Electronic health intervention to manage symptoms of immunotherapy in patients with cancer (SOFIA): Results from a randomized controlled pilot trial

BACKGROUND

For patients receiving immune checkpoint inhibitors, early detection of immune-related adverse events (irAEs) is critical for one's safety. To this end, a smartphone app (SOFIA) was developed that featured the assessment of electronic patient-reported outcomes (ePROs) focusing on irAEs as well as a set of comprehensive supportive information. Its feasibility and preliminary efficacy were evaluated in a randomized controlled trial (RCT).

METHODS

Patients who received immune checkpoint inhibition therapy were randomly assigned to an intervention group (IG) or a control group (CG; care as usual). During the 12-week intervention period, IG patients used SOFIA to report twice weekly ePROs and receive cancer- and immunotherapy-relevant contents. Before a patient's next clinical visit, the physician in charge was given the ePRO reports. The primary objective was to test the feasibility of SOFIA. Furthermore, the preliminary efficacy of SOFIA for health-related quality of life (HRQOL), psychosocial outcomes, and medical data was examined. Clinical outcomes were assessed at baseline (T0), post-intervention (T1), and a 3-month follow-up (T2).

RESULTS

Seventy-one patients were randomized to the IG (n = 34) or the CG (n = 37). SOFIA showed high feasibility and acceptance. At T1, patients in the IG reported significantly better HRQOL and role functioning and less depression, distress, and appetite loss. No significant differences were revealed regarding medical data, the utilization of supportive care services, or survival.

CONCLUSIONS

SOFIA showed high feasibility and acceptance and improved HRQOL and psychosocial outcomes. These results suggest further evaluation of efficacy in a large-scale confirmatory multicenter RCT.

Informing Mobile Health Policy for Pregnant Women in Rural Populations in Canada, with a Focus on Pre-Eclampsia

Canadian healthcare suffers rural disparities, especially in maternal and prenatal care. Drawing on a literature review, the paper highlights the potential of mobile health (mHealth) applications to bridge this gap and improve maternal care in rural communities. mHealth tools have great potential for knowledge and trust-building among healthcare workers and pregnant women. To support the success of these solutions, more funding and policy support are required. mHealth solutions have a great potential for great economic savings while addressing healthcare disparities and ensuring everyone has access to high quality care.

Assessing the clinical benefit, safety, and patient-reported outcomes with the use of the PAHcare™ digital platform in pulmonary arterial hypertension: a pilot study

Introduction

Digital health interventions, particularly mobile health platforms, have shown promise in supporting patients with respiratory conditions, but their application in pulmonary arterial hypertension (PAH) remains limited. We aimed to assess the feasibility, acceptability, and potential clinical benefit of the novel PAHcare™ digital platform as a patient-centred intervention for PAH management through a prospective, single-arm, multicenter pilot study conducted on 53 patients diagnosed with PAH who used the platform for 6 months.

Methods

The primary objective was to assess the impact on Health-Related Quality of Life (HRQoL) through questionnaires. Secondary objectives included evaluating clinical outcomes, including disease progression, PAH signs and symptoms, the 6-min walking test, and the patient's symptom perception. Additionally, we assessed patient satisfaction and engagement with the PAHcare™ platform, interaction with health coaches, retention, costs and healthcare resource utilisation (HCRU), and safety through monitoring device incidents.

Results

Minimal changes in HRQoL and clinical outcomes were observed over 6 months. A noteworthy 92.4% of patients actively used the platform in the first month, maintaining high usage throughout the study. Patient satisfaction was substantial, with more than half of the patients expressing excellence in service quality, willingness to reuse the platform, and fulfilment of their needs. Health coach interaction was high, with 76% of patients initiating contact within the first week. User retention rates were 70%, with prevalent ongoing usage and interaction with healthcare professionals even after the study. In terms of HCRU and costs, the study showed no significant changes in PAH-related hospital admissions, clinical visits, or tests. Finally, the low number of device-related incidents indicated platform safety.

Conclusion

This pilot study provides compelling evidence supporting the feasibility and acceptability of the PAHcare™ digital platform to empower patients to manage their disease and significantly enhance their overall experience with PAH.

Perceptions and effectiveness of episodic future thinking as digital micro-interventions based on mobile health technology

Objective

Delay discounting denotes the tendency for humans to favor short-term immediate benefits over long-term future benefits. Episodic future thinking (EFT) is an intervention that addresses this tendency by having a person mentally "pre-experience" a future event to increase the perceived value of future benefits. This study explores the feasibility of using mobile health (mHealth) technology to deliver EFT micro-interventions. Micro-interventions are small, focused interventions aiming to achieve goals while matching users' often limited willingness or capacity to engage with interventions. We aim to explore whether EFT delivered as digital micro-interventions can reduce delay discounting, the users' perceptions, and if there are differences between regular EFT and goal-oriented EFT (gEFT), a variant where goals are embedded into future events.

Method

A randomized study was conducted with 208 participants allocated to either gEFT, EFT, or a control group for a 21-day study.

Results

Results indicate intervention groups when combined achieved a significant reduction of Δ log k = - .80 in delay discounting (p = .017 ) compared to the control. When split into gEFT and EFT separately only the reduction of Δ log k = .96 in EFT delay discounting was significant (p = .045 ). We further explore and discuss thematic user perceptions.

Conclusions

Overall, user perceptions indicate gEFT may be slightly better for use in micro-interventions. However, perceptions also indicate that audio-based EFT micro-interventions were not always preferable to users, with findings suggesting that future EFT micro-interventions should be delivered using different forms of multimedia based on user preference and context and supported by other micro-interventions to maintain interest.

NPS MedicineWise application in supporting medication adherence in chronic heart failure: an acceptability and feasibility pilot study

Introduction

Heart failure (HF) is an increasing global concern. Despite evidence-based pharmacotherapy, associated morbidity and mortality remain high. This study aimed to assess the acceptability, feasibility, and value of the NPS MedicineWise dose reminder app in a tiered, pharmacist-led intervention to address medication non-adherence in patients with HF.

Methods

This prospective, single-blinded, randomised controlled trial recruited 55 patients with HF between September 2019 and October 2020. Participants were randomly assigned to either the intervention or control arms. Intervention participants used the app which prompted medication administration at each dosing interval. Control participants received standard care and remained blinded to the app throughout the study. Treatment non-adherence prompted a tiered, pharmacist-led intervention. Comparison of the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) at baseline and 6-months measured the app's value in supporting medication adherence. Secondary outcome measures included self-reported medication knowledge, health-related quality of life, psychological wellbeing, and signs and symptoms of HF. Data were analysed using standard statistical tests with significance set at α 0.05.

Results

Approximately half of respondents reported managing HF and medications better by using the MedicineWise app (Tier 1). Most respondents expressed satisfaction with the in-app messages (Tier 2) and pharmacists' phone calls (Tier 3). The intervention participants demonstrated a significant improvement in the SEAMS between baseline and 6-months follow-up.

Discussion

It is feasible and potentially of value to use the MedicineWise app with a tiered, pharmacist-led intervention to support medication adherence in patients with HF. Our findings provide clinicians with "real-world" information on the practicality and potential value of using mobile health to support treatment adherence in patients with HF.

Trial registration number

Australian New Zealand Clinical Trials Registry Clinical trial registration number: ACTRN12619000289112p (http://www.ANZCTR.org.au/ACTRN12619000289112p.aspx).

Women's comfort with mobile applications for menstrual cycle self-monitoring following the overturning of Roe v. Wade

Background

The overturning of Roe v. Wade in June 2022 has many implications for American women of reproductive age, as well as for researchers focused on women's health in the United States (U.S.). Personal reproductive health data, such as information collected by menstrual cycle (MC) tracking applications (apps), can now be bought, sold, or accessed by law enforcement to enforce limits on abortion. American women have grown concerned about data privacy and have even deleted MC tracking apps following the overturning of Roe v. Wade. This concern is problematic as these apps may advance our understanding of women's MC experiences by capturing time-sensitive data. The present study was designed to provide updated insight into women's perceptions of these apps, including the response rate to a study of this nature and women's willingness to self-report demographic information in this context, following the Supreme Court decision.

Methods

A total of 206 women aged 18-60 years who were identified as pre- or perimenopausal completed an anonymous, cross-sectional survey between August and November 2022.

Results

Most respondents had experience using a MC app at the time of reporting; 53.4% (n=110) were current users, and an additional 48 participants had used MC tracking apps in the past. Over one-third of participants (38.3%; n=75) indicated that they had reconsidered using such an app because of current events; 30.3% (n=59) preferred methods of MC tracking that did not involve app-based technology, and 34.2% (n=67) reported that they are not willing to participate in research that involves daily tracking of the MC.

Conclusions

Overall, the feasibility of menstruation-related research that includes mobile apps is fairly low, given women's current comfort with this technology compared to the Roe era, and there is a need to establish criteria and protections for use of mobile apps in women's health research.

Are older adults considered in asthma and chronic obstructive pulmonary disease mobile health research? A scoping review

BACKGROUND

The use of mobile health (mHealth) for asthma and chronic obstructive pulmonary disease (COPD) is rapidly growing and may help address the complex respiratory care needs of our ageing population. However, little is currently known about how airways mHealth is developed and used among older adults (≥65 years).

OBJECTIVE

To identify if and how older adults with asthma and COPD have been incorporated across the mHealth research cycle.

METHODS

We searched Ovid MEDLINE, EMBASE, CINAHL and the Cochrane Central Registry of Controlled Trials for studies pertaining to the development or evaluation of asthma and COPD mHealth for adults published after 2010. Study, participant and mHealth details, including any considerations of older age, were extracted, synthesised and charted.

RESULTS

A total of 334 studies of 191 mHealth tools were identified. Adults ≥65 years old were included in 33.3% of asthma mHealth studies and 85.3% of COPD studies. Discussions of older age focused on barriers to technology use. Methodologic and/or analytic considerations of older age were mostly absent throughout the research cycle. Among the 28 instances quantitative age-related analyses were detailed, 12 described positive mHealth use and satisfaction outcomes in older adults versus negative or equivocal outcomes.

CONCLUSION

We identified an overall lack of consideration for older age throughout the airways mHealth research cycle, even among COPD mHealth studies that predominantly included older adults. We also found a contrast between the perceptions of how older age might negatively influence mHealth use and available quantitative evaluations. Future airways mHealth research must better integrate the needs and concerns of older adults.

Corrigendum: The evolution of HIV self-testing and the introduction of digital interventions to improve HIV self-testing

[This corrects the article DOI: 10.3389/frph.2023.1121478.].

Effectiveness of personalized smoking cessation intervention based on ecological momentary assessment for smokers who prefer unaided quitting: protocol for a randomized controlled trial

Introduction

Ecological momentary assessment (EMA)-based smoking cessation intervention may help personalize intervention for smokers who prefer to quit smoking unaided. This study aims to evaluate the effectiveness of EMA-based phone counseling and instant messaging for smoking cessation.

Methods/design

This is a two-arm, accessor-blinded, simple individual randomized controlled trial (allocation ratio 1:1). Participants will be recruited from community sites and online platforms in Hong Kong. Interventions will be delivered via a phone call and instant messaging. Current adult smokers who (1) self-report no intention to use smoking cessation services and medication in the coming month and (2) have not used smoking cessation services or nicotine replacement therapy in the past 7 days will be recruited. Recruited participants will be randomized to intervention or control groups via an online randomizer. All participants will be required to complete EMAs (five times per day for 7 consecutive days). The intervention group (n = 220) will receive a nurse-led brief phone counseling immediately after the 1-week EMAs and 10-week EMA-based advice via instant messaging applications (e.g., WhatsApp, WeChat). The 10-week EMA-based advice covers a summary of the 1-week EMAs, and tailored cessation support focused on personalized smoking triggers. The control group (n = 220) will not receive any intervention during the same period. The primary outcomes are participants' progression toward smoking cessation assessed by the Incremental Behavior Change toward Smoking Cessation (IBC-S) and biochemically validated abstinence at the 3-month follow-up. Secondary outcomes include self-reported and biochemically validated tobacco abstinence at the 6-month follow-up.

Discussion

The findings will provide evidence that the EMA-based tailored smoking cessation intervention can be adapted as a new health promotion strategy for current smokers who are unwilling to use smoking cessation aids.

Clinical trial registration

https://classic.clinicaltrials.gov/ct2/show/NCT05212220, identifier: NCT05212220.

Older Adults' Use of and Interest in Technology and Applications for Health Management: A Survey Study

Background

Older adults face challenges with managing their medications, obtaining health education, and accessing health services. Mobile health (mHealth), defined as any medical or public health practice facilitated through mobile devices, could help to overcome these difficulties.

Objectives

To determine what technologies and apps are in current use by older adults, to explore the types of technologies and apps that may be of interest to people in this age group, to explore concerns about technologies, and to examine any age-related differences.

Methods

Adults 60 years of age or older were invited to complete a 35-item electronic survey, in either French or English, which was distributed through social media and by email from organizations working with older adults. The survey was conducted in mid-2020.

Results

A total of 266 respondents completed some or all of the survey. Most participants had a mobile phone (229/243, 94.2%), and approximately one-third (78/222, 35.1%) had used a health-related app in the previous 12 months; this level of usage was consistent across age groups. Most respondents were interested in using an app to improve their health (171/225, 76.0%), with variation by age: highest among those 60-64 years of age (82/95, 86.3%), lower among those 80 years or older (40/52, 76.9%), and lowest among those 65-69 years of age (6/14, 42.9%). Most older adults were interested in using an app to ask questions of pharmacists (161/219, 73.5%) and to review their medications (154/218, 70.6%). Participants' mHealth concerns focused on costs, disclosure of personal information, effectiveness, usability, and endorsement by health care providers. The study limitations included challenges related to electronic recruitment and survey distribution, as well as a high representation of participants with postsecondary education.

Conclusions

These findings suggest that a substantial proportion of older adults are already using and are interested in using mHealth for health information, to ask questions, and/or to review their medications with a health care team member.

Advancing Dermatological Care: A Comprehensive Narrative Review of Tele-Dermatology and mHealth for Bridging Gaps and Expanding Opportunities beyond the COVID-19 Pandemic

Mobile health (mHealth) has recently had significant advances in tele-dermatology (TD) thanks to the developments following the COVID-19 pandemic. This topic is very important, as telemedicine and mHealth, when applied to dermatology, could improve both the quality of healthcare for citizens and the workflow in the health domain. The proposed study was centered on the last three years. We conducted an overview on the opportunities, the perspectives, and the problems involved in TD integration with mHealth. The methodology of the narrative review was based on: (I) a search of PubMed and Scopus and (II) an eligibility assessment, using properly proposed parameters. The outcome of the study showed that during the COVID-19 pandemic, TD integration with mHealth advanced rapidly. This integration enabled the monitoring of dermatological problems and facilitated remote specialist visits, reducing face-to-face interactions. AI and mobile apps have empowered citizens to take an active role in their healthcare. This differs from other imaging sectors where information exchange is limited to professionals. The opportunities for TD in mHealth include improving service quality, streamlining healthcare processes, reducing costs, and providing more accessible care. It can be applied to various conditions, such as (but not limited to) acne, vitiligo, psoriasis, and skin cancers. Integration with AI and augmented reality (AR), as well as the use of wearable sensors, are anticipated as future developments. However, integrating TD with mHealth also brings about problems and challenges related to regulations, ethics, cybersecurity, data privacy, and device management. Scholars and policymakers need to address these issues while involving citizens in the process.

Virtual avatars as a new tool for human immunodeficiency virus prevention among men who have sex with men: a narrative review

Background and Objective

Human immunodeficiency virus (HIV) continues to affect sexual and gender minorities, predominantly men who have sex with men (MSM). Stigma, medical mistrust, and apprehension towards discussing sexual health with one's medical provider are significant barriers in seeking or accessing preventive services. Those obstacles could be surpassed through novel digital and electronic health interventions, specifically with virtual avatar technology. Avatars are digital self-representative agents that are controlled with an interactive electronic device. Avatars allow for virtual self-immersion within infinitely customizable environments to practice skill building, fostering relationships and more, through an optional incognito approach. The objective of this narrative review is to examine recent uses of and developments in avatar technology, highlight the personalization attribute of this technology, and evaluate its strengths and limitations as a tool for HIV prevention among MSM.

Methods

We reviewed recent scientific literature generated by PubMed that use virtual avatar technology in HIV prevention and treatment among populations put at risk. Articles that met the inclusion criteria were then categorized on how the avatar technology was used.

Key Content and Findings

We identified eleven studies that met inclusion criteria. Avatar technology was found to create a comfortable environment for participants to address and discuss their sexual behaviors with less hesitation. Avatars can build rapport with populations put at high risk, creating an opportunity for reevaluation of their sexual behavior while assisting them in being able seek information, preventive services, or treatment for HIV or other sexually transmitted infections (STIs).

Conclusions

Given the increased use of digital technology in health and prevention, avatars might be useful in sexual health education and HIV prevention among populations put at risk. The benefits and potential in utilizing this technology for HIV prevention are highlighted.

Designing and pilot-testing SmokefreeSGM: a text-based smoking cessation intervention for sexual and gender minority groups

Background

Although the prevalence of smoking is significantly higher among sexual and gender minorities (SGM) than the general population, no text-based smoking cessation intervention has been specifically tailored to this group. The objective of this phase of our study was to develop SmokefreeSGM, an SGM-tailored text-based smoking cessation program, and pilot test its design to inform the refinement of the program.

Methods

SmokefreeSGM was adapted from SmokefreeTXT, the National Cancer Institute's text-based smoking cessation program, to respond to the needs of SGM smokers. In addition to tailored text messages, SmokefreeSGM includes a new keyword, STRESS, to address the unique psychosocial stressors of SGM smokers. Text messages were distributed to users over a 6-week period, and participants were provided with nicotine patches to aid their efforts to quit smoking. Demographic and tobacco use information was collected at baseline. Quantitative (related to engagement and usability) and qualitative (related to usability and acceptability) data was also collected at the 1-month assessment.

Results

A total of 18 SGM smokers were recruited for the pilot test. 38.9% of participants were male, 38.9% were female, and 22.2% were nonbinary. 27.8% of participants identified as gay, 11.1% as lesbians, 27.8% as bisexual females, 16.7% as bisexual males, and the remaining 16.7% as other. At baseline, two-thirds (66.7%) were moderate to highly dependent on nicotine and 44.4% had made more than five attempts to quit smoking. The average engagement rate for bidirectional text messages was 63.8%. However, the response rate to the tailored text messages (54%) was higher than the non-tailored text messages (41.9%). Nine participants completed the 1-month assessment and interview (50% retention rate). The System Usability Scale (SUS) score was 81.67 (±15.46). Furthermore, four major themes emerged from our qualitative analysis of the interviews (i.e., appreciation for the intervention, program, content, and drawbacks).

Conclusions

Findings from the pilot test of SmokefreeSGM are not only encouraging in terms of engagement, usability and acceptability, but have also informed the refinement of the program prior to launching a feasibility trial.

The usability of daytime and night-time heart rate dynamics as digital biomarkers of depression severity

BACKGROUND

Alterations in heart rate (HR) may provide new information about physiological signatures of depression severity. This 2-year study in individuals with a history of recurrent major depressive disorder (MDD) explored the intra-individual variations in HR parameters and their relationship with depression severity.

METHODS

Data from 510 participants (Number of observations of the HR parameters = 6666) were collected from three centres in the Netherlands, Spain, and the UK, as a part of the remote assessment of disease and relapse-MDD study. We analysed the relationship between depression severity, assessed every 2 weeks with the Patient Health Questionnaire-8, with HR parameters in the week before the assessment, such as HR features during all day, resting periods during the day and at night, and activity periods during the day evaluated with a wrist-worn Fitbit device. Linear mixed models were used with random intercepts for participants and countries. Covariates included in the models were age, sex, BMI, smoking and alcohol consumption, antidepressant use and co-morbidities with other medical health conditions.

RESULTS

Decreases in HR variation during resting periods during the day were related with an increased severity of depression both in univariate and multivariate analyses. Mean HR during resting at night was higher in participants with more severe depressive symptoms.

CONCLUSIONS

Our findings demonstrate that alterations in resting HR during all day and night are associated with depression severity. These findings may provide an early warning of worsening depression symptoms which could allow clinicians to take responsive treatment measures promptly.

Time-varying model of engagement with digital self reporting: Evidence from smoking cessation longitudinal studies

Objective

Insufficient engagement is a critical barrier impacting the utility of digital interventions and mobile health assessments. As a result, engagement itself is increasingly becoming a target of studies and interventions. The purpose of this study is to investigate the dynamics of engagement in mobile health data collection by exploring whether, how, and why response to digital self-report prompts change over time in smoking cessation studies.

Method

Data from two ecological momentary assessment (EMA) studies of smoking cessation among diverse smokers attempting to quit (N = 573) with a total of 65,974 digital self-report prompts. We operationalize engagement with self-reporting in term of prompts delivered and prompt response to capture both broad and more granular engagement in self-reporting, respectively. The data were analyzed to describe trends in prompt delivered and prompt response over time. Time-varying effect modeling (TVEM) was employed to investigate the time-varying effects of response to previous prompt and the average response rate on the likelihood of current prompt response.

Results

Although prompt response rates were relatively stable over days in both studies, the proportion of participants with prompts delivered declined steadily over time in one of the studies, indicating that over time, fewer participants charged the device and kept it turned on (necessary to receive at least one prompt per day). Among those who did receive prompts, response rates were relatively stable. In both studies, there is a significant, positive and stable relationship between response to previous prompt and the likelihood of response to current prompt throughout all days of the study. The relationship between the average response rate prior to current prompt and the likelihood of responding to the current prompt was also positive, and increasing with time.

Conclusion

Our study highlights the importance of integrating various indicators to measure engagement in digital self-reporting. Both average response rate and response to previous prompt were highly predictive of response to the next prompt across days in the study. Dynamic patterns of engagement in digital self-reporting can inform the design of new strategies to promote and optimize engagement in digital interventions and mobile health studies.

The evolution of HIV self-testing and the introduction of digital interventions to improve HIV self-testing

HIV self-testing (HIVST) complements traditional HIV testing programmes by removing barriers and increasing access to testing for key populations, and digital interventions have been developed for HIVST to improve the testing and linkage to care experience for users. The first HIVST kit was proposed in 1986, but it took 10 years for the home sample collection (HSC) HIVST to become available and another 16 years for rapid diagnostic test HIVST to be approved by the Federal Drug Administration. Since then, studies have shown high usability and performance of HIVST, which led the World Health Organization formally recommending HIVST in 2016, and currently almost 100 countries have incorporated HIVST into their national testing strategy. Despite the popularity, HIVST present challenges around pre-and post-test counselling, as well as the ability to report results and link users to care, and digital interventions for HIVST have been introduced to address these challenges. The first digital intervention for HIVST was introduced in 2014 and showed that digital interventions could be used to distribute HIVST kits, report results and link users to care. Since then, dozens of studies have been conducted, which have validated and expanded on these early findings, but many were pilot studies with small sample sizes and lacked the standardization of indicators required to aggregate data across platforms to prove impact at scale. For digital interventions for HIVST to be championed for scale-up, they must continue to show measurable impact at larger scales, while still maintaining and standardizing data security and integrity.

Investigating Popular Mental Health Mobile Application Downloads and Activity During the COVID-19 Pandemic

OBJECTIVE

This article analyzes the changes in downloads and activity of users of select popular mental health mobile applications (mHealth apps) during coronavirus disease 2019 (COVID-19).

BACKGROUND

The outbreak of the COVID-19 crisis has shown a negative impact on public mental health. Mobile health has the potential to help address the psychological needs of existing and new patients during the pandemic and beyond.

METHOD

Downloads data of 16 widely used apps were analyzed. The quality of apps was reviewed using the Mobile Application Rating Scale (MARS) framework. Correlation analysis was conducted to investigate the relationship between app quality and app popularity.

RESULTS

Among the 16 apps, 10 were meditational in nature, 13 showed increased downloads, with 11 apps showing above 10% increase in the downloads after the pandemic started. The popular apps were satisfactory in terms of functionality and esthetics but lacked clinical grounding and evidence base. There exists a gap between app quality and app popularity.

CONCLUSION

This study provided evidence for increased downloads of mental mHealth apps (primarily meditation apps) during the COVID-19 pandemic but revealed several gaps and opportunities to address deficiencies in evidence-based design, usability and effective assessment, and integration into current workflows.

APPLICATION

The COVID-19 pandemic is a potential turning point for mHealth applications for mental health care. Whereas the evidence suggests a need for alternative delivery of care, human factors and ergonomics methods should be utilized to ensure these tools are user-centered, easy to use, evidence-based, well-integrated with professional care, and used sustainably.

Mobile health-based home rehabilitation education improving early outcomes after anterior cruciate ligament reconstruction: A randomized controlled clinical trial

Objective

This study aimed to assess changes in joint range of motion (ROM) and knee joint function between patients who received the mobile health-based intervention and those who received regular care at 2 and 6 weeks after anterior cruciate ligament (ACL) reconstruction to provide better interventions in the future.

Methods

Patients who underwent ACL reconstruction were randomized into the experimental [Mobile health-based intervention (MHI); n = 62] and control (CON) groups (n = 63). The CON group underwent home-based rehabilitation exercise following the paper rehabilitation schedule, while the intervention group received additional mobile health-based education at weeks 1-6 after surgery. ROM, thigh circumference difference, and flexion pain were the primary outcomes. The secondary outcomes were the international knee documentation committee knee evaluation form (IKDC) scores and rehabilitation compliance scores. All the outcomes were measured 1 day before surgery as references and at 2 and 6 weeks after surgery.

Results

There was no statistical difference in the patients' ROM, thigh circumference difference, and VAS scores at the 2-week follow-up. At the 6-week follow-up, the ROM of the affected leg was (118.1 ± 20.5)° in the CON group and (126.6 ± 20.5)° in the MHI group, and the difference was statistically significant (P = 0.011). The difference in thigh circumference was 3.0 (2.0, 3.5) cm in the CON group and 2.5 (1.0, 3.0) cm in the MHI group. The difference was statistically significant (P < 0.001). The VAS score in the CON group was 3.0 (2.0, 4.0), and the MHI group was 2.5 (1.0, 3.0). The difference was statistically significant (P < 0.05). At the 6-week follow-up, the compliance score of patients in the MHI group was significantly higher than that in the CON group (P = 0.047, β = 2.243, 95%CI: 0.026-4.459). There is no statistically significant difference in IKDC scores.

Conclusion

Mobile health-based intervention positively affected patients undergoing ACL reconstruction surgery, particularly in improving the clinical outcome indicators of the knee joint.

MyDietCam: Development and usability study of a food recognition integrated dietary monitoring smartphone application

Background

Diet monitoring has been linked with improved eating habits and positive health outcomes such as prevention of obesity. However, this is often unsustainable as traditional methods place a high burden on both participants and researchers through pen and paper recordings and manual nutrient coding respectively. The digitisation of dietary monitoring has greatly reduced these barriers. This paper proposes a diet application with a novel food recognition feature with a usability study conducted in the real world.

Methods

This study describes the development of a mobile diet application (MyDietCam) targeted at healthy Malaysian adults. Focus group discussions (FGD) were carried out among dietitians and potential users to determine ideal features in a diet application. Thirty participants were recruited from a local university to log their meals through MyDietCam for six days and submit the Malay mHealth Application Usability Questionnaire (M-MAUQ) at the end of the study.

Results

The findings from the FGD led to the implementation of the main features: individualised recommendations, food logging through food recognition to reduce steps for data entry and provide detailed nutrient analyses through visuals. An average overall usability score of 5.13 out of a maximum of seven was reported from the M-MAUQ which is considered acceptable.

Conclusion

The development of a local (Malaysian) mobile diet application with acceptable usability may be helpful in sustaining the diet monitoring habit to improve health outcomes. Future work should focus on improving the issues raised before testing the effectiveness of the application for improving health outcomes.

The potential of mHealth for older adults on dialysis and their care partners: What's been done and where do we go from here?

Self-care, or the dynamic, daily process of becoming actively involved in one's own care, is paramount to prevent and manage complications of end-stage kidney disease. However, many older dialysis patients face distinctive challenges to adequate engagement in self-care. One promising strategy for facilitating self-care among older dialysis patients and their care partners is the utilization of mobile health (mhealth). mHealth encompasses mobile and wireless communication devices used to improve healthcare delivery, patient and care partner outcomes, and patient care. In other disease populations, mHealth has been linked to maintenance of or improvements in self-management, medication compliance, patient education, and patient-provider communication, all of which can slow disease progression. Although mHealth is considered feasible, acceptable, and clinically useful, this technology has predominately targeted younger patients. Thus, there is a need to develop mHealth for older dialysis patients and their care partners. In this article, we describe current mHealth usage in older dialysis patients, including promising findings, challenges, and research gaps. Given the lack of research on mHealth among care partners of older dialysis patients, we highlight lessons learned from other disease populations to inform the future design and implementation of mHealth for these key stakeholders. We also propose that leveraging care partners represents an opportunity to meaningfully tailor mHealth applications and, by extension, improve care partner physical and mental health and decrease caregiver burden. We conclude with a summary of future directions to help older dialysis patients and their care partners receive recognition as target end-users amid the constant evolution of mHealth.

Using Smartphones to Identify Momentary Characteristics of Persecutory Ideation Associated With Functional Disability

Objectives

Though often a feature of schizophrenia-spectrum disorders, persecutory ideation (PI) is also common in other psychiatric disorders as well as among individuals who are otherwise healthy. Emerging technologies allow for a more thorough understanding of the momentary phenomenological characteristics that determine whether PI leads to significant distress and dysfunction. This study aims to identify the momentary phenomenological features of PI associated with distress, dysfunction, and need for clinical care.

Methods

A total of 231 individuals with at least moderate PI from 43 US states participated in a study involving 30 days of data collection using a smartphone data collection system combining ecological momentary assessment and passive sensors, wherein they reported on occurrence of PI as well as related appraisals, responses, and cooccurring states. Most (N = 120, 51.9%) participants reported never having received treatment for their PI, while 50 participants had received inpatient treatment (21.6%), and 60 (26.4%) had received outpatient care only.

Results

Individuals with greater functional disability did not differ in PI frequency but were more likely at the moment to describe threats as important to them, to ruminate about those threats, to experience distress related to them, and to change their behavior in response. Groups based on treatment-seeking patterns largely did not differ in baseline measures or momentary phenomenology of PI as assessed by self-report or passive sensors.

Conclusions

Smartphone data collection allows for granular assessment of PI-related phenomena. Functional disability is associated with differences in appraisals of and responses to PI at the moment.

Feasibility and scalability of a fitness tracker study: Results from a longitudinal analysis of persons with multiple sclerosis

Background

Consumer-grade fitness trackers offer exciting opportunities to study persons with chronic diseases in greater detail and in their daily-life environment. However, attempts to bring fitness tracker measurement campaigns from tightly controlled clinical environments to home settings are often challenged by deteriorating study compliance or by organizational and resource limitations.

Objectives

By revisiting the study design and patient-reported experiences of a partly remote study with fitness trackers (BarKA-MS study), we aimed to qualitatively explore the relationship between overall study compliance and scalability. On that account, we aimed to derive lessons learned on strengths, weaknesses, and technical challenges for the conduct of future studies.

Methods

The two-phased BarKA-MS study employed Fitbit Inspire HR and electronic surveys to monitor physical activity in 45 people with multiple sclerosis in a rehabilitation setting and in their natural surroundings at home for up to 8 weeks. We examined and quantified the recruitment and compliance in terms of questionnaire completion and device wear time. Furthermore, we qualitatively evaluated experiences with devices according to participants' survey-collected reports. Finally, we reviewed the BarKA-MS study conduct characteristics for its scalability according to the Intervention Scalability Assessment Tool checklist.

Results

Weekly electronic surveys completion reached 96%. On average, the Fitbit data revealed 99% and 97% valid wear days at the rehabilitation clinic and in the home setting, respectively. Positive experiences with the device were predominant: only 17% of the feedbacks had a negative connotation, mostly pertaining to perceived measurement inaccuracies. Twenty-five major topics and study characteristics relating to compliance were identified. They broadly fell into the three categories: "effectiveness of support measures", "recruitment and compliance barriers", and "technical challenges". The scalability assessment revealed that the highly individualized support measures, which contributed greatly to the high study compliance, may face substantial scalability challenges due to the strong human involvement and limited potential for standardization.

Conclusion

The personal interactions and highly individualized participant support positively influenced study compliance and retention. But the major human involvement in these support actions will pose scalability challenges due to resource limitations. Study conductors should anticipate this potential compliance-scalability trade-off already in the design phase.

Perceptions on a mobile health intervention to improve maternal child health for Syrian refugees in Turkey: Opportunities and challenges for end-user acceptability

Background

Mobile health (mhealth) technology presents an opportunity to address many unique challenges refugee populations face when accessing healthcare. A robust body of evidence supports the use of mobile phone-based reminder platforms to increase timely and comprehensive access to health services. Yet, there is a dearth of research in their development for displaced populations, as well as refugee perspectives in design processes to improve effective adoptions of mhealth interventions.

Objective

This study aimed to explore healthcare barriers faced by Syrian refugee women in Turkey, and their perceptions of a maternal-child health mobile application designed to provide antenatal care and vaccine services. These findings guided development of a framework for enhancing acceptability of mobile health applications specific to refugee end-users.

Methods

Syrian refugee women who were pregnant or had at least one child under the age of 2 years old at the time of recruitment (n = 14) participated in semi-structured in-depth interviews. Participants had the opportunity to directly interact with an operational maternal-child health mobile application during the interview. Using a grounded theory approach, we identified critical factors and qualities mhealth developers should consider when developing user-friendly applications for refugees.

Results

It was observed that a refugee's perception of the mobile health application's usability was heavily influenced by past healthcare experiences and the contextual challenges they face while accessing healthcare. The in-depth interviews with refugee end-users identified that data security, offline capability, clear-user directions, and data retrievability were critical qualities to build into mobile health applications. Among the features included in the maternal-child health application, participants most valued the childhood vaccination reminder and health information features. Furthermore, the application's multi-lingual modes (Arabic, Turkish, and English) strengthened the application's usability among Syrian refugee populations living in Turkey.

Conclusions

The inclusion of refugee perceptions in mhealth applications offers unique developer insights for building more inclusive and effective tools for vulnerable populations. Basic upfront discussions of the mobile application's health goals and its personal value to the user may improve their long-term use. Further prospective research is needed on retention and use of mobile health applications for refugee women and other displaced populations.

Weight loss in a digital app-based diabetes prevention program powered by artificial intelligence

Objective

The National Diabetes Prevention Program (DPP) reduces diabetes incidence and associated medical costs but is typically staffing-intensive, limiting scalability. We evaluated an alternative delivery method with 3933 members of a program powered by conversational Artificial Intelligence (AI) called Lark DPP that has full recognition from the Centers for Disease Control and Prevention (CDC).

Methods

We compared weight loss maintenance at 12 months between two groups: 1) CDC qualifiers who completed ≥4 educational lessons over 9 months (n  =  191) and 2) non-qualifiers who did not complete the required CDC lessons but provided weigh-ins at 12 months (n  =  223). For a secondary aim, we removed the requirement for a 12-month weight and used logistic regression to investigate predictors of weight nadir in 3148 members.

Results

CDC qualifiers maintained greater weight loss at 12 months than non-qualifiers (M  =  5.3%, SE  =  .8 vs. M  =  3.3%, SE  =  .8; p  =  .015), with 40% achieving ≥5%. The weight nadir of 3148 members was 4.2% (SE  =  .1), with 35% achieving ≥5%. Male sex (β = .11; P  =  .009), weeks with ≥2 weigh-ins (β = .68; P < .0001), and days with an AI-powered coaching exchange (β = .43; P < .0001) were associated with a greater likelihood of achieving ≥5% weight loss.

Conclusions

An AI-powered DPP facilitated weight loss and maintenance commensurate with outcomes of other digital and in-person programs not powered by AI. Beyond CDC lesson completion, engaging with AI coaching and frequent weighing increased the likelihood of achieving ≥5% weight loss. An AI-powered program is an effective method to deliver the DPP in a scalable, resource-efficient manner to keep pace with the prediabetes epidemic.

Employing Smartphone Health Apps in Weight Management for Adolescents: Analysis on Experiences and Perspectives From Pediatric Providers

The rising popularity of smartphone health applications (apps) offers great potential for facilitating pediatric weight management. Pediatric providers can determine health interventions for young patients with excess weight. We surveyed 51 pediatric providers at a Midwest academic medical institution and found that 78% thought currently available resources were not sufficient for pediatric weight management. In all, 76% of respondents reported use of at least one smartphone health app for their personal health. The quality of pediatric providers' experiences with their favorite app was strongly associated with their willingness to recommend the app to their patients (P < .001), but few of them have made such a recommendation in practice, mainly due to the lack of either personal knowledge about health apps or about evidence-based health apps for pediatric weight management. Moreover, respondents shared ideas about qualities for an effective health app, which shed new light on developing apps specifically for adolescents with excess weight.

"I Beat Cancer to Feel Sick:" Qualitative Experiences of Sleep Disturbance in Black Breast Cancer Survivors and Recommendations for Culturally Targeted Sleep Interventions

BACKGROUND

Sleep disturbance is common and distressing among cancer survivors. Black breast cancer survivors (BBCS) suffer disproportionately from sleep disturbance, yet there is limited research on how to address this issue.

PURPOSE

This study aimed to understand the multifaceted experiences of sleep disturbance among BBCS and how to culturally target a mobile health (mHealth) intervention to improve sleep outcomes in BBCS.

METHODS

Semi-structured interviews were conducted in a purposive sample of 10 BBCS. Interviews were audio-recorded, transcribed, and coded for key barriers to sleep and potential solutions to incorporate into behavioral interventions using NVivo 12. Inductive applied thematic analysis techniques were employed to identify emergent themes.

RESULTS

Ten BBCS (mean age = 54, SD = 10) described their experiences of sleep disturbance with themes including: (1) barriers to quality sleep (e.g., cancer worry, personal responsibilities), (2) psychosocial impacts of sleep disturbance (e.g., fatigue, distress), and (3) commonly used strategies to improve sleep. The second section discusses suggestions for developing mHealth interventions to improve sleep for BBCS including: (1) feedback on an existing mHealth intervention and (2) intervention topics suggested by BBCS.

CONCLUSIONS

Our findings highlight the challenges associated with sleep disturbance in BBCS. Participants report culturally targeted mHealth interventions are needed for BBCS who experience chronic sleep disturbance that affects their overall quality of life. These interventions should address coping with sleep-related issues relevant to many breast cancer survivors and BBCS (e.g., sexual intimacy, fear of cancer recurrence) and should incorporate intervention strategies acceptable to BBCS (e.g., prayer, meditation).

Quality and Presence of Behaviour Change Techniques in Mobile Apps for the Mediterranean Diet: A Content Analysis of Android Google Play and Apple App Store Apps

Smartphone apps might represent an opportunity to promote adherence to the Mediterranean diet (MedDiet). This study aimed to evaluate the quality of commercially available apps for the MedDiet and the presence of behavioural change techniques (BCTs) used by these apps. A systematic search was conducted on the Apple App and Google Play stores in November 2021. Apps were included if they provided information on the MedDiet or if their objective was to promote a healthy lifestyle through adherence to the MedDiet. Eligible apps were independently evaluated by two reviewers with regard to their quality (engagement, functionality, aesthetics and information quality) using the 5-point Mobile App Rating Scale (MARS; with higher scores indicating higher quality), and the presence of BCTs using an established 26-item BCT taxonomy. Of the 55 analysed apps, 52 (94.5%) were free, 50 (90.9%) provided recipe ideas, 29 (52.7%) provided meal plans, and 22 (40%) provided information on the health benefits of the MedDiet. The overall quality mean MARS score was 2.84 (standard deviation (SD) = 0.42), with functionality being the highest scored MARS domain (mean = 3.58, SD = 0.44) and engagement the lowest (mean = 2.29, SD = 0.61). The average number of BCTs in the analysed apps was 2.3 (SD = 1.4; range: 0-6 per app). The number of BCTs was positively correlated with app information quality (rrho = 0.269, p = 0.047), overall MARS score (rrho = 0.267, p = 0.049), app subjective quality (rrho = 0.326, p = 0.015) and app-specific quality (rrho = 0.351, p = 0.009). These findings suggest that currently available apps might provide information on the MedDiet, but the incorporation of more BCTs is warranted to maximise the potential for behaviour change towards the MedDiet.

Will Apple devices' passive atrial fibrillation detection prevent strokes? Estimating the proportion of high-risk actionable patients with real-world user data

OBJECTIVE

Utilizing integrated electronic health record (EHR) and consumer-grade wearable device data, we sought to provide real-world estimates for the proportion of wearers that would likely benefit from anticoagulation if an atrial fibrillation (AFib) diagnosis was made based on wearable device data.

MATERIALS AND METHODS

This study utilized EHR and Apple Watch data from an observational cohort of 1802 patients at Cedars-Sinai Medical Center who linked devices to the EHR between April 25, 2015 and November 16, 2018. Using these data, we estimated the number of high-risk patients who would be actionable for anticoagulation based on (1) medical history, (2) Apple Watch wear patterns, and (3) AFib risk, as determined by an existing validated model.

RESULTS

Based on the characteristics of this cohort, a mean of 0.25% (n = 4.58, 95% CI, 2.0-8.0) of patients would be candidates for new anticoagulation based on AFib identified by their Apple Watch. Using EHR data alone, we find that only approximately 36% of the 1802 patients (n = 665.93, 95% CI, 626.0-706.0) would have anticoagulation recommended even after a new AFib diagnosis.

DISCUSSION AND CONCLUSION

These data suggest that there is limited benefit to detect and treat AFib with anticoagulation among this cohort, but that accessing clinical and demographic data from the EHR could help target devices to the patients with the highest potential for benefit. Future research may analyze this relationship at other sites and among other wearable users, including among those who have not linked devices to their EHR.

User Preferences for an mHealth Approach to Support HIV Self-Testing and Linkage to HIV Prevention or Care Services for MSM in China

This research qualitatively explored user preferences for an app-based mHealth approach to support HIV self-testing and linkage to HIV prevention or care services developed for men who have sex with men (MSM) in China. We conducted 12 online focus group discussions with MSM participants (N = 48) about their preferences for using an app to meet their HIV self-testing and service linkage needs. Data were examined using thematic analysis. Participants specified four domains to align program delivery with their preferences for app-based intervention: (1) expanding HIV prevention/antiretroviral therapy concepts beyond basic knowledge; (2) enhancing the style and presentation of app-based messages; (3) incorporating interactive and dynamic app-engagement features; and (4) creating a "one station" app that covers the continuum of HIV services. Given the changing landscapes of HIV knowledge and community/user preferences for app-based interaction, findings underscore how engagement with end-user participants is essential to optimize mHealth interventions for HIV.

Evaluation of Android and Apple Store Depression Applications Based on Mobile Application Rating Scale

There are a large number of mobile applications that allow the monitoring of health status. The quality of the applications is only evaluated by users and not by standard criteria. This study aimed to examine depression-related applications in major mobile application stores and to analyze them using the rating scale tool Mobile Application Rating Scale (MARS). A search of digital applications for the control of symptoms and behavioral changes in depression was carried out in the two reference mobile operating systems, Apple (App Store) and Android (Play Store), by means of two reviewers with a blind methodology between September and October 2019 in stores from Spain and the United Kingdom. Eighteen applications from the Android Play Store and twelve from the App Store were included in this study. The quality of the applications was evaluated using the MARS scale from 1 (inadequate) to 5 (excellent). The average score of the applications based on the MARS was 3.67 ± 0.53. The sections with the highest scores were “Functionality” (4.51) and “Esthetics” (3.98) and the lowest “Application Subjective quality” (2.86) and “Information” (3.08). Mobile Health applications for the treatment of depression have great potential to influence the health status of users; however, applications come to the digital market without health control.

A novel mHealth App (RyPros) for prostate cancer management: an accessibility and acceptability study

Background

Over the past decade, there has been a significant increase in research on the use of mobile health (mHealth) apps as disease management tools. However, very few apps are currently available for prostate cancer (PCa) patient management, and the available apps do not combine the needs of physicians with the requirements of patients. This study aimed to describe the development of a mHealth application for PCa survivors called RyPros, which includes dynamic visualization, intelligent reminders, and instant messaging to support decision-making regarding treatment and follow-up and test the initial accessibility and acceptability application.

Methods

The application was developed through a three-step procedure: logical structure design, application programming, and testing. Dynamic visualization, intelligent reminders, and instant messaging were the core functions of RyPros. Twenty-eight participants who had PCa were enrolled in four weeks of follow-up using the RyPros App. We initially evaluated participants' acceptance of RyPros based on their use of the app (login data, questionnaire completion) and a satisfaction survey.

Results

We successfully designed and tested the application. A total of 32 participants were enrolled, of whom 28 completed the 4-week follow-up, yielding a participation rate of 87.5%. Each participant logged on an average of 2.82 times and achieved an average of 0.89 questionnaires per week over the four weeks. Most participants (64%) liked the app, and most participants (71%) were satisfied, giving the RyPros app a rating of 4 or 5. More than half of the participants (61%) intended to use the RyPros app regularly, and the majority of participants agreed that the three core functionalities of RyPros were helpful (20/28, 71% for instant messaging; 16/28, 57% for visualization; and 18/28, 64% for reminders and assessments).

Conclusions

The mHealth application we developed for PCa survivor management provided dynamic visualization, reminders, assessments, and instant messaging to support decision-making based on multidisciplinary collaboration. PCa survivors showed high acceptance of the RyPros app.

Digital Citizen Science for Responding to COVID-19 Crisis: Experiences from Iran

The Coronavirus Disease 2019 (COVID-19) pandemic has so far been the most severe global public health emergency in this century. Generally, citizen science can provide a complement to authoritative scientific practices for responding to this highly complex biological threat and its adverse consequences. Several citizen science projects have been designed and operationalized for responding to COVID-19 in Iran since the infection began. However, these projects have mostly been overlooked in the existing literature on citizen science. This research sheds light on the most significant online citizen science projects to respond to the COVID-19 crisis in Iran. Furthermore, it highlights some of the opportunities and challenges associated with the strengths and weaknesses of these projects. Moreover, this study captures and discusses some considerable insights and lessons learned from the failures and successes of these projects and provides solutions to overcome some recognized challenges and weaknesses of these projects. The outcomes of this synthesis provide potentially helpful directions for current and future citizen science projects-particularly those aiming to respond to biological disasters such as the COVID-19 pandemic.

An mHealth-Based Intervention for Adolescents With Type 1 Diabetes and Their Parents: Pilot Feasibility and Efficacy Single-Arm Study

Background

Type 1 diabetes (T1D) affects more than 165,000 individuals younger than 20 years in the United States of America. The transition from parent management to parent-child team management, with the child taking on increased levels of self-care, can be stressful and is associated with a deterioration in self-management behaviors. Therefore, a mobile app intervention, MyT1DHero, was designed to facilitate diabetes-specific positive parent-adolescent communication and improve diabetes-related outcomes. The MyT1DHero intervention links an adolescent with T1D and their parent through 2 separate app interfaces and is designed to promote positive communication regarding T1D management.

Objective

The aim of this pilot study was to determine (1) the initial efficacy of the MyT1DHero intervention in improving diabetes outcomes in adolescents, specifically the hemoglobin A_1c (HbA_1c) levels, diabetes care adherence, and quality of life, and (2) the adolescents’ overall satisfaction with this intervention.

Methods

This pilot study included 30 adolescent-parent pairs who used the MyT1DHero app in a 12-week single-arm clinical trial. Participants were recruited from the local pediatric endocrinology subspecialty clinic via snowball sampling. HbA_1c levels, diabetes care adherence, quality of life, family conflict, and satisfaction levels were measured and analyzed using paired sample two-sided t tests and linear regression analyses.

Results

The final analysis included 25 families. The mean age of the adolescents was 12.28 (SD 1.62) years. Half of the participants (13/25) reported a diabetes diagnosis of less than 5 years. After 12 weeks of the intervention, diabetes care adherence significantly improved (before the study: mean 3.87 [SD 0.59]; after the study: mean 4.19 [SD 0.65]; t₂₁=–2.52, P=.02, d=0.52) as did quality of life (before the study: mean 4.02 [SD 0.84]; after the study: mean 4.27 [SD 0.73]; t₂₄=2.48, P=.01, d=0.32). HbA_1c levels (before the study: mean 8.94 [SD 1.46]; after the study: mean 8.87 [SD 1.29]; t₂₄=0.67, P=.51, d=0.04) and family conflict (before the study: mean 2.45 [SD 0.55]; after the study: mean 2.61 [SD 0.45]; t₂₃=0.55, P=.14, d=0.32) changed in the hypothesized direction, but the change was not significant. However, higher use of the mobile app was associated with more improvement in HbA_1c levels (F_1,20=9.74, P<.005; R²=0.33). Overall, the adolescents were satisfied with the app intervention.

Conclusions

In a 12-week pilot study of the mobile app intervention designed to facilitate parent-adolescent communication for improving diabetes outcomes, significant benefits were demonstrated in self-care adherence and quality of life. A randomized controlled trial with a longer intervention is needed to replicate these findings and to determine the stability of the intervention effects.

Trial Registration

ClinicalTrials.gov NCT03436628; https://clinicaltrials.gov/ct2/show/NCT03436628

Digital Health Interventions: New opportunities for health science librarians

This article acquaints health science librarians with digital health interventions (DHIs) and suggests ways they can become involved with initiatives in their own organisations. Examples of DHIs are provided and the risks and benefits of these applications are examined, including increasing accuracy of diagnosis & treatment, and health care efficiencies within legal and ethical frameworks. The WHO Guideline on digital interventions for health system strengthening is a useful resource which highlights ways that countries can use digital health technology to improve people's health and essential services. JM proposes the creation of a road map to assist health science librarians in becoming involved in digital health, providing practical suggestions to inform the development of action plans within your local service provision. J.M.

Relationship Between Major Depression Symptom Severity and Sleep Collected Using a Wristband Wearable Device: Multicenter Longitudinal Observational Study

Background

Sleep problems tend to vary according to the course of the disorder in individuals with mental health problems. Research in mental health has associated sleep pathologies with depression. However, the gold standard for sleep assessment, polysomnography (PSG), is not suitable for long-term, continuous monitoring of daily sleep, and methods such as sleep diaries rely on subjective recall, which is qualitative and inaccurate. Wearable devices, on the other hand, provide a low-cost and convenient means to monitor sleep in home settings.

Objective

The main aim of this study was to devise and extract sleep features from data collected using a wearable device and analyze their associations with depressive symptom severity and sleep quality as measured by the self-assessed Patient Health Questionnaire 8-item (PHQ-8).

Methods

Daily sleep data were collected passively by Fitbit wristband devices, and depressive symptom severity was self-reported every 2 weeks by the PHQ-8. The data used in this paper included 2812 PHQ-8 records from 368 participants recruited from 3 study sites in the Netherlands, Spain, and the United Kingdom. We extracted 18 sleep features from Fitbit data that describe participant sleep in the following 5 aspects: sleep architecture, sleep stability, sleep quality, insomnia, and hypersomnia. Linear mixed regression models were used to explore associations between sleep features and depressive symptom severity. The z score was used to evaluate the significance of the coefficient of each feature.

Results

We tested our models on the entire dataset and separately on the data of 3 different study sites. We identified 14 sleep features that were significantly (P<.05) associated with the PHQ-8 score on the entire dataset, among them awake time percentage (z=5.45, P<.001), awakening times (z=5.53, P<.001), insomnia (z=4.55, P<.001), mean sleep offset time (z=6.19, P<.001), and hypersomnia (z=5.30, P<.001) were the top 5 features ranked by z score statistics. Associations between sleep features and PHQ-8 scores varied across different sites, possibly due to differences in the populations. We observed that many of our findings were consistent with previous studies, which used other measurements to assess sleep, such as PSG and sleep questionnaires.

Conclusions

We demonstrated that several derived sleep features extracted from consumer wearable devices show potential for the remote measurement of sleep as biomarkers of depression in real-world settings. These findings may provide the basis for the development of clinical tools to passively monitor disease state and trajectory, with minimal burden on the participant.

Quality, Features, and Presence of Behavior Change Techniques in Mobile Apps Designed to Improve Physical Activity in Pregnant Women: Systematic Search and Content Analysis

Background

Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity.

Objective

The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women.

Methods

A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified.

Results

Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality.

Conclusions

Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women.

A systematic review of smartphone apps for gastro-oesophageal reflux disease: the need for regulation and medical professional involvement

BACKGROUND

Expansion in smartphone use and mobile health (mHealth) apps has generated a large and unregulated sector. Gastro-oesophageal Reflux Disease (GORD) is a widely prevalent disease in the UK. The aim of this study is to evaluate the smartphone apps focused on GORD, available on major digital platforms, with particular emphasis on their recorded evidence base (EB) and the extent of medical professional involvement (MPI) in their constitution.

METHODS

Relevant apps were extracted using defined search terms and inclusion (using a wide array of search terms) and exclusion criteria (non-English language, duplicates) were applied. Data was collected from the overview provided by the developer in the app store and from the developer website for each app, and classified according to various variables. EB and professional involvement data was obtained from the application details provided in the app stores as well as information section of individual apps.

RESULTS

A vast majority of the apps (97.3%) were developed targeting the general public. Of the 73 apps, 11 (15.1%) had a documented EB. Two apps stated if healthcare professionals were involved in the development, screening or assessment of the app content, meaning only 2.73% of the apps (2/73) stated their content had been contributed by medical professionals (individual, group or organisation of health providers). Thirty-four apps had recent updates in 2019 (47%, 34/73).

CONCLUSIONS

Regulation and accreditation of mHealth apps related to GORD are needed.

High cellphone use associated with greater risk of depression among young women aged 15-24 years in Soweto and Durban, South Africa

BACKGROUND

The ubiquity of cellular phone (cellphone) use in young people's daily lives has emerged as a priority area of concern for youth mental health.

OBJECTIVE

This study measured the prevalence of depression and its association with high cellphone use among youth in Soweto and Durban, South Africa.

METHODS

We analysed cross-sectional, baseline survey data among youth aged 16-24 who participated in a dual-site cohort study, 'AYAZAZI', conducted from 2014 to 2017. The primary outcome was depression using the 10-item Center for Epidemiologic Studies Depression Scale, with a score of ≥ 10 indicating probable depression. Cellphone use was measured via self-reported average number of hours of active use, with 'high cellphone use' defined as daily usage of ≥ 8. Multivariable logistic regression models assessed the independent relationship between high cellphone use and probable depression, adjusting for potential confounders.

RESULTS

Of 425 participants with a median age of 19 years (IQR = 18-21), 59.5% were young women. Overall, 43.3% had probable depression, with a higher prevalence among women (49.0% vs. 34.9%, P = .004). Nearly all (94.6%) owned a cellphone. About one-third (29.5%) reported spending ≥ 8 hours per day using their cellphone (39.3% of women vs. 14.9% of men, P < .001). In the overall adjusted model, youth reporting high daily cellphone use had higher odds of probable depression (aOR: 1.83, 95% CI: 1.16-2.90). In gender-stratified models, high daily cellphone use was associated with probable depression among women (aOR: 2.51, 95% CI: 1.47-4.31), but not among men (aOR: 0.87, 95% CI: 0.35-2.16).

CONCLUSIONS

Among a cohort of South African youth, we found a high prevalence of probable depression and high cellphone use (30%). The findings indicate a need for intersectoral initiatives focused on meaningful mental health support for South African youth to support positive growth and development.

Design of a Mobile Application and Evaluation of Its Effects on Psychological Parameters of Covid-19 Inpatients: A Protocol for a Randomized Controlled Trial

Background: Panic of the disease and the associated concerns can lower the quality of life and physical performance. As long as the COVID-19 pandemic is ever on the rise, the psychological pandemic of the disease is on the rise, too. The high prevalence of COVID-19 has further increased physicians' work pressure. Patients' needs are not met adequately by physicians. It seems essential to use aids to monitor patients' needs and serve them properly. Thus, in the present research, suggestions are made on how to evaluate patients' physical and psychological conditions during the treatment via a mobile application. Methods and Analysis: The present research is a randomized, two parallel-group, controlled trial. One-hundred-twelve inpatients diagnosed with the coronavirus will be assigned randomly to the control and intervention groups. In the intervention group, a mobile application will be provided to educate patients, establish two-way interactions between patients and care providers and record patients' symptoms. Those in the control group will receive the usual care. The primary outcome is the change to the depression anxiety stress scales-21 (DASS-21) score from the baseline to 2 weeks after discharge from hospital. It will be measured at the baseline, at the time of discharge, and two weeks later. Ethics and Dissemination: The Ethics committee of Mashhad University of Medical Sciences' approval date was 2020-04-19 with IR.MUMS.REC.1399.118 reference code. Thus far, participants' recruitment has not been completed and is scheduled to end in March 2021. The results will be disseminated in a peer-reviewed journal. Trial Registration: IRCT20170922036314N4 (https://www.irct.ir/trial/47383).

Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient sleep

BACKGROUND

Improving sleep for hospitalized patients is an essential clinical need. Compared to the traditional "one-size-fits-all" interventions designed by clinicians for all patients, an individualized strategy engaging patients to identify salient sleep disruptors and seek their input how to address these disruptors are more likely to succeed. Followed by our work of developing the Factors Affecting Inpatient Sleep (FAIS) scale, in this report we developed a set of icons illustrating 14 common sleep disruptors on the FAIS scale, and proposed behavioral sleep promotion tips addressing each sleep disruptor. The set of icons and sleep promotion tips were built into the mobile health (mHealth) tool SLEEPKit, which was the start of our endeavor using mHealth technology to support individualized sleep promotion.

METHODS

A participatory iterative approach including feedbacks from patients, family members, and clinicians was used to develop and refine the icons and sleep promotion tips. Focus groups were used to inform the initial development and to brainstorm for the refinement of the icons. Individual interviews with patients and clinicians were conducted to validate each version of the icons using a standardized Content Validity Index (CVI) on a 4-point Likert scale, and offered comments and suggestions for improvement. Strategies of sleep promotion were first identified by the literature review, and then enriched by the summary of data from our previous work. Focus groups were conducted in order to learn empirically if the sleep promotion tips on the current version were acceptable to both patients and clinicians, and how they could be improved.

RESULTS

Six focus groups were conducted and achieved saturation in suggestions for improvement. A total of 5 patients and 3 family members who served on the Patient/ Family Advisory Council, and 42 nurses who served on the interdisciplinary professional practice committees participated in the focus groups. A total of 75 patients and 50 clinicians offered individual feedback and the CVI test for the icons. Successive two or four phases of iterative icon evaluation and refinement were carried out until the average CVI ratings for each icon achieved 3 and above. The sleep promotion tips were created to demonstrate a collaborative effort between patients and clinicians. To empower patients for bedside communication related to their sleep, examples of communication starters ("Try saying") were included in the tips for patients.

CONCLUSIONS

By using the participatory iterative approach, these icons for common sleep disturbing factors were understandable by both patients and clinicians, and the sleep promotion tips were perceived to be feasible and effective in the acute care hospital setting. This work moved the individualized sleep promotion forward, and supported the development of a novel mHealth tool for inpatient sleep promotion tailored to individual patient's needs.

Evaluating the Reproducibility of Physiological Stress Detection Models

Recent advances in wearable sensor technologies have led to a variety of approaches for detecting physiological stress. Even with over a decade of research in the domain, there still exist many significant challenges, including a near-total lack of reproducibility across studies. Researchers often use some physiological sensors (custom-made or off-the-shelf), conduct a study to collect data, and build machine-learning models to detect stress. There is little effort to test the applicability of the model with similar physiological data collected from different devices, or the efficacy of the model on data collected from different studies, populations, or demographics. This paper takes the first step towards testing reproducibility and validity of methods and machine-learning models for stress detection. To this end, we analyzed data from 90 participants, from four independent controlled studies, using two different types of sensors, with different study protocols and research goals. We started by evaluating the performance of models built using data from one study and tested on data from other studies. Next, we evaluated new methods to improve the performance of stress-detection models and found that our methods led to a consistent increase in performance across all studies, irrespective of the device type, sensor type, or the type of stressor. Finally, we developed and evaluated a clustering approach to determine the stressed/not-stressed classification when applying models on data from different studies, and found that our approach performed better than selecting a threshold based on training data. This paper's thorough exploration of reproducibility in a controlled environment provides a critical foundation for deeper study of such methods, and is a prerequisite for tackling reproducibility in free-living conditions.

Mobile RDoC: Using Smartphones to Understand the Relationship Between Auditory Verbal Hallucinations and Need for Care

Objective

Auditory verbal hallucinations (AVH) are common in multiple clinical populations but also occur in individuals who are otherwise considered healthy. Adopting the National Institute of Mental Health's Research Domain Criteria (RDoC) framework, the aim of the current study was to integrate a variety of measures to evaluate whether AVH experience varies across clinical and nonclinical individuals.

Methods

A total of 384 people with AVH from 41 US states participated in the study; 295 participants (77%) who received inpatient, outpatient, or combination treatments for AVH and 89 participants (23%) who never received care. Participants used a multi-modal smartphone data collection system to report on their AVH experiences and co-occurring psychological states multiple times daily, over 30 days. In parallel, smartphone sensors recorded their physical activity, geolocation, and calling and texting behavior continuously.

Results

The clinical sample experienced AVH more frequently than the nonclinical group and rated their AVH as significantly louder and more powerful. They experienced more co-occurring negative affect and were more socially withdrawn, spending significantly more time at home and significantly less time near other people. Participants with a history of inpatient care also rated their AVH as infused with significantly more negative content. The groups did not differ in their physical activity or use of their smartphones for digital communication.

Conclusion

Smartphone-assisted remote data collection revealed real-time/real-place phenomenological, affective, and behavioral differences between clinical and nonclinical samples of people who experience AVH. The study provided strong support for the application of RDoC-informed approaches in psychosis research.

Geolocation as a Digital Phenotyping Measure of Negative Symptoms and Functional Outcome

OBJECTIVE

Negative symptoms and functional outcome have traditionally been assessed using clinical rating scales, which rely on retrospective self-reports and have several inherent limitations that impact validity. These issues may be addressed with more objective digital phenotyping measures. In the current study, we evaluated the psychometric properties of a novel "passive" digital phenotyping method: geolocation.

METHOD

Participants included outpatients with schizophrenia or schizoaffective disorder (SZ: n = 44), outpatients with bipolar disorder (BD: n =19), and demographically matched healthy controls (CN: n = 42) who completed 6 days of "active" digital phenotyping assessments (eg, surveys) while geolocation was recorded.

RESULTS

Results indicated that SZ patients show less activity than CN and BD, particularly, in their travel from home. Geolocation variables demonstrated convergent validity by small to medium correlations with negative symptoms and functional outcome measured via clinical rating scales, as well as active digital phenotyping behavioral indices of avolition, asociality, and anhedonia. Discriminant validity was supported by low correlations with positive symptoms, depression, and anxiety. Reliability was supported by good internal consistency and moderate stability across days.

CONCLUSIONS

These findings provide preliminary support for the reliability and validity of geolocation as an objective measure of negative symptoms and functional outcome. Geolocation offers enhanced precision and the ability to take a "big data" approach that facilitates sophisticated computational models. Near-continuous recordings and large numbers of samples may make geolocation a novel outcome measure for clinical trials due to enhanced power to detect treatment effects.

A Mobile Phone-Based Sexual and Reproductive Health Intervention for Female Sex Workers in Kenya: Development and Qualitative Study

BACKGROUND

Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women's Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya.

OBJECTIVE

This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants' responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability.

METHODS

The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach.

RESULTS

The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information.

CONCLUSIONS

Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs' lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.

An Individualized, Data-Driven Digital Approach for Precision Behavior Change

Chronic disease now affects approximately half of the US population, causes 7 in 10 deaths, and accounts for roughly 80% of US health care expenditure. Because the root causes of chronic diseases are largely behavioral, effective therapies require frequent, individualized interventions that extend beyond the hospital and clinic to reach patients in their day-to-day lives. However, a mismatch currently exists between what the health care system is equipped to provide and the interventions necessary to effectively address the chronic disease burden. To remedy this health crisis, we present an individualized, data-driven digital approach for chronic disease management and prevention through precision behavior change. The rapid growth of information, biological, and communication technologies makes this an opportune time to develop digital tools that deliver precision interventions for health behavior change to address the chronic disease crisis. Building on this rapid growth, we propose a framework that includes the precise targeting of risk-producing behaviors using real-time sensing technology, machine learning data analysis to identify the most effective intervention, and delivery of that intervention with health-reinforcing feedback to provide real-time, individualized support to empower sustainable health behavior change.

Impact of mobile health in diabetic retinopathy awareness and eye care behavior among Indigenous women

BACKGROUND

Diabetes is increasingly widespread among Indigenous people, and diabetic retinopathy (DR) is a diabetes eye complication and a common cause of vision loss among adults in Canada. Indigenous women have a high risk of diabetes which increases their risk for DR. This study explored utilizing mobile health (mHealth) via text messages to provide DR awareness and improve diabetic-eye care behavior. This study identified the changes in DR awareness and eye care behavior due to a mHealth education intervention among Indigenous women with or at risk of diabetes.

METHODS

A pre-post study which adopted an embedded concurrent mixed methods approach guided by self-determination theory and the medicine wheel. Study participants were First Nations and Métis women living with or at risk of diabetes in Saskatoon, Canada. Data was collected via sharing circles and a DR knowledge, attitude, and practice survey. Pre-intervention participants' baseline information on DR knowledge and behavior were obtained from participants. After that, participants received daily text messages on diabetes-eye related information for 12 weeks. Post-intervention, the impact of the mHealth intervention on DR awareness and eye care behavior was assessed.

RESULTS

Following the intervention, the DR knowledge, attitude, and practice scores significantly improved. Individuals living with diabetes had increased DR attitude and practice post-scores compared to those at risk of diabetes. Older women had a lower pre-post change in practice scores compared to younger women. The mHealth intervention provided a holistic approach to support diabetes-eye care and empowered the study participants to eat healthily, take medication as prescribed, and have regular medical and eye check-ups.

CONCLUSIONS

The mHealth education intervention increased DR awareness and fostered a change in diabetes-eye care behavior. Health information via text messaging can motivate, provide support, and empower individuals as well as prevent and manage chronic conditions and reduce the risk of complications.

Continuous Detection of Physiological Stress with Commodity Hardware

Timely detection of an individual's stress level has the potential to improve stress management, thereby reducing the risk of adverse health consequences that may arise due to mismanagement of stress. Recent advances in wearable sensing have resulted in multiple approaches to detect and monitor stress with varying levels of accuracy. The most accurate methods, however, rely on clinical-grade sensors to measure physiological signals; they are often bulky, custom made, and expensive, hence limiting their adoption by researchers and the general public. In this article, we explore the viability of commercially available off-the-shelf sensors for stress monitoring. The idea is to be able to use cheap, nonclinical sensors to capture physiological signals and make inferences about the wearer's stress level based on that data. We describe a system involving a popular off-the-shelf heart rate monitor, the Polar H7; we evaluated our system with 26 participants in both a controlled lab setting with three well-validated stress-inducing stimuli and in free-living field conditions. Our analysis shows that using the off-the-shelf sensor alone, we were able to detect stressful events with an F1-score of up to 0.87 in the lab and 0.66 in the field, on par with clinical-grade sensors.