing is necessary in future mHealth literacy tool development.

Understanding motivation for Australian adolescents and young adults with cystic fibrosis: Modifiable factors to support self-management

Cystic fibrosis (CF) is Australia's most common life limiting genetic condition, characterised by declining health and quality of life (QoL) over time. Despite improvements in treatment, there remains no cure. Adolescents and young adults (AYAs) with CF experience broad impacts to psychosocial functioning and QoL, as well as major transitions in care, all at a time of significant developmental change. The importance of developmentally tailored approaches to youth health care and self-management for young people with CF are well understood. However, to date, models of youth specific self-management have been lacking and motivation for young people with CF has not been well explored. This qualitative study, based on a social constructionist epistemological framework, addresses this gap. A total of 21 AYAs aged 15-30 years were recruited through one paediatric and one adult Australian CF centre. Demographic, clinical and distress data were captured to describe health complexity. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis. Participants were representative of Australian AYAs with CF by demography and clinical status. Alarmingly, over a third reported clinically significant distress. Two themes emerged. The first Identified impacts to motivation and self-management resulting from the challenges of managing CF, life and care. These included time and competing priorities, changing health statis, mental health, social factors, unmet needs and health system complexity. The second identified factors that support motivation including: achievement, meaning and purpose; consequence avoidance; and accountability. These results illustrate the importance of AYA specific, theoretically founded, holistic self-management models which extend beyond current theoretical approaches that aim to understand behaviour change or address barriers, in isolation from motivation. Improved approaches to care based on these findings are essential to foster positive behavioural change, support self-management and foster the best health outcomes for young people living with CF.

Role of Social and App-Related Factors in Behavioral Engagement With mHealth for Improved Well-being Among Chronically Ill Patients: Scenario-Based Survey Study

Background

The last decade has seen a considerable increase in the number of mobile health (mHealth) apps in everyday life. These mHealth apps have the potential to significantly improve the well-being of chronically ill patients. However, behavioral engagement with mHealth apps remains low.

Objective

The aim of this study was to describe the behavioral engagement of chronically ill patients with mHealth apps by investigating (1) how it is affected by social factors (ie, physician recommendation) and app-related factors (ie, app integration) and (2) how it affects patient well-being. This study also considers the moderating effect of attachment to traditional health care and the mobile app experience among patients.

Methods

We carried out a scenario-based survey study of chronically ill patients (N=521). A Bayesian structural equation modeling with mediation and moderation analysis was conducted in MPlus.

Results

Both physician recommendations for mHealth app use and app integration have positive effects on the behavioral engagement of chronically ill patients with mHealth apps. Higher behavioral engagement positively affects the hedonic well-being (extent of pleasure) and the eudaemonic well-being (extent of self-efficacy) of chronically ill patients. Mobile app experience, however, positively moderates the relationship between app integration and behavioral engagement, whereas patient attachment to traditional care does not moderate the relationship between physician recommendation and behavioral engagement. Taken together, the proportion of variance explained (R²) equals 21% for behavioral engagement and 52.8% and 62.2% for hedonic and eudaemonic well-being, respectively, thereby providing support for the strong influence of app integration and physician recommendation via the mediation of the patients’ behavioral engagement on both patients’ hedonic and eudaemonic well-being.

Conclusions

Physician recommendation and app integration enable behavioral engagement and promote well-being among chronically ill patients. It is thus important to take social and app-related factors into consideration during and after the development of mHealth apps.

Directly observed therapy to promote medication adherence in adolescent heart transplant recipients

PURPOSE

HT recipients experience high levels of medication non-adherence during adolescence. This pilot study examined the acceptability and feasibility of an asynchronous DOT mHealth application among adolescent HT recipients. The app facilitates tracking of patients' dose-by-dose adherence and enables transplant team members to engage patients. The DOT application allows patients to self-record videos while taking their medication and submit for review. Transplant staff review the videos and communicate with patients to engage and encourage medication adherence.

METHODS

Ten adolescent HT recipients with poor adherence were enrolled into a single-group, 12-week pilot study examining the impact of DOT on adherence. Secondary outcomes included self-report measures from patients and parents concerning HRQOL and adherence barriers. Long-term health outcomes assessed included AR and hospitalization 6 months following DOT.

FINDINGS

Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility. Patients submitted 90.1% of possible videos demonstrating medication doses taken. MLVI values for the 10 patients initiating DOT decreased from 6 months prior to the intervention (2.86 ± 1.83) to 6 months following their involvement (2.08 ± 0.87) representing a 21.7% decrease in non-adherence, though not statistically significant given the small sample size.

CONCLUSIONS

Result of this pilot study provides promising insights regarding the feasibility, acceptability, and potential impact of DOT for adolescent HT recipients. Further randomized studies are required to confirm these observations.

Feasibility Testing of Tubes@HOME: A Mobile Application to Support Family-Delivered Enteral Care

BACKGROUND

Assistance from medical devices is common for children with medical complexity (CMC) but introduces caregiving challenges. We tested the feasibility of "Tubes@HOME," a mobile application supporting CMC family-delivered care using enteral care as a model.

METHODS

Caregivers of CMC with enteral tubes participated in a 30-day feasibility study of Tubes@HOME November 2020 through January 2021. Tubes@HOME was available on mobile devices and designed to support collaborative care and tracking over time. Key features include child profile, caregiving network management, care routines, feedback loop, and action plans. Care routines delineated nutrition, medication, and procedural tasks needed for the child: frequencies, completions, and reminders. Metadata summarized feature use among users. Feasibility was evaluated with postuse questionnaires and interviews. Measures of Tubes@HOME's usability and usefulness included the NASA Task Load Index (TLX), System Usability Scale (SUS), and Acceptability and Use of Technology Questionnaire (AUTQ).

RESULTS

Among n = 30 children, there were 30 primary (eg, parent) and n = 22 nonprimary caregivers using Tubes@HOME. Children had a median (IQR) 10 (5.5-13) care routines created. For care routines created, 93% were marked complete at least once during the study period, with participants engaging with routines throughout study weeks 2 to 4. Results (mean [SD]) indicated low mental workload (TLX) 30.9 (12.2), good usability (SUS) 75.4 (14.7), and above-average usefulness (AUTQ) 4.0 (0.7) associated with Tubes@HOME, respectively. Interviews contextualized usefulness and suggested improvements.

CONCLUSIONS

Longitudinal use of Tubes@HOME among caregiving networks appeared feasible. Efficacy testing is needed, and outcomes could include reliability of care delivered in home and community.

Young adult preferences for digital health interventions to support adherence to inhaled corticosteroids in asthma: a qualitative study

Objective: Adherence to inhaled corticosteroids (ICS) among young adults living with asthma is low and in need of appropriate intervention. Digital health interventions (DHIs) have demonstrated potential to improve ICS adherence; however, young adult preferences for these DHIs and how their use could support adherence in this population remain understudied. Therefore, this study aimed to explore young adult preferences for ICS adherence supports and potential DHI features to deliver these supports, in order to improve adherence behaviour throughout this critical developmental stage of the lifespan.

Methods: Qualitative, semi-structured interviews were conducted with 13 young adults living with asthma. Analysis followed an inductive, reflexive thematic approach.

Results: Participant’s age ranged from 18 to 30 years (M = 24.7; 8 female). Three themes were developed from the analysis: ‘Enabling young adults to find their ‘own way of knowing', ‘Support for making a habit of adherence’, and ‘Providing accessible information’ which included the sub-themes: ‘Education on asthma self-management and medication’, ‘Self-monitoring information’ and ‘Personal feedback on outcomes of adherence’. Suggested features to deliver these supports included a medication and prescription refill reminder, adherence charts, symptom and trigger monitoring, rewards for adherence, visual representations of lungs demonstrating the impact of adherence and lung function monitoring.

Conclusion: DHIs may offer an appropriate solution to improve suboptimal adherence to ICS in young adults. However, it is crucial that young adult preferences for adherence supports and features are integrated into these interventions in order to optimise engagement and support adherence behaviour in this population.

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

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

Investigating the use of digital health tools in physiotherapy: facilitators and barriers

BACKGROUND

Digital tools are becoming more and more common in healthcare. Their potential to improve treatment, monitoring, and coaching in physiotherapy has been recognized. Yet studies report that the adoption of digital health tools in ambulatory physiotherapy is rather low and that their potential is underexploited.

OBJECTIVE

This paper aims to investigate how digital health tools in general, and the mobile health tool physitrack^TM (hereafter the app) more particularly, are used in outpatient physiotherapy clinics and also to identify what facilitates or hinders the app's use.

METHODS

The paper is part of a larger study and adopts an ethnographic approach. It is based on observational and interview data collected at two outpatient clinics.

RESULTS

We reveal how physiotherapists and patients use the app in physiotherapy and identify 16 interdependent factors, on the macro-, meso-, and micro-level, that either facilitate or hinder its use.

CONCLUSIONS

We argue that a single factor's facilitating or hindering impact cannot be grasped in isolation but needs to be investigated as one piece of a dynamic interplay. Further qualitative research is required, especially to shed more light on the app's compatibility with physiotherapy practice and use in therapist-patient interactions.

Supporting Management of Noncommunicable Diseases With Mobile Health (mHealth) Apps: Experimental Study

BACKGROUND

Noncommunicable diseases (NCDs) are the leading global health problem in this century and are the principal causes of death and health care spending worldwide. Mobile health (mHealth) apps can help manage and prevent NCDs if people are willing to use them as supportive tools. Still, many people are reluctant to adopt these technologies. Implementing new apps could result in earlier intervention for many health conditions, preventing more serious complications.

OBJECTIVE

This research project aimed to test the factors that facilitate the adoption of mHealth apps by users with NCDs. We focused on determining, first, what user interface (UI) qualities and complexity levels appeal to users in evaluating mHealth apps. We also wanted to determine whether people prefer that the data collected by an mHealth app be analyzed using a physician or an artificial intelligence (AI) algorithm. The contribution of this work is both theoretical and practical. We examined users' considerations when adopting mHealth apps that promote healthy lifestyles and helped them manage their NCDs. Our results can also help direct mHealth app UI designers to focus on the most appealing aspects of our findings.

METHODS

A total of 347 respondents volunteered to rate 3 models of mHealth apps based on 16 items that measured instrumentality, aesthetics, and symbolism. Respondents rated each model after reading 1 of 2 different scenarios. In one scenario, a physician analyzed the data, whereas, in the other, the data were analyzed by an AI algorithm. These scenarios tested the degree of trust people placed in AI algorithms versus the "human touch" of a human physician regarding analyzing data collected by an mHealth app.

RESULTS

As shown by the responses, the involvement of a human physician in the application had a significant effect (P<.001) on the perceived instrumentality of the simple model. The complex model with more controls was rated significantly more aesthetic when associated with a physician performing data analysis rather than an AI algorithm (P=.03).

CONCLUSIONS

Generally, when participants found a human touch in the mHealth app (connection to a human physician who they assumed would analyze their data), they judged the app more favorably. Simple models were evaluated more positively than complex ones, and aesthetics and symbolism were salient predictors of preference. These trends suggest that designers and developers of mHealth apps should keep the designs simple and pay special attention to aesthetics and symbolic value.

Human-Centered Design of Mobile Health Apps for Older Adults: Systematic Review and Narrative Synthesis

BACKGROUND

The world is aging. The number of older patients is on the rise, and along with it comes the burden of noncommunicable diseases, both clinical and economic. Attempts with mobile health (mHealth) have been made to remedy the situation with promising outcomes. Researchers have adopted human-centered design (HCD) in mHealth creation to ensure those promises become a reality.

OBJECTIVE

This systematic review aims to explore existing literature on relevant primary research and case studies to (1) illustrate how HCD can be used to create mHealth solutions for older adults and (2) summarize the overall process with recommendations specific to the older population.

METHODS

We conducted a systematic review to address the study objectives. IEEE Xplore, Medline via Ovid, PubMed, and Scopus were searched for HCD research of mHealth solutions for older adults. Two independent reviewers then included the papers if they (1) were written in English, (2) included participants equal to or older than 60 years old, (3) were primary research, and (4) reported about mHealth apps and their HCD developments from start to finish. The 2 reviewers continued to assess the included studies' qualities using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was then carried out and completed.

RESULTS

Eight studies passed the eligibility criteria: 5 were mixed methods studies and 3 were case studies. Some studies were about the same mHealth projects with a total of 5 mHealth apps. The included studies differed in HCD goals, target groups, and details of their HCD methodologies. The HCD process was explored through narrative synthesis in 4 steps according to the International Standardization Organization (ISO) standard 9241-210: (1) understand and specify the context of use, (2) specify the user requirements, (3) produce design solutions to meet these requirements, and (4) evaluate the designs against requirements. The overall process and recommendations unique to older adults are summarized logically with structural order and time order based on the Minto pyramid principle and ISO 9241-210.

CONCLUSIONS

Findings show that HCD can be used to create mHealth solutions for older adults with positive outcomes. This review has also summarized practical HCD steps and additional suggestions based on existing literature in the subfield. However, evidence-based results are still limited because most included studies lacked details about their sampling methods and did not set objective and quantifiable goals, leading to failure to draw significant conclusions. More studies of HCD application on mHealth for older adults with measurable design goals and rigorous research strategy are warranted.

Is mHealth a useful therapy for improving physical or emotional health in adolescents with cystic fibrosis? A systematic review

Cystic fibrosis (CF) is a rare disease that severely compromises health and interferes with the lives of those who suffer from it and is especially challenging in adolescence. The use of tools such as MHealth may benefit the physical and psychological health of adolescents with CF. Therefore, this study aims to examine the benefits of MHealth in adolescents with CF through a systematic review. A search of the scientific literature following the PRISMA guidelines was conducted in the ProQuest Central, PubMed, Web Of Science, Embase and ínDICE databases, resulting in 186 studies, of which seven were selected (based on inclusion and exclusion criteria). Two blinded evaluators conducted the searches, the selection and data extraction process and the quality evaluation of the studies. The agreement between evaluators was excellent in all cases (Kappa ranged from .78 to .96). 214 pediatric CF patients (61.71% female) participated in the final analysis. The mean age was 12.76 years. The studies evaluated different types of mHealth tools, with greater homogeneity in the independent and dependent variables. The quality of the studies analyzed was poor, since these had small samples selected for convenience, conducted non-experimental and low-quality designs, recorded few variables, and their statistical analyses were not sufficiently robust. Further research is needed in this field, improving research designs and considering physical and psychological adjustment variables, as well as patients and family members in the process of health improvement.

Use of a Mobile App for the Process Evaluation of an Intervention in Health Care: Development and Usability Study

BACKGROUND

Process evaluation measures the context in which an outcome was or was not achieved through the ongoing monitoring of operations. Mobile apps are a potentially less burdensome tool for collecting these metrics in real time from participants. Research-driven apps are not always developed while paying attention to their usability for target users. Usability testing uncovers gaps in researchers', developers', and users' mental models of what an efficient, effective, and satisfying product looks like and facilitates design improvement. Models may vary by user demographics.

OBJECTIVE

This study describes the development of a mobile app for collecting process evaluation metrics in an intervention study with health care workers that uses feedback at multiple stages to refine the app design, quantify usage based on workers' overall adoption of the app and the app's specific function, and compare the demographic and job characteristics of end users.

METHODS

An app was developed to evaluate the Center for Promotion of Health in the New England Workplace Healthy Workplace Participatory Program, which trains teams to develop solutions for workforce health obstacles. Labor-management health and safety committee members, program champions, and managers were invited to use the app. An accompanying website was available for team facilitators. The app's 4 functions were meeting creation, postmeeting surveys, project time logs, and chat messages. Google Analytics recorded screen time. Two stages of pilot tests assessed functionality and usability across different device software, hardware, and platforms. In stage 1, student testers assessed the first functional prototype by performing task scenarios expected from end users. Feedback was used to fix issues and inform further development. In stage 2, the app was offered to all study participants; volunteers completed task scenarios and provided feedback at deployment. End user data for 18 months after deployment were summarized and compared by user characteristics.

RESULTS

In stage 1, functionality problems were documented and fixed. The System Usability Scale scores from 7 student testers corresponded to good usability (mobile app=72.9; website=72.5), whereas 15 end users rated usability as ok (mobile app=64.7; website=62.5). Predominant usability themes from student testers were flexibility and efficiency and visibility of system status; end users prioritized flexibility andefficiency and recognition rather than recall. Both student testers and end users suggested useful features that would have resulted in the large-scale restructuring of the back end; these were considered for their benefits versus cost. In stage 2, the median total use time over 18 months was 10.9 minutes (IQR 23.8) and 14.5 visits (IQR 12.5). There were no observable patterns in use by demographic characteristics.

CONCLUSIONS

Occupational health researchers developing a mobile app should budget for early and iterative testing to find and fix problems or usability issues, which can increase eventual product use and prevent potential gaps in data.

A Personalized Medical Decision Support System Based on Explainable Machine Learning Algorithms and ECC Features: Data from the Real World

Artificial intelligence can help physicians improve the accuracy of breast cancer diagnosis. However, the effectiveness of AI applications is limited by doctors’ adoption of the results recommended by the personalized medical decision support system. Our primary purpose is to study the impact of external case characteristics (ECC) on the effectiveness of the personalized medical decision support system for breast cancer assisted diagnosis (PMDSS-BCAD) in making accurate recommendations. Therefore, we designed a novel comprehensive framework for case-based reasoning (CBR) that takes the impact of external features of cases into account, made use of the naive Bayes and k-nearest neighbor (KNN) algorithms (CBR-ECC), and developed a PMDSS-BCAD system by using the CBR-ECC model and external features as system components. Under the new case-based reasoning framework, the accuracy of the combined model of naive Bayes and KNN with an optimal K value of 2 is 99.40%. Moreover, in a real hospital scenario, users rated the PMDSS-BCAD system, which takes into account the external characteristics of the case, better than the original personalized system. These results suggest that PMDSS-BCD can not only provide doctors with more personalized and accurate results for auxiliary diagnosis, but also improve doctors’ trust in the results, so as to encourage doctors to adopt the results recommended by the personalized system.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Use of Home-Based Connected Devices in Patients With Cystic Fibrosis for the Early Detection and Treatment of Pulmonary Exacerbations: Protocol for a Qualitative Study

BACKGROUND

Early detection of pulmonary exacerbations (PEx) in patients with cystic fibrosis (CF) is important to quickly trigger treatment and reduce respiratory damage. We hypothesized that using home-based and wearable connected devices (CDs) and educating patients to react in case of abnormal variations in a set of parameters would allow patients to detect and manage their PEx early with their care team.

OBJECTIVE

This qualitative study aimed to assess the feasibility and appropriate conditions of a new PEx management process from the users' point of view by analyzing the experience of patients and of CF center teams regarding the education program, the use of CDs, and the relationship between the patient and the care team during PEx management.

METHODS

We have been conducting a multicenter pilot study involving 36 patients with CF aged ≥12 years. The intervention was divided into 3 phases. In phase 1 (3 months), patients were equipped with CDs, and their parameters were collected on 3 nonconsecutive days each week. Phase 2 involved the development of a "React to PEx" educational program aimed at providing patients with a personalized action plan. A training session to the educational program was organized for the physicians. Physicians then determined the patients' personalized alert thresholds by reviewing the data collected during phase 1 and their patients' clinical history. In phase 3 (12 months), patients were educated by the physician during a clinic visit, and their action plan for reacting in timely fashion to their PEx signs was defined. Education and action plans were revised during clinic visits. At the end of the project, the patients' experience was collected during semistructured interviews with a researcher as part of the qualitative study. The experience of CF teams was collected during focus groups using a semistructured guide once all their patients had finished the study. The interviews and focus groups were recorded and transcribed verbatim to be analyzed. Data from educational sessions were collected throughout the educational program to be put into perspective with the learnings reported by patients. Analyses are being led by 2 researchers using NVivo (QSR International).

RESULTS

The study received the favorable reception of the Committee for the Protection of Persons (CPP NORTH WEST III) on June 10, 2017 (#2017-A00723-50). Out of the 36 patients included in phase 1, 27 were educated and entered phase 3. We completed collection of all data from the patients and care providers. Qualitative analysis will provide a better understanding of users' experience on the conditions of data collection, how useful CDs are for detecting PEx, how useful the PEx action plan is for reacting quickly, what patients learned about PEx management, and the conditions for this PEx management to be sustainable in routine care.

CONCLUSIONS

This study will open new perspectives for further research into the implementation of an optimal PEx care process in the organization of care teams in order to support patient self-management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03304028; https://clinicaltrials.gov/ct2/show/results/NCT03304028.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14552.

Perceptions of Social Media Use to Augment Health Care Among Adolescents and Young Adults With Cystic Fibrosis: Survey Study

BACKGROUND

For individuals with cystic fibrosis (CF), adolescence and young adulthood are times of significant vulnerability and have been associated with clinical and psychosocial challenges. Social media may offer innovative care delivery solutions to address these challenges.

OBJECTIVE

This study explored motivations and attitudes regarding current social media use and preferences for a social media platform in a sample of adolescents and young adults (AYA) with CF.

METHODS

A cross-sectional survey was administered to 50 AYA with CF followed at a large pediatric-adult CF center. The survey included questions regarding social media platform utilization, attitudes toward general and CF-specific online activities, and preferences for a CF-specific care delivery platform.

RESULTS

YouTube, Snapchat, and Instagram were the most commonly used social media platforms. AYA with CF do not report routinely using social media for health-related information acquisition, social support, or help with adherence. However, their perceptions of social media utilization and preferences for platform development suggest interest in doing so in the future.

CONCLUSIONS

AYA with CF use social media and expressed interest in the development of a social media platform. Platform development will allow for gaps in health care delivery to be addressed by improving social support and adherence while augmenting current methods of health information acquisition.

A Focus Group Study Among Inactive Adults Regarding the Perceptions of a Theory-Based Physical Activity App

Background: Despite the increasing attention for the positive effects of physical activity (PA), nearly half of the Dutch citizens do not meet the national PA guidelines. A promising method for increasing PA are mobile exercise applications (apps), especially if they are embedded with theoretically supported persuasive strategies (e.g., goal setting and feedback) that align with the needs and wishes of the user. In addition, it is argued that the operationalization of the persuasive strategies could increase the effectiveness of the app, such as the actual content or visualization of feedback. Although much research has been done to examine the preferences for persuasive strategies, little is known about the needs, wishes, and preferences for the design and operationalization of persuasive strategies.

Objective: The purpose of this study was to get insight in the needs, wishes, and preferences regarding the practical operationalization of persuasive strategies in a mobile application aimed at promoting PA in healthy inactive adults.

Methods: Five semistructured focus groups were performed. During the focus groups, the participants were led into a discussion about the design and operationalization of six predefined theory-based persuasive strategies (e.g., self-monitoring, feedback, goal setting, reminders, rewards, and social support) directed by two moderators. The audio-recorded focus groups were transcribed verbatim and analyzed following the framework approach.

Results: Eight men and 17 women between 35 and 55 years (mean age, 49.2) participated in the study. Outcomes demonstrated diverse preferences for implementation types and design characteristics of persuasive strategies in mobile applications. Basic statistics (such as distance, time and calories), positive feedback based on easy-to-achieve goals that relate to health guidelines, and motivating reminders on a relevant moment were preferred. Participants had mixed preferences regarding rewards and a social platform to invite other users to join PA.

Conclusions: Findings indicated that in mHealth applications for healthy but inactive adults, persuasive strategies should be designed and implemented in a way that they relate to health guidelines. Moreover, there is a need for an app that can be adapted or can learn based on personal preferences as, for example, preferences with regard to timing of feedback and reminders differed between people.

Self-Management Apps for People With Epilepsy: Systematic Analysis

BACKGROUND

Patients with epilepsy (PWEs) are motivated to manage and cope with their disorder themselves (ie, self-management [SM] is encouraged). Mobile health (mHealth) apps have multiple features that have a huge potential to improve SM of individuals with chronic disorders such as epilepsy.

OBJECTIVE

This study aimed to review all freely available apps related to the SM of PWEs and to determine the SM domains covered in these apps.

METHODS

We performed a search of apps on Google Play and App Store using the keywords "epilepsy" or "seizures" from May to August 2018. Apps were included if they were free and in English language. We excluded apps with installation-related issues and not related to epilepsy self-management (eSM).

RESULTS

A total of 22 eSM apps were identified in our search: 6 of these run only on iOS, 7 only on Android, and 9 run on both operating systems. Of the 11 domains of SM, seizure tracking and seizure response features were covered by most apps (n=22 and n=19, respectively), followed by treatment management (n=17) and medication adherence (n=15). Three apps (Epilepsy Journal, Epilepsy Tool Kit, and EpiDiary) were installed more than 10,000 times, with features focused specifically on a few domains (treatment management, medication adherence, health care communication, and seizure tracking). Two apps (Young Epilepsy and E-Epilepsy Inclusion) covered more than 6 SM domains but both had lower installation rates (5000+ and 100+, respectively).

CONCLUSIONS

Both Android and iOS mHealth apps are available to improve SM in epilepsy, but the installation rate of most apps remains low. The SM features of these apps were different from one another, making it difficult to recommend a single app that completely fulfills the needs of PWEs. The common features of the apps evaluated included seizure tracking and seizure response. To improve the efficacy and availability of these apps, we propose the following: (1) involve the stakeholders, such as physicians, pharmacists, and PWEs, during the development of mHealth apps; (2) assess the efficacy and acceptance of the apps objectively by performing a usability analysis; and (3) promote the apps so that they benefit more PWEs.

Characterizing medication management and the role of pharmacists in caring for people living with cystic fibrosis: A work system approach

BACKGROUND

Cystic fibrosis (CF) is an autosomal recessive genetic disease requiring complex, lifelong medication regimens. Given the importance of medication in CF treatment, pharmacists are vital CF care team members in the care of people living with CF (PwCF).

OBJECTIVES

This study aimed to (1) define patients' CF medication experiences and educational needs and (2) investigate the CF outpatient clinic and community pharmacist's role in addressing patient challenges.

METHODS

A work system approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model was used to characterize knowledge and perception of CF medication regimens, educational modalities, and pharmacist interactions for PwCF. Semistructured interviews were conducted with adults living with CF at a CF center clinic. Data analyses identified relationships between the themes in the data and 4 SEIPS work system domains: tasks, tools and technology, person, and environment.

RESULTS

Thirty PwCF interviews highlighted 4 themes regarding health care experiences: (1) medication use experience, (2) medication education needs, (3) disease experience, and (4) pharmacist and pharmacy interactions. Patients reported complex medication regimens leading to challenges with medication adherence, although the benefit of treatment was recognized. Although a high level of disease-state knowledge was identified among the participants, PwCF desired to learn about CF medication benefits and adverse effects through credible sources using multiple modalities. Many reported a benefit of pharmacist involvement in their care.

CONCLUSION

Pharmacists are well-positioned to support PwCF in adherence, medication regimen management, and medication education. Opportunities exist for growth in these supportive roles of a pharmacist in both community and outpatient clinic settings.

Apps for Older People's Pain Self-Management: Perspectives of Primary Care and Allied Health Clinicians

BACKGROUND

Chronic arthritic pain is one of the major causes of physical suffering and disability among older people. Primary care and allied health clinicians use various approaches to help their older clients better manage their arthritic pain. The growing uptake of technology among older people offers the potential for clinicians to integrate an arthritic pain app into their patients' self-management plans. This study explored the perspectives of Australian primary care and allied health clinicians regarding the use of pain self-management apps to help their older patients/clients better manage their arthritic pain.

METHODS

Qualitative design using a semistructured interview approach. Interviews were conducted via telephone with primary and allied health clinicians (N = 17) across Australia.

RESULTS

The overarching theme underlying participants' views on integration of apps into older people's pain self-management strategy was that this approach is an idealistic but uniquely challenging endeavor. Four subthemes emerged, namely: 1) self-management apps are a potentially useful tool but require careful consideration; 2) clinicians' involvement is crucial yet potentially onerous; 3) no single app is right for every older person with arthritic pain; and 4) patient data access is beneficial, but caution is needed for real-time data access.

DISCUSSION

The predominant clinician perspective of integrating apps into their older patients/clients' pain self-management strategies was that this approach is an idealistic but uniquely challenging endeavor. Apps were seen as having potential to support various aspects of patients' self-management behaviors; however, there were notable concerns with regards to the challenges inherent in this approach for both clinicians and older users (patients/clients).

User-Centered Design Process of an mHealth App for Health Professionals: Case Study

Background

User-centered design processes are infrequently employed and not fully explored for building mobile health (mHealth) apps that are particularly targeted to health professionals as end users. The authors have used a user-centered design–based approach to build an mHealth app for health professionals, tasked to deliver medical laboratory-related information on a daily basis.

Objective

Our objective is to generate a simple and functional user-centered design process for mHealth apps for health professionals. This paper presents the key learnings from design activities.

Methods

A stratified random sample of doctors and nurses was recruited for the study. The design activities were planned in the following sequence: focus group discussion for situation analysis and information architecture, design activity 1 for wireframe designing, design activity 2 for wireframe testing, and user testing sessions 1 and 2.

Results

The final design and functions of the app, information architecture, and interactive elements were largely influenced by the participatory design–based user-centered design activities. As a result of the design process, we could identify the mental models of processing requests for information and personal preferences based on the experience. These findings were directly or indirectly incorporated into the app design. Furthermore, finding alternative ways of working within time constraints and cultural barriers and the methods employed to manage the challenges of interdisciplinary discourse stood out among the lessons learned.

Conclusions

We recommend a user-centered design process based on a participatory design approach in mHealth app design, enriched with focus group discussions where possible.

Influencing Factors of Acceptance and Use Behavior of Mobile Health Application Users: Systematic Review

Purpose/Significance: Mobile health applications provide a convenient way for users to obtain health information and services. Studying the factors that influence users’ acceptance and use of mobile health applications (apps or Apps) will help to improve users’ actual usage behavior. Method/Process: Based on the literature review method and using the Web of Science core database as the data source, this paper summarizes the relevant research results regarding the influencing factors of the acceptance and use behavior of mobile health application users and makes a systematic review of the influencing factors from the perspectives of the individual, society, and application (app or App) design. Result/Conclusion: In terms of the individual dimension, the users’ behavior is influenced by demographic characteristics and motivations. Social attributes, source credibility, and legal issues all affect user behavior in the social dimension. In the application design dimension, functionality, perceived ease of use and usefulness, security, and cost are the main factors. At the end of the paper, suggestions are given to improve the users’ acceptability of mobile health applications and improve their use behavior.

Access to Technology and Preferences for an mHealth Intervention to Promote Medication Adherence in Pediatric Acute Lymphoblastic Leukemia: Approach Leveraging Behavior Change Techniques

Background

Suboptimal adherence to 6-mercaptopurine (6-MP) is prevalent in pediatric acute lymphoblastic leukemia (ALL) and associated with increased risk of relapse. Rapid uptake of personal technology makes mobile health (mHealth) an attractive platform to promote adherence.

Objective

Study objectives were to examine access to mobile technology and preferences for an mHealth intervention to improve medication adherence in pediatric ALL.

Methods

A cross-sectional survey was administered in oncology clinic to parents of children with ALL as well as adolescents and young adults (AYAs) with ALL receiving maintenance chemotherapy.

Results

A total of 49 parents (median age [IQR] 39 [33-42] years; female 76% [37/49]) and 15 patients (median age [IQR] 17 [16-19]; male 80% [12/15]) participated. All parents and AYAs owned electronic tablets, smartphones, or both. Parents’ most endorsed mHealth app features included a list of medications (71%, 35/49), information about 6-MP (71%, 35/49), refill reminders (71%, 35/49), and reminders to take 6-MP (71%, 35/49). AYAs' most endorsed features included refill reminders (73%, 11/15), reminders to take 6-MP (73%, 11/15), and tracking 6-MP (73%, 11/15).

Conclusions

Parents and AYAs reported ubiquitous access to mobile technology and strong interest in multiple adherence-specific mHealth app features. Parents and AYAs provided valuable insight into preferred features for a multifunctional behavioral intervention (mHealth app) to promote medication adherence in pediatric ALL.

A Mobile Health Platform for Self-Management of Pediatric Cystic Fibrosis: Qualitative Study of Adaptation to Stakeholder Needs and Integration in Clinical Settings

Background

Cystic fibrosis (CF) is an inherited chronic condition that requires extensive daily care and quarterly clinic visits with a multidisciplinary care team. The limited exchange of information outside of the quarterly clinic visits impedes optimal disease self-management, patient engagement, and shared decision making.

Objective

The aim of this study is to adapt a mobile health (mHealth) app originally developed in Sweden to the needs of patients, families, and health care providers in a CF center in the United States and to test it as a platform for sharing patient-generated health data with the CF health care team.

Methods

Focus groups with health care providers of patients with CF, adolescents with CF, and caregivers of children with CF were conducted to determine what modifications were necessary. Focus group data were analyzed using a thematic analysis, and emergent themes were ranked according to desirability and technical feasibility. The mHealth platform was then modified to meet the identified needs and preferences, and the flow of patient-generated health data to a secure Research Electronic Data Capture database was tested. Protocols for data management and clinical follow-up were also developed.

Results

A total of 5 focus groups with 21 participants were conducted. Recommended modifications pertained to all functionalities of the mHealth platform, including tracking of symptoms, treatments, and activities of daily care; creating and organizing medication lists and setting up reminders; generating reports for the health care team; language and presentation; sharing and privacy; and settings and accounts. Overall, health care providers recommended changes to align the mHealth platform with US standards of care, people with CF and their caregivers requested more tracking functionalities, and both groups suggested the inclusion of a mental health tracker as well as more detailed response options and precise language. Beta testers of the modified platform reported issues related to translatability to US environment and various bugs.

Conclusions

This study demonstrated the importance of identifying the needs and preferences of target users and stakeholders before adopting existing mHealth solutions. All relevant perspectives, including those of clinicians, patients, and caregivers, should be thoroughly considered to meet both end users’ needs and evidence-based practice recommendations.

Design Features for Improving Mobile Health Intervention User Engagement: Systematic Review and Thematic Analysis

Background

Well-designed mobile health (mHealth) interventions support a positive user experience; however, a high rate of disengagement has been reported as a common concern regarding mHealth interventions. To address this issue, it is necessary to summarize the design features that improve user engagement based on research over the past 10 years, during which time the popularity of mHealth interventions has rapidly increased due to the use of smartphones.

Objective

The aim of this review was to answer the question “Which design features improve user engagement with mHealth interventions?” by summarizing published literature with the purpose of guiding the design of future mHealth interventions.

Methods

This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Databases, namely, PubMed, Web of Science, Cochrane Library, Ovid EMBASE, and Ovid PsycINFO, were searched for English and Chinese language papers published from January 2009 to June 2019. Thematic analysis was undertaken to assess the design features in eligible studies. The Mixed Methods Appraisal Tool was used to assess study quality.

Results

A total of 35 articles were included. The investigated mHealth interventions were mainly used in unhealthy lifestyle (n=17) and chronic disease (n=10) prevention programs. Mobile phone apps (n=24) were the most common delivery method. Qualitative (n=22) and mixed methods (n=9) designs were widely represented. We identified the following 7 themes that influenced user engagement: personalization (n=29), reinforcement (n=23), communication (n=20), navigation (n=17), credibility (n=16), message presentation (n=16), and interface aesthetics (n=7). A checklist was developed that contained these 7 design features and 29 corresponding specific implementations derived from the studies.

Conclusions

This systematic review and thematic synthesis identified useful design features that make an mHealth intervention more user friendly. We generated a checklist with evidence-based items to enable developers to use our findings easily. Future evaluations should use more robust quantitative approaches to elucidate the relationships between design features and user engagement.

Usability and acceptability of a mobile application prototype for a combined behavioural activation and physical rehabilitation intervention in acute respiratory failure survivors

BACKGROUND

Acute respiratory failure survivors experience depression symptoms and new impairments in physical function. Behavioural activation, an evidence-based nonpharmacological treatment for depression, combined with physical rehabilitation, is a promising intervention. Notably, mHealth applications (Apps) are potentially effective methods of delivering home-based interventions.

OBJECTIVES

The objective of this study was to evaluate the usability and acceptability of a prototype App to deliver a combined, home-based behavioural activation and rehabilitation intervention to acute respiratory failure survivors.

METHODS

A prospective user-preference study was conducted with acute respiratory failure survivors and self-designated care partners. Survivors were adults with at least mild depression symptoms before hospital discharge who received mechanical ventilation in the intensive care unit for ≥24 h. Survivors and care partners reviewed the App during a single in-person home visit and completed the System Usability Scale (range: 0-100; score >73 considered "good") and a semistructured interview.

RESULTS

Ten patient/care partner dyads completed study. The median [interquartile range] patient age was 50 [40-64] years, and 50% were female. The median System Usability Scale scores among patients and care partners were 76 [68-83] and 88 [75-94], respectively. Qualitative feedback supported usability and acceptability of the App, with three themes reported: (1) stigma associated with depression, (2) App as a motivator for recovery, and (3) App providing multidisciplinary support for survivor and care partner.

CONCLUSIONS

A mobile App prototype designed to deliver a combined behavioural activation and rehabilitation intervention was usable and acceptable to survivors of acute respiratory failure and their care partners. Given the reported stigma associated with depression, the self-directed App may be particularly valuable for motivation and multidisciplinary support.

Mobile Phone Apps for Food Allergies or Intolerances in App Stores: Systematic Search and Quality Assessment Using the Mobile App Rating Scale (MARS)

Background

Food allergies and intolerances are increasing worldwide, and mobile phone apps could be a promising tool for self-management of these issues.

Objective

This study aimed to systemically search and assess food allergy or intolerance apps in app stores using the multidimensional Mobile App Rating Scale (MARS) to rate the objective and subjective quality and to identify critical points for future improvements.

Methods

This systematic search identified apps through the keywords “food allergy,” “food intolerance,” and “allergens” in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ≥3 (of 5 stars) to limit the selection to the most highly rated apps; ≥1000 reviews as an indicator of reliability; and the most recent update performed up to 2017. Then, the apps were divided according to their purpose (searching for allergen-free “food products,” “restaurants,” or recipes in “meal planners”) and evaluated on a scale of 1 to 5 points using the MARS in terms of (1) app classification category with a descriptive aim; (2) app subjective and objective quality categories comprised of engagement, functionality, esthetics, and information sections (Medline was searched for eligible apps to check whether they had been tested in trials); and (3) an optional app-specific section. Furthermore, the output and input features were evaluated. Differences between MARS sections and between app purposes and correlations among MARS sections, star ratings, and numbers of reviews were evaluated.

Results

Of the 1376 apps identified, 14 were included: 12 related to food allergies and intolerances that detect 2-16 food allergens and 2 related only to gluten intolerance. The mean (SD) MARS scores (maximum 5 points) were 3.8 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5 (SD 0.6) for subjective quality; and 3.6 (SD 0.7) for the app-specific section. Therefore, a rating ≥3 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1, SD 0.6), esthetics (mean 4, SD 0.5), and information (mean 3.8, SD 0.4). However, when the apps were compared by purpose, critical points were identified: meal planner apps showed significantly higher engagement (mean 4.1, SD 0.4) than food product (mean 3.0, SD 0.6; P=.05) and restaurant (mean 3.2, SD 0.3; P=.02) apps.

Conclusions

In this systematic search of food allergy or intolerance apps, acceptable MARS quality was identified, although the engagement section for food product and restaurant purpose apps should be improved and the included apps should be tested in trials. The critical points identified in this systematic search can help improve the innovativeness and applicability of future food allergy and intolerance apps.

User-Centered Design and Evaluation of a Web-Based Decision Aid for Older Adults Living With Mild Cognitive Impairment and Their Health Care Providers: Mixed Methods Study

Background

Mild cognitive impairment (MCI) is often considered a transitional state between normal and pathologic (eg, dementia) cognitive aging. Although its prognosis varies largely, the diagnosis carries the risk of causing uncertainty and overtreatment of older adults with MCI who may never progress to dementia. Decision aids help people become better informed and more involved in decision making by providing evidence-based information about options and possible outcomes and by assisting them in clarifying their personal values in relation to the decision to be made.

Objective

This study aimed to incorporate features that best support values clarification and adjust the level of detail of a web-based decision aid for individuals with MCI.

Methods

We conducted a rapid review to identify options to maintain or improve cognitive functions in individuals with MCI. The evidence was structured into a novel web-based decision aid designed in collaboration with digital specialists and graphic designers. Qualitative and user-centered evaluations were used to draw on users’ knowledge, clarify values, and inform potential adoption in routine clinical practice. We invited clinicians, older adults with MCI, and their caregivers to evaluate the decision aid in 6 consecutive rounds, with new participants in each round. Quantitative data were collected using the Values Clarity and Informed subscales of the Decisional Conflict Scale, the System Usability Scale, the Ottawa Acceptability questionnaire, and a 5-point satisfaction rating scale. We verified their comprehension using a teach-back method and recorded usability issues. We recorded the audio and computer screen during the session. An inductive thematic qualitative analysis approach was used to identify and describe the issues that arose. After each round, an expert panel met to prioritize and find solutions to mitigate the issues. An integrated analysis was conducted to confirm our choices.

Results

A total of 7 clinicians (social workers, nurses, family physicians, psychologists) and 12 older (≥60 years) community-dwelling individuals with MCI, half of them women, with education levels going from none to university diploma, were recruited and completed testing. The thematic analysis revealed 3 major issues. First, the user should be guided through the decision-making process by tailoring the presentation of options to users’ priorities using the values clarification exercise. Second, its content should be simple, but not simplistic, notably by using information layering, plain language, and pictograms. Third, the interface should be intuitive and user friendly, utilize pop-up windows and information tips, avoid drop-down menus, and limit the need to scroll down. The quantitative assessments corroborated the qualitative findings.

Conclusions

This project resulted in a promising web-based decision aid that can support decision making for MCI intervention, based on the personal values and preferences of the users. Further ongoing research will allow its implementation to be tested in clinical settings.

Acceptability and practicability of self-management for patients with Parkinson's disease based on smartphone applications in China

BACKGROUND

China has had about 1.2 billion mobile-phone users, and this number continues to grow. However, mobile-health services (mHealth) are currently in the initial stage, and have not yet prevailed in China. Additionally, the prevalence of Parkinson's disease (PD) in China is 1700/100,000 (≥65 years). Indeed, these PD patients would benefit from mHealth to manage their disease. Therefore, we designed a study to determine attitudes toward smartphone applications (apps) for chronic condition self-management, and to discover the practicality of these apps among PD patients in China.

METHODS

We selected 204 participants with PD between 52 and 87 years old and surveyed their attitudes concerning the use of smartphone apps for chronic condition management via questionnaires.

RESULTS

Among the participants, 65.19% had smartphones. Among these smartphone users, 82.84% expressed a preference for using apps for PD management. This group tended to be younger and more frequent web users with higher education and better medication compliance, and they tended to have a longer PD course and worse conditions (P < 0.001, P = 0.001, P < 0.001, P = 0.041, P < 0.001, P = 0.013). Additionally, the willingness to apply apps for PD self-management was positively related to education (P < 0.001) and negatively related to age and PD course (P = 0.017, P < 0.001).

CONCLUSION

In China, patients with PD have a generally positive attitude towards self-management through smartphone apps. Consequently, improving the coverage of smartphones with practical and handy apps is a promising strategy for PD self-management.

mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review

Background

Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement.

Objective

The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions.

Methods

An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis.

Results

A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals.

Conclusions

mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population.

User-Centered App Design for Acutely Ill Children and Adolescents

Background and Objectives: The high level of acceptance and consistent use of smartphones by children and adolescents present new opportunities to monitor and collect health data. For acutely ill children and adolescents, collecting symptom data via smartphone applications (apps) provides patient-reported data that can be collected daily and offers the potential to provide a more comprehensive picture of the symptom experience. The purpose of this study was to employ user-centered design principles and medical professional input in order to obtain feedback and insight into redesigning our Technology Recordings for better Understanding Blood and Marrow Transplant (TRU-PBMT) app. This redesigned app will be used for children and adolescents with cancer or undergoing blood and marrow transplantation. Method: We interviewed six pediatric blood and marrow transplant patients (ages 10-17 years) who had pilot tested the app, and we surveyed 30 pediatric oncology clinicians. Results: Interview feedback from previous app users and survey feedback from clinicians guided the app redesign. We incorporated suggestions to make the app more engaging, meaningful, personal, and motivating in order to increase symptom reporting. We added emojis to the symptom tracker, a mood scale, and personalized symptom graphs. Conclusion: Leveraging mobile health technologies may be a useful and acceptable approach to obtain symptom data; however, design and software development needs to be evidenced-based and informed by user needs. Our approach using patient and clinician feedback was valuable in the redesign of the TRU-PBMT app and will contribute to symptom research for acutely ill children and adolescents.

Codesign and Usability Testing of a Mobile Application to Support Family-Delivered Enteral Tube Care

BACKGROUND

Enteral tubes are prevalent among children with medical complexity (CMC), and complications can lead to costly health care use. Our objective was to design and test the usability of a mobile application (app) to support family-delivered enteral tube care.

METHODS

Human-centered design methods (affinity diagramming, persona development, and software development) were applied with family caregivers of CMC to develop a prototype. During 3 waves of usability testing with design refinement between waves, screen capture software collected user-app interactions and inductive content analysis of narrative feedback identified areas for design improvement. The National Aeronautics and Space Administration Task Load Index and the System Usability Scale quantified mental workload and ease of use.

RESULTS

Design participants identified core app functions, including displaying care routines, reminders, tracking inventory and health data, caregiver communication, and troubleshooting. Usability testing participants were 80% non-Hispanic white, 28% lived in rural settings, and 20% had not completed high school. Median years providing enteral care was 2 (range 1-14). Design iterations improved app function, simplification, and user experience. The mean System Usability Scale score was 76, indicating above-average usability. National Aeronautics and Space Administration Task Load Index revealed low mental demand, frustration, and effort. All 14 participants reported that they would recommend the app, and that the app would help with organization, communication, and caregiver transitions.

CONCLUSIONS

Using a human-centered codesign process, we created a highly usable mobile application to support enteral tube caregiving at home. Future work involves evaluating the feasibility of longitudinal use and effectiveness in improving self-efficacy and reduce device complications.

Assessing Parents' Needs in Using Phone Applications to Improve Medication Adherence in an Outpatient Pediatric Oncology Clinic

BACKGROUND

Poor adherence in pediatric oncology leads to significant morbidity and mortality. Currently used medication reminder aids have shown little to no benefit in improving adherence. Phone applications (apps) have demonstrated improved adherence in recent studies involving the adult and pediatric patients. At this time, no pediatric oncology center is recommending a particular phone app.

OBJECTIVE

The objective of this study was to determine the proportion of parents of pediatric oncology patients interested in using a phone app for medication reminders and desired features.

METHODS

In this single-center observational trial, 45 questionnaires were completed by parents accompanying their child at a pediatric oncology center. See Supplemental Digital Content 1 (http://links.lww.com/JPHO/A327) for a copy of the questionnaire. Participants had a child on active cancer treatment and were able to read and write English. Primary outcomes included a number of parents currently using a phone app, the number of parents interested in using a phone app, main reasons for not using a phone app and desired phone app features.

RESULTS

Overall, 95.6% of parents had never used a phone app to aid in medication adherence. Over 85% of these parents were highly interested in using a phone app, but most were not aware of available phone apps to use (57.1%). Desired features included: refill notifications, tracking doses administered, personalizable medication schedule, free of charge, no advertisements, ability to input special instructions, use on multiple devices, unique alarms, tracking child's results, and privacy protection.

CONCLUSIONS

A majority of parents at an outpatient pediatric oncology clinic were interested in using a phone app to assist in medication adherence but were unaware of an available phone app. An ideal criteria list was created with 10 desired features to evaluate available phone apps that may be recommended for this population. Further studies are needed to evaluate if phone apps recommended by this tool improve adherence.

Usability of a Consumer Health Informatics Tool Following Completion of a Clinical Trial: Focus Group Study

Background

Mobile health (mHealth) apps have the potential to be effective tools for encouraging patients with chronic diseases to self-manage their health. The success of mHealth apps is related to technology acceptance and its subsequent use by intended consumers. Therefore, it is essential to gain insights from consumers’ perspectives about their use of mHealth apps in daily life.

Objective

The purpose of this work was to understand consumers’ perspectives on use of a self-management app following completion of a clinical trial that tested the efficacy of the app for improving health outcomes.

Methods

We conducted five focus groups with paricipants of a clinical trial (NCT03182738) who were randomized to use the video information provider (VIP) for HIV-associated nonAIDS (HANA) conditions app (VIP-HANA) or an attention control app. Thematic analysis was conducted, and the themes were organized according to the two key constructs of the technology acceptance model framework: perceived usefulness and perceived ease of use.

Results

Thirty-nine people living with HIV (20 from the intervention group and 19 from the control group) participated in the focus group sessions. Of the eight themes identified from focus group data, the five themes related to perceived usefulness were: (1) self-monitoring HIV-related symptoms of HANA conditions, (2) enhanced relationship with clinical providers, (3) improvement in physical and emotional health, (4) long-term impact of self-care strategies on improvement in symptoms of HANA conditions, and (5) inspired lifestyle changes to manage symptoms. The three themes related to perceived ease of use were: (1) easy to navigate, (2) avatar personalization, and (3) privacy/confidentiality maintained even when changing the location of app use.

Conclusions

Perceived ease of use was similar in both study groups but perceived usefulness differed between study groups. Participants in both study groups found the VIP-HANA app to be useful in monitoring their symptoms and enhancing communication with their clinical care providers. However, only intervention group participants perceived the app to be useful in improving overall health and long-term symptom management. Findings from this study highlight factors that are essential to ensure the usefulness of self-management apps and facilitate sustained use of mHealth apps for people living with chronic illnesses.

Development of the InCharge Health Mobile App to Improve Adherence to Hydroxyurea in Patients With Sickle Cell Disease: User-Centered Design Approach

Background

Sickle cell disease (SCD) is an inherited blood disorder causing acute complications and chronic progressive end organ damage. SCD is associated with significant morbidity, early mortality, impaired health-related quality of life, and increased acute health care utilization. Hydroxyurea is a US Food and Drug Administration–approved medication that reduces disease complications, acute health care utilization, and costs. However, adherence to hydroxyurea is suboptimal. Mobile health (mHealth) interventions have the potential to improve hydroxyurea adherence, but few examples exist that are specific to the SCD population.

Objective

This study aimed to design a mHealth intervention for individuals with SCD to improve adherence to hydroxyurea, using a user-centered design that was informed by specific barriers to hydroxyurea adherence and utilization in this population.

Methods

This study consisted of 4 phases. In phase 1, individuals with SCD and health care providers participated in an optimization digital workshop. In phase 2, patients completed surveys pertaining to their interest in mHealth use, barriers and facilitators to hydroxyurea use, and health literacy. Phases 3 and 4 involved semistructured interviews and focus groups, respectively, and used the Health Belief Model (HBM) as the framework to investigate drivers of poor hydroxyurea adherence and to inform the development of an app prototype. In addition, in phase 4, we have incorporated the patients’ feedback on the preliminary app prototype and its features.

Results

Barriers to hydroxyurea adherence were consistent with the literature and included forgetfulness and several specific thoughts and emotions associated with hydroxyurea use (eg, fear of side effects, depression, stigma, and hopelessness). In addition, more than half of the participants reported potentially low health literacy. Preferred patient app features included 7 key components, namely (1) medication reminders and tracker, (2) disease education, (3) communication, (4) personalization, (5) motivation, (6) support during pain episodes, and (7) social support. Utilizing a user-centered design approach, data obtained from patients and providers were translated into features within the app, mapping to components of the HBM and the specific drivers of hydroxyurea adherence and matching the literacy level of the population, resulting in the development of a novel mobile app called InCharge Health.

Conclusions

The InCharge Health app is an mHealth intervention developed with substantial input from users and by mapping the HBM as the framework that guided the choice for its components. InCharge Health is a customized product for the SCD population aimed at optimizing medication adherence, with the end goal of improving quality of life and health outcomes among patients with SCD. The efficacy and implementation of the InCharge Health app as an mHealth intervention to promote hydroxyurea adherence will be tested in a future stepped-wedge multicenter trial for adolescents and adults with SCD.

Proposal for the User-Centered Design Approach for Health Apps Based on Successful Experiences: Integrative Review

Background

Different strategies encompassed within mHealth have shown themselves to be effective for maintaining good health or controlling certain diseases. However, there is usually a very high rate of abandonment of health apps. Therefore, it would seem obvious that there is a need for involving the end users (whether they are health professionals, patients, or both) in the design process from the early stages in order to enable their needs and characteristics to be identified. In this sense, it is common knowledge that focusing on the user permits the consideration of valuable details aimed at making the correct adjustment between the patient, the technology, and the organization of attention.

Objective

The goal of the research was to propose a methodology based on the review of previous successful user experiences in setting up health apps by using qualitative techniques (focus groups and discussion groups) that includes the participation of information technology and health professionals and the patients themselves.

Methods

An integrative review was made of studies in which a qualitative methodology was employed mainly through focus and/or discussion groups for the design and development of health apps, consulting diverse databases (PubMed, Scopus, and Proquest) with the following search strategy: “mHealth AND apps AND focus group OR discussion group.” A total of 69 papers were included in the review.

Results

A proposal structured in 4 sessions of variable duration was made in which information technology and health professionals and patients take part: composing, preparing, and organizing contents (session 1); testing structure and usability (session 2); does the app fit the needs of end users? (session 3); and last testing—keep on improving (session 4). Throughout the sessions, we propose studying aspects like previous user experiences in mHealth, barriers to the adoption of mHealth, interface contents, management and browsability, usability, perceived quality, security and privacy, capacity to self-manage disease with the app, ergonomics, and glanceability, etc. Specific tools that have proved useful in previous research for measuring these aspects are presented.

Conclusions

These work sessions would be based on predominantly qualitative methodologies although, as they evolve, validated questionnaires permitting the assessment of the objectivity of certain technical aspects could be incorporated. With this proposal, a project centered on end users could be effected, responding to their needs. However, this requires validation that will be made via implementation in the development of health apps, with the subsequent measurement of results in terms of adherence and improvement in the clinical variables of the end users.

Designing a mobile app to promote healthy behaviors and prevent obesity: analysis of adolescents' preferences

To ensure that adolescents adhere to programmes promoting healthy behaviors, these programmes must be appealing and interesting. This study aims to characterize and assess the devices, operating system and type of mobile apps frequently used by adolescents; understand the features that mHealth apps should have to be appealing; comprehend the facilitators and barriers for adolescents to use mHealth apps. The sample comprised 165 adolescents (12-18 years) from the main population, recruited in 2018. Most participants used smartphones and the Android system. Food and physical activity suggestions were considered the most important features for an mHealth app. 62.6% had never tried an mHealth app. For those who had tried one, 26.0% stated it was to improve health status/lifestyle. Their favorite feature was physical exercise tips/plans (41.8%). Adolescents pointed out that the reasons that made them keep using the app were utility and interest (35.7%). Regarding possible barriers, 48.4% reported a lack of a senseof need/practical utility, and 18.8% considered notifications as their least favorite feature. Lack of interest was pointed out for 38.2% as the main reason for stopping use. Results provide practical information for the planning, design, and implementation of future mHealth apps for the promotion of healthy behaviors - an important implication for future research in this area.

The future of cystic fibrosis care: a global perspective

The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.

What makes a good health 'app'? Identifying the strengths and limitations of existing mobile application evaluation tools

Research using mHealth apps has the potential to positively impact health care management and outcomes. However, choosing an appropriate mHealth app may be challenging for the health researcher. The author team used existing evaluation tools, checklists, and guidelines to assess selected mHealth apps to identify strengths, challenges, and potential gaps within existing evaluation tools. They identified specific evaluation tool components, questions, and items most effective in examining app content, usability, and features, including literacy demand and cultural appropriateness; technical information; practical aspects of app functionality; and evolving capabilities of mobile medical apps. Challenges included the subjective nature of the results, time required to complete the evaluation, lack of emphasis on evidence-based content, and inadequate tool flexibility. Health researchers considering the integration of mobile apps into research will benefit from evaluation tools that assess both evidence-based content and the ability of the mobile app to securely integrate with other digital technologies involved in patient care. Next steps will include the involvement of health care providers and professionals, including nurses a wide range of expertise, to develop an mHealth evaluation tool that focuses on identifying quality, evidence-based mobile apps into patient outcomes research.

Adult patients' experiences of symptom management during pulmonary exacerbations in cystic fibrosis: A thematic synthesis of qualitative research

Objective

The aim of this review was to describe how patients experience an exacerbation of cystic fibrosis in terms of symptom management.

Methods

A systematic literature search was performed in MEDLINE, CINAHL, EMBASE, PSYCINFO and ASSIA. Studies were included that contained any direct quotes or summaries of quotes from patients with cystic fibrosis aged 16 or older and were related to symptom experience and management during an exacerbation. Framework analysis, guided by Symptom Management Theory, was used to present the findings.

Results

The review included 18 qualitative studies. In addition to physiological symptoms, patients highlighted the significant role of psychological symptoms. Delayed help-seeking was a common first response. Participants choose their self-management strategies taking both physiological and psychological symptoms into account. Maintaining normality was an important short-term outcome for patients, leading to conflict with health professionals. Patients’ symptom management during exacerbation was greatly influenced by the structure of cystic fibrosis care.

Discussion

Our findings provide an initial understanding of factors influencing patient self-management during an exacerbation. The transferal of these findings into clinical practice will provide a basis for shared goal setting and intervention planning. In addition, our findings have implications for future development of patient-reported outcome measures and intervention research.