Integrating mHealth and Systems Science: A Combination Approach to Prevent and Treat Chronic Health Conditions

'Value-based methodology for person-centred, integrated care supported by Information and Communication Technologies' (ValueCare) for older people in Europe: study protocol for a pre-post controlled trial

Background

Older people receive care from multiple providers which often results in a lack of coordination. The Information and Communication Technology (ICT) enabled value-based methodology for integrated care (ValueCare) project aims to develop and implement efficient outcome-based, integrated health and social care for older people with multimorbidity, and/or frailty, and/or mild to moderate cognitive impairment in seven sites (Athens, Greece; Coimbra, Portugal; Cork/Kerry, Ireland; Rijeka, Croatia; Rotterdam, the Netherlands; Treviso, Italy; and Valencia, Spain). We will evaluate the implementation and the outcomes of the ValueCare approach. This paper presents the study protocol of the ValueCare project; a protocol for a pre-post controlled study in seven large-scale sites in Europe over the period between 2021 and 2023.

Methods

A pre-post controlled study design including three time points (baseline, post-intervention after 12 months, and follow-up after 18 months) and two groups (intervention and control group) will be utilised. In each site, (net) 240 older people (120 in the intervention group and 120 in the control group), 50–70 informal caregivers (e.g. relatives, friends), and 30–40 health and social care practitioners will be invited to participate and provide informed consent. Self-reported outcomes will be measured in multiple domains; for older people: health, wellbeing, quality of life, lifestyle behaviour, and health and social care use; for informal caregivers and health and social care practitioners: wellbeing, perceived burden and (job) satisfaction. In addition, implementation outcomes will be measured in terms of acceptability, appropriateness, feasibility, fidelity, and costs. To evaluate differences in outcomes between the intervention and control group (multilevel) logistic and linear regression analyses will be used. Qualitative analysis will be performed on the focus group data.

Discussion

This study will provide new insights into the feasibility and effectiveness of a value-based methodology for integrated care supported by ICT for older people, their informal caregivers, and health and social care practitioners in seven different European settings.

Trial registration

ISRCTN registry number is 25089186. Date of trial registration is 16/11/2021.

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.

Effects of a WhatsApp-Delivered Education Intervention to Enhance Breast Cancer Knowledge in Women: Mixed-Methods Study

Background

Breast cancer is the leading cause of cancer-related death in the female population. Health education interventions based on the use of mobile technologies enable the development of health self-care skills and have emerged as alternative strategies for the control of breast cancer. In previous studies, WhatsApp has stood out as a useful tool in health education strategies; however, it has not yet been applied for breast cancer education.

Objective

This study aimed to analyze the potential of WhatsApp as a health education tool used to improve women's knowledge on the risk reduction of breast cancer. It also aimed to understand how women feel sensitized within the WhatsApp group throughout the intervention and how they incorporate information posted to improve knowledge about early detection and risk reduction methods.

Methods

The study involved a pre-post health educational intervention with 35 women (aged 45-69 years) included in a WhatsApp group to share information (audio, video, text, and images) over 3 weeks on the early detection and risk reduction of breast cancer. Data were collected through questionnaires on topics related to risk reduction, as well as qualitative content analysis of group interactions. Effectiveness and feasibility were analyzed through conversations and the comparison of the scores obtained in the questionnaires before and after the intervention.

Results

A total of 293 messages were exchanged (moderator 120 and users 173). The average scores of the participants were 11.21 and 13.68 points before and after the educational intervention, respectively, with sufficient sample evidence that the difference was significant (P<.001). The intervention enabled women to improve their knowledge on all topics addressed, especially “myths and truths,” “incidence,” “clinical manifestations,” and “protective factors.” Some themes emerged from the interactions in the group, including group dynamics, general doubts, personal narratives, religious messages, daily news, and events.

Conclusions

The use of groups for women in WhatsApp for health education purposes seems to be a viable alternative in strategies on breast cancer control, especially as it provides a space for the exchange of experiences and disinhibition. However, the need for a moderator to answer the questions and the constant distractions by members of the group represent important limitations that should be considered when improving this strategy.

Study of active neighborhoods in Detroit (StAND): study protocol for a natural experiment evaluating the health benefits of ecological restoration of parks

BACKGROUND

Individuals living in deprived inner cities have disproportionately high rates of cancers, Type 2 diabetes and obesity, which have stress- and physical inactivity-related etiologies. This study aims to quantify effects of ecological park restoration on physical activity, stress and cardio-metabolic health outcomes.

METHODS

The Study of Active Neighborhoods in Detroit is a quasi-experimental, longitudinal panel natural experiment with two conditions (restored park intervention (INT) and control (CNT)) and annual measurements at baseline and 3-years post-restoration. Individuals (sampled within 500 m of an INT/CNT park) serve as the unit of analysis. Restoration (n = 4 parks) involves replacing non-native plants and turf with native plants; creating trails; posting signage; and leading community stewardship events. The CNT condition (n = 5) is an unmaintained park, matched to INT based on specified neighborhood conditions. Recruitment involves several avenues, with a retention goal of 450 participants. Park measures include plant/avian diversity; usage of the park (SOPARC); signs of care; auditory environment recordings; and visual greenness using 360 imagery. Health outcomes include device-based physical activity behavior (primary outcome); salivary cortisol (secondary outcome); and several downstream health outcomes. Exposure to the INT will be assessed through visual contact time and time spent in the park using GPS data. Changes in health outcomes between years and INT versus CNT will be tested using generalized linear (mixed) models.

DISCUSSION

Our study will examine whether restored urban greenspaces increase physical activity and lower stress, with public health planning implications, where small changes in neighborhood greenspaces may have large health benefits in low-income neighborhoods.

STUDY REGISTRATION

Registration: OSF Preregistration registered March 31, 2020. Accessible from https://osf.io/surx7.

Toward Integration of mHealth in Primary Care in the Netherlands: A Qualitative Analysis of Stakeholder Perspectives

Background: There is a growing need to structurally change the way chronic illness care is organized as health systems struggle to meet the demand for chronic care. mHealth technologies can alter traditional approaches to health care provision by stimulating self-management of chronically ill patients. The aim of this study was to understand the complex environment related to the introduction of mHealth solutions into primary care for chronic disease management while considering health system functioning and stakeholder views.

Methods: A transdisciplinary approach was used informed by the Interactive Learning and Action (ILA) methodology. Exploratory interviews (n = 5) were held with representatives of stakeholder groups to identify and position key stakeholders. Subsequently, professionals and chronically ill patients were consulted separately to elaborate on the barriers and facilitators in integration, using semi-structured interviews (n = 17) and a focus group (n = 6). Follow-up interviews (n = 5) were conducted to discuss initial findings of the stakeholder analysis.

Results: Most stakeholders, in particular primary care practitioners and patients, seem to have a supporting or mixed attitude toward integration of mHealth. On the other hand, several powerful stakeholders, including primary care information system developers and medical specialists are likely to show resistance or a lack of initiative toward mHealth integration. Main barriers to mHealth integration were a lack of interoperability with existing information systems; difficulties in financing mHealth implementation; and limited readiness in general practices to change. Potential enablers of integration included co-design of mHealth solutions and incentives for pioneers.

Conclusion: Stakeholders acknowledge the benefits of integrating mHealth in primary care. However, important barriers perceived by end-users prevent them to fully adopt and use mHealth. This study shows that the complexity of introducing mHealth into primary care calls for strategies encouraging collaboration between multiple stakeholders to enhance successful implementation.

Promoting healthy teenage behaviour across three European countries through the use of a novel smartphone technology platform, PEGASO fit for future: study protocol of a quasi-experimental, controlled, multi-Centre trial

BACKGROUND

Behaviour change interventions targeting physical activity, diet, sleep and sedentary behaviour of teenagers show promise when delivered through smartphones. However, to date there is no evidence of effectiveness of multicomponent smartphone-based interventions. Utilising a user-centred design approach, we developed a theory-based, multi-dimensional system, PEGASO Fit For Future (PEGASO F4F), which exploits sophisticated game mechanics involving smartphone applications, a smartphone game and activity sensors to motivate teenagers to take an active role in adopting and maintaining a healthy lifestyle. This paper describes the study protocol to assess the feasibility, usability and effectiveness (knowledge/awareness and behavioural change in lifestyle) of the PEGASO system.

METHODS

We are conducting a quasi-experimental controlled cluster trial in 4 sites in Spain, Italy, and UK (England, Scotland) over 6 months. We plan to recruit 525, in a 2:1 basis, teenagers aged 13-16 years from secondary schools. The intervention group is provided with the PEGASO system whereas the comparison group continues their usual educational routine. Outcomes include feasibility, acceptance, and usability of the PEGASO system as well as between and within group changes in motivation, self-reported diet, physical activity, sedentary and sleeping behaviour, anthropometric measures and knowledge about a healthy lifestyle.

DISCUSSION

PEGASO F4F will provide evidence into the cross-cultural similarities and differences in the feasibility, acceptability and usability of a multi-dimensional smartphone based behaviour change intervention for teenagers. The study will explore facilitating factors, challenges and barriers of engaging teenagers to adapt and maintain a healthy lifestyle when using smartphone technology. Positive results from this ICT based multi component intervention may have significant implications both at clinical level, improving teenagers health and at public health level since it can present an influential tool against the development of chronic disease during adulthood.

TRIAL REGISTRATION

https://clinicaltrials.gov Registration number: NCT02930148, registered 4 October 2016.

The role of telehealth counselling with mobile self-monitoring on blood pressure reduction among overseas Koreans with high blood pressure in Vietnam

INTRODUCTION

Rapid globalization has produced a growing demand for the chronic care management of overseas populations living in medically underserved areas. This study investigated the utilization pattern of telehealth counselling among overseas Koreans with high blood pressure, and evaluated the relationships between mobile self-monitoring application and blood pressure reduction.

METHODS

A global chronic management programme consisting of lifestyle modification and self-monitoring blood pressure was launched to provide a telehealth counselling service for Koreans with high blood pressure living in Vietnam from August 2016 to December 2017. During the first telehealth session, doctors educated patients on lifestyle modifications using a mobile self-monitoring application and checked the change of blood pressure in a follow-up telehealth visit. We examined utilization patterns and compared the blood pressure change among the mobile self-monitoring group versus the control group using Wilcoxon signed rank tests.

RESULTS

A total of 234 patients with systolic blood pressure of more than 130 mmHg or diastolic blood pressure of more than 80 mmHg were registered, installed the mobile app and were provided with automated blood pressure devices with the telehealth counselling service by Korean doctors. A follow-up telehealth counselling session was provided at three months. Only 15% (36/234) received two or more telehealth counselling sessions. Significant differences were found in the mean change of systolic blood pressure at three months in the monitoring group and the non-monitoring group (-16.0 vs. -5.7, p = 0.008).

DISCUSSION

In this unique telehealth study, a mobile self-monitoring application was associated with significantly reducing systolic blood pressure levels in three months. Encouraging patients via a mobile application that includes a self-monitoring function might have the potential for self-managing chronic diseases, especially in resource-limited environments.

Know Your Numbers: Creation and implementation of a novel community health mobile application (app) by student pharmacists

OBJECTIVES

A free mobile application (app), Know Your Numbers (KYN), was developed by student pharmacists to assist underserved community members to track their health numbers. The study objectives included creating a health app, implementing a pilot program, and analyzing the frequency of app use and perceptions of community members toward their health numbers, pharmacists, and health apps.

SETTING

Student pharmacists recruited participants at the community clinics and health fairs organized in underserved communities of the Atlanta metropolitan area.

PRACTICE DESCRIPTION

This study used a pre- and post-survey study design to compare perceptions before and after use of a health app. Eligible participants completed a 22-item pre-survey that assessed understanding of their health numbers, previous health app use, and perceptions of pharmacists.

EVALUATION

Frequency of app use and change in perceptions of community members toward health numbers, pharmacists, and health apps before and after enrolling in KYN were analyzed with the use of descriptive statistics and Wilcoxon signed rank tests for matched pre- and post-surveys.

RESULTS

Thirty-three participants were enrolled for 56 days. African American participants (93.9%) earned less than $25,000 annually (56.7%). On average, participants had 3.98 interactions per week. Before using the mobile health app, 84.8% of users felt comfortable using a health app, but only 9% used one regularly. The post-survey response rate was 27.2% (n = 9). More participants agreed that a health app helped them to meet their health goals after the program (24.4% to 100%; P = 0.0006). More than 90% of participants agreed in both surveys that it is important to check their health numbers regularly and that they trust pharmacists to provide accurate information.

CONCLUSION

KYN is a novel mobile tool that promotes chronic disease self-management and the profession of pharmacy. These findings support the benefits of mobile health app's usability and its ability to assist in achieving personal health goals.

mHealth for diabetes support: a systematic review of apps available on the Italian market

mHealth is an expanding field of research and experimentation, concerned with the potentialities of mobile applications as tools to enhance patients' abilities in the management of chronic conditions. We present a systematic review of mHealth applications available on the Italian market and for the Italian speakers in order to assess their reported usability and functions. The review shows that there are rather few products on offer and the ones that are available display weak educational components, do not seem to be based on solid theoretical models of behavior change or decision making, and do not seem to be intended as devices to be integrated in the ecology of the doctor-patient relationship.

A Multimodal Counseling-Based Adolescent Physical Activity Intervention

PURPOSE

National guidelines recommend adolescents achieve 60 minutes of moderate-to-vigorous physical activity (MVPA)/day, yet few adolescents meet these guidelines.

METHODS

We piloted a novel quasi-randomized physical activity intervention to promote adolescent's use of their surrounding built environment among 30 intervention and 30 control overweight/obese adolescents aged 10-16 years living in greater Boston from 2013 to 2015. Location-specific MPVA was measured by accelerometry and global positioning system for three one-week periods (Time 1 [T1], Time 2 [T2], and Time 3 [T3]). One month after T1, intervention participants received individualized counseling on how to use their surrounding built environment to increase MVPA, and control participants received standard-of-care lifestyle modification counseling; both groups received their T1 physical activity data. T2 assessment occurred the week after the counseling visit and T3 assessment 3-4 months later. The main outcome was change in average daily minutes of MVPA; the secondary outcome was meeting national MVPA guidelines. Multivariable modeling accounted for covariates (baseline MVPA, body mass index, age, sex, race/ethnicity) and clustering by study group and town.

RESULTS

Among the 60 adolescents recruited, 55 (92%) completed data collection. Short-term (T2) intervention effects included increased average MVPA of +13.9 minutes intervention versus -.6 minutes control (p < .0001). Differential increase in mean daily MVPA was sustained at T3 (9.3 minutes more in intervention group; p = .0006). The proportion of adolescents in the intervention group who achieved 60 minutes/day of MVPA increased from 11% (T1) to 21% (T2), whereas declining (7%-0%) among controls.

CONCLUSIONS

Individualized counseling about the built environment can help increase MVPA among overweight and obese adolescents.