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

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

Willingness to use smartphone apps for lifestyle management among patients with schizophrenia

Mobile technology is a popular intervention mode for patients with schizophrenia because of its accessibility and functionality. We examined patients' willingness to use smartphone apps for lifestyle management and its effect on self-reported lifestyle habits. Five hundred fifty-five inpatients from various mental health institutions participated. Willingness to use smartphone apps was associated with age, education, income, device type, and body mass index. Positive opinions on smartphone app use were significantly associated with willingness to use apps, which was significantly associated with dietary and living habits. Thus, improving willingness to use apps can help patients improve their lifestyle, potentially preventing relapse.     

The efficacy of mobile health interventions used to manage acute or chronic pain: A systematic review

Chronic pain is a significant health issue that affects approximately 50 million adults in the United States. Traditional interventions are not always an effective treatment strategy for pain control. However, the wide adoption of smartphones and the rapid growth of health information technologies over the past decade have created opportunities to use mobile health (mHealth) applications (apps) for pain tracking and self‐management. In this PRISMA‐compliant systematic review, we assessed the current U.S.‐based research on pain‐related mHealth apps to describe the app components and determine the efficacy of these interventions for persons with acute or chronic pain. We conducted a comprehensive search of five databases based on methodological guidelines from the Joanna Briggs Institute. We included articles reporting original data on mHealth interventions with pain intensity as a primary or secondary outcome and excluded articles that utilized multimodal interventions. Of the original 4959 articles, only five studies met the eligibility criteria. Most of the interventions included feasibility or pilot studies, and all studies were published between 2015 and 2018. Two of the five studies used visual analog scales. Only two of the studies reported statistically significant pain intensity outcomes, and considerable heterogeneity between the studies limited our ability to generalize findings or conduct a meta‐analysis. Research investigating the components and efficacy of pain‐related mHealth apps as interventions is an emerging field. To better understand the potential clinical benefits of mHealth apps designed to manage pain, further research is needed.     

PS1-49: Methods for Integrating Patient-Reported Outcomes Into the Electronic Health Record

Background/Aims Patient-reported outcomes (PROs) provide valuable information to the clinician about the patient's symptoms and how the patient is responding to treatment. In some cases, electronic or phone-based PROs can reduce the need for office visits. In order to be maximally useful, PROs need to be integrated with electronic health record (EHR) data so providers can evaluate the PRO in the context of a patient's complete clinical record. In this work we identified methods for integrating PROs into the EHR. We focused primarily on PROs collected through electronic interfaces such as personal health records, email, external websites and standalone apps for smartphones and tablets. Methods We compared the benefits and drawbacks of different methods for integrating PROs into Epic Systems Corporations' suite of EHR products. Available methods for automatic integration of PROs into the EHR includes the flowsheet and questionnaire extensions to Epic's MyChart product and HL7 messaging from external applications such as websites or smartphone/tablet apps. Results The questionnaire and flowsheet methodologies within Epic's MyChart product provide a technically simple way to collect PROs. However, these methods are relatively inflexible in terms of how you can present information to the patient. For example, neither method allows you to present images or drawings that can help patients better express concepts such as where symptoms occur in their body. In contrast, website and smartphone/tablet applications can provide much more flexible patient interface options, but the data can be harder to integrate into the EHR system. Regardless of how PROs are collected, integrating the information into the provider's workflow remains a challenge. Discussion Multiple methodologies exist for collecting and integrating PROs into the Epic EHR. Major trade-offs include the flexibility of the patient interface and the ease of integrating the data back into the EHR.     

Brief Educational Sessions to Promote Health App Use

The increase in smartphone ownership by underserved populations provides a unique opportunity to use technology to improve health. Health apps are often free and have programs to empower individuals to engage in health promotion and self-management of chronic illnesses. To promote the use of health apps in an underserved community, investigators provided brief educational sessions to teach individuals to how access and use health apps. Educational sessions increased health app knowledge, comfort in using health apps, and likelihood of using health apps.     

The validation of smartphone applications for heart rate measurement

Abstract

Background: The smartphone apps provide a user-friendly option for measurement of heart rate (HR) by detecting pulsatile photoplethysmographic signals with built-in cameras from the fingertips, however, the validation study is limited.

Methods: We compared HR detected by the smartphone apps (App1?=?Instant HR, App2?=?Cardiio: HR Monitor and App3?=?Runtastic HR Monitor) with simultaneous standard ECG monitoring in the adult patients at the critical care unit.

Results: HR measurements were obtained from 140 patients with mean age 67.6?±?15.3 years. Mean baseline HR was 89.1?±?19.1 bpm (range, 32–136 bpm). Sinus rhythm was presented in 111 patients (79.3%), atrial fibrillation in 25 patients (17.9%), pacemaker rhythm in 3 patients (2.1%), and high-grade AV block in 1 patient (0.7%). The ECG-derived HR correlated well with App1 (r?=?0.98), App2 (r?=?0.97), and App3 (r?=?0.92). In patients with regular rhythm, mean absolute deviation was 0.8?±?1, 0.7?±?0.9, 1.0?±?1.3 bpm on App1, App2 and App3, respectively. In the patients with irregular rhythm, median absolute deviation (IQR) was 3 (2–5.5), 4 (1.5–11.5), and 6 (2–13) bpm. Skin colour did not affect with the HR measurement.

Conclusions: HR measurements from all applications were correlated well with ECG monitoring. However, it was less accurate in case of irregular rhythm such as atrial fibrillation.

• Key messages

• Several reports on inaccuracy of mobile health apps have been published. We conducted the validation study in the real patients by using popular mobile apps.

• Heart rate measurements from mobile apps were correlated well with standard ECG. The accuracy of HR from apps was worse at irregular rate and tachycardia.

     

A qualitative study of depressive symptoms and well-being among first-time mothers

Scand J Caring Sci; 2012; 26; 458–466 A qualitative study of depressive symptoms and well‐being among first‐time mothers Background and aim: Ten to 15% of women experience postpartum depression. First‐time mothers are particularly at risk. The present qualitative study aimed to gain insight in terms of why some women find the transition of becoming a mother to be so emotionally taxing that they feel some level of depressed mood, while others feel mostly content after having a baby. Method: Semi‐structured interviews were conducted with 12 self‐selected first‐time mothers. Participants described their pregnancy and birth experience, expectations and experiences with regard to the postpartum period, social support and what they considered important with regard to well‐being and depression in the postpartum period. Data were analysed by means of thematic analyses. Ethical approval was granted by the Regional Ethics Committee. Results: Two approaches to motherhood emerged, which we refer to as ‘relaxed’ and ‘controlled’. These approaches influenced how the mothers had envisioned the postpartum period, their need for mastery and how they experienced it emotionally. Social support and managing breastfeeding stood out as important with regard to well‐being and depressive symptoms. Conclusion: Frequent consultations with midwifes and public health nurses during the pregnancy and the postpartum period gives unique opportunities for preventive work. The consultations should to a greater extent focus on the woman’s expectations and needs, and the partner should be present for an open discussion on how they best support each other in this vulnerable period.     

Professionals’ views on the use of smartphone technology to support children and adolescents with memory impairment due to acquired brain injury

Purpose To identify from a health-care professionals’ perspective whether smartphones are used by children and adolescents with acquired brain injury as memory aids; what factors predict smartphone use and what barriers prevent the use of smartphones as memory aids by children and adolescents. Method A cross-sectional online survey was undertaken with 88 health-care professionals working with children and adolescents with brain injury. Results Children and adolescents with brain injury were reported to use smartphones as memory aids by 75% of professionals. However, only 42% of professionals helped their clients to use smartphones. The only factor that significantly predicted reported smartphone use was the professionals’ positive attitudes toward assistive technology. Several barriers to using smartphones as memory aids were identified, including the poor accessibility of devices and cost of devices. Conclusion Many children and adolescents with brain injury are already using smartphones as memory aids but this is often not facilitated by professionals. Improving the attitudes of professionals toward using smartphones as assistive technology could help to increase smartphone use in rehabilitation.

• Implications for Rehabilitation

• Smartphones could be incorporated into rehabilitation programs for young people with brain injury as socially acceptable compensatory aids.

• Further training and support for professionals on smartphones as compensatory aids could increase professionals’ confidence and attitudes in facilitating the use of smartphones as memory aids.

• Accessibility could be enhanced by the development of a smartphone application specifically designed to be used by young people with brain injury.

     

Postpartum Taiwanese women: their postpartum depression, social support and health-promoting lifestyle profiles

Background. To reach the Millennium Development Goals, maternal health‐promoting behaviours need to be encouraged after childbirth; little is known about the health‐promoting behaviour among first‐time mothers during their postpartum period. Aim. To examine levels of engagement in health‐promoting behaviours and related factors among postpartum women in Taiwan. Methods. This cross‐sectional study was conducted through a convenience sample of 122 qualified women. Participants self‐completed a questionnaire and mailed it back using a stamped, self‐addressed envelope from July to September 2003. Instruments of this study included a demographic questionnaire as well as three Likert‐type scales: the Health Promotion Lifestyle Profile scale, the Edinburgh Postnatal Depression scale and a self‐developed social support scale. Results. The average overall Health Promotion Lifestyle Profile score was low (mean, 2·83 SD 1·35), with exercise rated lowest among the six subscales. Postpartum women perceived that they had high levels of social support from their mothers‐in‐law, mothers and husbands. An astonishing 42·6% of women experienced postnatal depression. Based on results of multiple regressions, 25% of the variance in health‐promoting lifestyle practices was explained by postpartum depression and social support. Social support was found to predict all subscales significantly except exercise. Postpartum depression can significantly predict self‐actualization, interpersonal relationships, nutrition and stress management. All modifying factors were excluded from the regression model. Conclusions. This study validates the theoretical relationships among concepts in the Health Promotion Model. Nursing interventions are recommended which are tailored to enhance women's social support and decrease their depression to promote their pursuit of healthy lifestyles. Relevance to clinical practice. This study highlights the implications of social support to nursing practice, especially in Chinese culture which has a strict ritual during a women's postpartum period. Findings of this study provide information and data for service planning and community care to support postpartum care in the communities.     

‘How do we know if this is the best?’ Mental health‐care professionals' views on national guidelines for psychosocial interventions

National guidelines are released regularly, and professionals are expected to adopt and implement them. However, studies dealing with mental health‐care professionals' views about guidelines are sparse. The aim of the present study was to highlight mental health‐care staff's views on the Swedish national guidelines for ‘psychosocial interventions for schizophrenia or schizophrenia‐type symptoms’ and their implementation. The study took place in the southeast parts of Sweden, and data were collected through five group interviews consisting of 16 professionals working either in the county council or in the municipalities. The transcribed text was analysed by content analysis, revealing two categories. The first category ‘a challenge to the practice of care as known’ reflected that the release of guidelines could be perceived as a challenge to prevailing care and culture. The second category ‘anticipating change to come from above’ mirrored views on how staff expected the implementation process to flow from top to bottom. To facilitate working in accordance with guidelines, we suggest that future guidelines should be accompanied by an implementation plan, where the educational needs of frontline staff are taken into account. There is also a need for policy makers and managers to assume responsibility in supporting the implementation of evidence‐based practice.     

Transit Apps for People With Brain Injury and Other Cognitive Disabilities: The State of the Art

Individuals with cognitive disability have difficulty using public transit, but little research is directed toward this issue. Recent studies suggest that smartphones may be useful assistive devices in this context. Current objectives were to (1) survey research into difficulties people with cognitive disabilities experience when using public transit, (2) survey the current state of the art of transit and personal navigation applications (apps) and features, (3) recommend best existing transit apps for people with cognitive disability, and (4) recommend the best designs and features of these apps to developers of future transit apps. Potentially useful features were found in four categories: Transit apps for (1) individuals with cognitive disabilities and (2) healthy individuals, and personal navigation apps for (3) individuals with cognitive disabilities and (4) healthy individuals. A total of 159 apps were examined, but only seven were found specific to public transit for cognitive disability. By comparing research recommendations and currently available features, we identified several unmet needs. We note that there appears to be a shortage of apps for this population-function but that there is good research in the area and it is well suited to inform app development.     

FEASIBILITY AND RELIABILITY OF A WEB-BASED SMARTPHONE APPLICATION FOR JOINT POSITION MEASUREMENT

ObjectiveMeasurement of joint angles is usually performed using a simple goniometer, which can often be time-consuming and inaccurate, however smartphones can measure angles, this technology could be used to measure joint position. Studies of smartphone applications for this purpose lack consistency and homogeneity. The aim of the current study is to analyse the reliability and accuracy of 3 inertial motion unit-based smartphone applications for goniometric measurement, using 3 different industry standards as external controls.MethodsIn the first 2 phases of the study, measurements of angles between 90° and 165° (simulating knee extension) using 3 smartphone applications were analysed against the 3 industry standards. In the third phase, the smartphone’s raw data was individually analysed against a digital inclinometer across the x, y and z axes.Results and conclusionResults from the 3 phases of this study indicate a high degree of reliability and validity of the applications compared with the industry standards, with no clinically significant deviations. Thus, this technology could be used in a clinical setting. However, further clinical research, focussing on joint motions with greater than a single degree of freedom, is required before the use of such applications for joint position measurement in clinical practice.LAY ABSTRACTThe range of movement of various joints in the human body is regularly measured in a clinical setting, using a traditional angle measurement device (a goniometer), during functional assessments by doctors and physical and occupational therapists. However, such measurements can often be time-consuming and inaccurate. This study analysed the accuracy of smartphone apps for measuring joint angles compared with a goniometer. The results show that smartphone apps could be a good alternative for measuring joint angles.Key words: goniometry, goniometer, measurement, joint angle, smartphone application, joint position, range of motion, proprioception, accelerometer

Joint angle measurement is a fundamental part of functional assessment in diagnosis and rehabilitation, it is routinely used by doctors, physical and occupational therapists to quantify baseline range of movement or their limitations, to plan interventions and subsequently to analyse the efficacy of interventions by use of serial measurements (1, 2). Joint position sense or joint angle reproduction testing using joint angle measurement is also used to analyse proprioceptive performance, which can be reduced in pathologies such as stroke, peripheral nervous disorders, degenerative diseases of joints (e.g. in osteoarthritis or ageing) (3–8).The measurement of joint angle for these purposes is commonly performed in a clinical setting, using a manual goniometer, digital inclinometer or isokinetic dynamometer (4, 9–12). It is generally accepted that individuals with proprioceptive deficit are prone to greater magnitudes of joint position or angle error (3–5, 6, 8). These methods often provide tactical, visual or auditory cues that have a confounding effect on the measurement, and therefore need to be eliminated during testing. However, despite the widespread use of joint position testing, the reliability and validity of these methods have rarely been evaluated against different controls in research (13, 14).The use of a simple goniometer is considered the industry standard for clinical use to measure joint angle, due to its small size, low cost, availability, usability and prevalence in literature (13). However, the greatest limitation with a manual goniometer is the intra- and inter-rater variability. Studies have also reported variable reliability using a simple or universal goniometer with change in direction of motion (13–15). As such, an isokinetic dynamometer is often used, due to increased reliability, and is commonly used for laboratory studies. However, the use of an isokinetic dynamometer in clinical scenarios is limited, due to the cost and large size of the equipment (15, 16).Technological advancement has always been a significant driver of improvements in medical practice. Although smartphones have become an integral part of our lives, their use in the everyday clinical setting is limited. Today’s smartphones have a camera, 3-dimensional accelerometer, magnetometer, gyroscope and an inertial motion unit (IMU), whose potential has not been fully used to improve clinical practice (17–19). IMUs in smartphones are present as a chip, gathering data from the accelerometer, gyroscope and magnetometer to measure velocities and orientation (19).To explore their potential, several researchers have examined the utility of smartphone-based Joint Position Reproduction measurements. Studies by Ferriero et al. and Jeon et al. analysed the reliability and validity of a photography-based DrGoniometer smartphone application (app) (designed by CDM s.r.l., Milano, Italy) as an alternative to a simple manual goniometer (20, 21). Both studies suggested good inter- and intra-rater reliability and validity of the smartphone app (20, 21). The DrGoniometer app was also evaluated by Mitchell et al. and Otter et al. (22, 23), who agreed that smartphone-based goniometric measurements could prove a viable alternative in clinical practice for joint angle measurement. However, Mitchell et al. concluded that an inclinometer-based GetMyROM app (designed by Interactive Medical Productions, LLC, Hampton, New Hampshire, USA) was superior to the photography-based DrGoniometer app. Ockendon & Gilbert tested a novel accelerometer-based app (24)against a simple goniometer among healthy volunteers to measure knee joint angle. The study reported excellent reliability of the app and recommended its use in clinical settings (24).Together, the data from these studies suggest that a smartphone app could be a valid alternative to a standard manual goniometer and an isokinetic dynamometer; however, there are some inconsistencies in the study designs and outcomes. Although most studies report superior or similar outcomes to a simple goniometer, the necessary controls and the smartphone apps used in these studies, vary. Most studies compared the measurements of photography-based and accelerometer/gyroscope-based apps against a simple or universal goniometer, both of which have inherent issues. To date, an isokinetic dynamometer has not been used to compare static angle measurements, despite its superior reliability to a simple goniometer (15, 16). In addition, the studies have not evaluated raw data collected from a smartphone against a simple goniometer or an isokinetic dynamometer; instead they rely on data from third-party apps, which process and present the data to the observer.The objective of this study was to analyse the reliability and accuracy of smartphone-based goniometric measurements, by comparing the results from 3 apps against various external controls. Although this study did not aim to measure dynamic angular movements, an isokinetic dynamometer was used as the main control for static angle measurements during testing as it has already been demonstrated to have superior reliability compared with a simple hand-held manual goniometer (15, 16). A manual goniometer, along with a digital inclinometer, were also used as external controls to be compared with 3 different iPhone® (Apple Inc., Cupertino, CA, USA) apps used to measure angles.     

Recognition of,and beliefs about,causes of mental disorders: A cross‐sectional study of US and Chinese undergraduate nursing students

Nursing students' beliefs about etiology and manifestation of mental illness will impact on their professional attitudes in future clinical practice. The aims of the present study were to examine and compare US and Chinese undergraduate nursing students' recognition of, and beliefs about, causes of depression and schizophrenia. A total of 310 US (n = 152) and Chinese (n = 158) nursing students completed the Australian National Mental Health Literacy Survey questionnaire between April 2016 and April 2017. Although nursing students in the USA and China were highly accurate in recognizing depression and schizophrenia, the US students were more likely to nominate multiple items alongside the correct diagnosis than the Chinese students. The Chinese students were more likely to view depression and schizophrenia as multi‐causally‐determined mental disorders than the US students. The findings highlight the need for the incorporation of mental health issues, including symptomatology of different mental disorders and their application to patient care, into various aspects of the US nursing curriculum. In China, opportunities can be created for nursing students to discuss the impact of personal beliefs on care delivery and social stigma during clinical placement.     

Mobile health technologies for the management of urinary incontinence: A systematic review of online stores in Brazil

BackgroundUrinary incontinence (UI) is a serious condition for which often times insufficient non-surgical treatment options are provided or sought. Mobile health (mHealth) applications (apps) offer potential to assist with the self-management of UI.ObjectiveTo perform a systematic review of available mHealth apps for UI in Brazil.MethodsA search for UI mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 4 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).ResultsOf the 1111 mHealth apps found, 12 were eligible for inclusion. Four offered exclusively exercise programs, six offered exercise and educational content, and two offered tools to track patient-reported symptoms. The included apps scored poorly on the MARS quality scale, with a mean ± standard deviation score of 2.7 ± 0.6 on a 0–5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement.ConclusionAlthough there is growing interest in the development of mHealth technologies to support patients with UI, currently available tools in Brazil are of poor quality and limited functionality. Effective collaboration between industry and research is needed to develop new user-centered mHealth apps that can empower patients with UI.     

‘I know what I need to recover’: Patients’ experiences and perceptions of forensic psychiatric inpatient care

Patients find forensic psychiatric care inadequate in that they are not treated as individuals and not involved in their own care. The purpose of this study was to describe patients’ experiences and perceptions of forensic psychiatric inpatient care. Semi‐structured interviews were conducted with 11 inpatients. A qualitative content analysis resulted in a recurring theme, ‘I know what I need to recover’, and three main categories: ‘A need for meaning in a meagre existence’, ‘A need to be a person in an impersonal context’, and ‘A need for empowerment in a restricted life’. Participants experienced and perceived forensic care as predominantly monotonous, predetermined, and not adapted to them as individuals, forcing them to fight and adapt to get through it and not lose themselves. Perceived needs were largely ignored or opposed by staff due to the content and structure of care. Findings suggest a need for reflective practices and patient involvement in order to develop and maintain a person‐centred and recovery‐oriented nursing practice. The study adds to previous research showing the importance of patients in forensic psychiatric inpatient care being listened to and involved in their care. The study is reported in accordance with the COREQ guidelines.     

The relationship between smartphone use and subjective musculoskeletal symptoms and university students

[Purpose] The purpose of this study was to investigate the use of smartphones by university students in selected areas, their musculoskeletal symptoms, and the associated hazard ratio. [Subjects and Methods] This involved the completion of a self-administered questionnaire by dental hygiene students in Seoul, Gyeonggido, and Gyeongsangbukdo. The 292 completed copies of the questionnaire were then analyzed. [Results] The most painful body regions after the use of smartphones were found to be the shoulders and neck. In the musculoskeletal system, back pain was found to have a positive correlation with the size of the smartphone’s liquid crystal display (LCD) screen, and pain in legs and feet were found to have a negative correlation with the length of time that the smartphone was used. As a result, it was revealed that the use of a smartphone was correlated with musculoskeletal symptoms. [Conclusion] Therefore, in today’s environment, where the use of smartphones is on the rise, it is necessary to improve the ways that they are used and to develop a preventive program to alleviate the symptoms of musculoskeletal damage.Key words: Smartphone, Musculoskeletal symptoms, Prevent