JMIR mHealth and uHealth

Mobile and tablet apps, ubiquitous and pervasive computing, wearable computing and domotics for health.

Development and Deployment of a Mobile App for Hypertension Management Based on Clinical Practice Guidelines: a Cohort Study

Background: Hypertension is a chronic and lifestyle-related disease that requires continuous preventive care. Although there are many evidence-based clinical practice guidelines (CPGs) for hypertension management, applying them to daily management can be difficult for hypertension patients. A mobile app based on CPGs could help hypertension patients to manage their disease. Objective: This study aimed to develop a mobile app for hypertension management based on CPGs and evaluate its effectiveness in hypertension patients in terms of the perceived usefulness, user satisfaction, and medication adherence. Methods: The hypertension management app (HMA) was developed according to the Web-Roadmap methodology using planning, analysis, design, implementation, and evaluation phases. The HMA was provided to 29 hypertension patients who were recruited in person, and the perceived usefulness and user satisfaction were surveyed. Changes in medication adherence were measured in 19 hypertension patients between before and after using the HMA for 4 weeks. Results: The perceived usefulness score was 3.7 out of 5. The user satisfaction scores with regard to using the HMA for blood pressure recording, medication recording, data sending, alerting, recommending, and educating about medicine were 4.3, 3.8, 3.1, 3.2, 3.4, and 3.8 out of 5, respectively, in the 29 patients. Medication adherence as measured by the Modified Morisky Scale was significantly improved (p=0.001) in the 19 hypertension patients after they had used the HMA. Conclusions: This study showed that a mobile app for hypertension management based on CPGs is effective at improving medication adherence.

2015-07-01

(June 2015) Thomson Reuters, producer of the Journal Citation Reports and Web of Science and other database products, is creating a new edition of Web of Science (Emerging Sources Citation Index, ESCI); and we are proud to report that JMIR journals have been selected for the content expansion. 

The new Thomson Reuters Web of Science edition ESCI, which launches later in 2015, will include influential journals covering a variety of disciplines. "The journals selected have been identified as important to key opinion leaders, funders, and evaluators worldwide.", say a Thomson Reuters communication about the database. "We are proud that the Thomson Reuters team recognizes the influence of the JMIR journals", says Gunther Eysenbach, publisher at JMIR Publications.

The following journals are confirmed to be part of the initial ESCI release, with more JMIR journals to be added:

JMIR Publications is working on getting its newer journals such as JMIR Mental Health into the collection as well. JMIR Publications is now publishing over a dozen journals with topics covering innovation in health and technology.

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Journal Description

JMIR mhealth and uhealth (mobile and ubiquitous health) (JMU, ISSN 2291-5222) is a new spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2013: 4.7). The journal focusses on health and biomedical applications in mobile and tablet computing, pervasive and ubiquitous computing, wearable computing and domotics.

JMIR mHealth and uHealth publishes even faster and has a broader scope with including papers which are more technical or more formative/developmental than what would be published in the Journal of Medical Internet Research.
In addition to peer-reviewing paper submissions by researchers, JMIR mHealth and uHealth offers peer-review of medical apps itself (developers can submit an app for peer-review here).

JMIR mHealth and uHealth features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

JMIR mHealth and uHealth is indexed in PubMed Central/PubMed).

JMIR mHealth and uHealth adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics.

 

Recent Articles:

  • Untitled.

    Mobile Phone-Connected Wearable Motion Sensors to Assess Postoperative Mobilization

    Abstract:

    Background: Early mobilization after surgery reduces the incidence of a wide range of complications. Wearable motion sensors measure movements over time and transmit this data wirelessly, which has the potential to monitor patient recovery and encourages patients to engage in their own rehabilitation. Objective: We sought to determine the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility. Methods: Consecutive subjects were recruited under the Department of Neurosurgery at Columbia University. Patients were enrolled during physical therapy sessions. The total number of steps counted by the two blinded researchers was compared to the steps recorded on four activity sensors positioned at different body locations. Results: A total of 148 motion data points were generated. The start time, end time, and duration of each walking session were accurately recorded by the devices and were remotely available for the researchers to analyze. The sensor accuracy was significantly greater when placed over the ankles than over the hips (P<.001). Our multivariate analysis showed that step length was an independent predictor of sensor accuracy. On linear regression, there was a modest positive correlation between increasing step length and increased ankle sensor accuracy (r=.640, r2=.397) that reached statistical significance on the multivariate model (P=.03). Increased gait speed also correlated with increased ankle sensor accuracy, although less strongly (r=.444, r2=.197). We did not note an effect of unilateral weakness on the accuracy of left- versus right-sided sensors. Accuracy was also affected by several specific measures of a patient’s level of physical assistance, for which we generated a model to mathematically adjust for systematic underestimation as well as disease severity. Conclusions: We provide one of the first assessments of the accuracy and utility of widely available and wirelessly connected activity sensors in a postoperative patient population. Our results show that activity sensors are able to provide invaluable information about a patient’s mobility status and can transmit this data wirelessly, although there is a systematic underestimation bias in more debilitated patients.

  • (cc) Subhi et al. CC-BY-SA 2.0, please cite as (http://mhealth.jmir.org/article/viewFile/4169/1/54184).

    Expert Involvement and Adherence to Medical Evidence in Medical Mobile Phone Apps: A Systematic Review

    Abstract:

    Background: Both clinicians and patients use medical mobile phone apps. Anyone can publish medical apps, which leads to contents with variable quality that may have a serious impact on human lives. We herein provide an overview of the prevalence of expert involvement in app development and whether or not app contents adhere to current medical evidence. Objective: To systematically review studies evaluating expert involvement or adherence of app content to medical evidence in medical mobile phone apps. Methods: We systematically searched 3 databases (PubMed, The Cochrane Library, and EMBASE), and included studies evaluating expert involvement or adherence of app content to medical evidence in medical mobile phone apps. Two authors performed data extraction independently. Qualitative analysis of the included studies was performed. Results: Based on inclusion criteria, 52 studies were included in this review. These studies assessed a total of 6520 apps. Studies dealt with a variety of medical specialties and topics. As much as 28 studies assessed expert involvement, which was found in 9-67% of the assessed apps. Thirty studies (including 6 studies that also assessed expert involvement) assessed adherence of app content to current medical evidence. Thirteen studies found that 10-87% of the assessed apps adhered fully to the compared evidence (published studies, recommendations, and guidelines). Seventeen studies found that none of the assessed apps (n=2237) adhered fully to the compared evidence. Conclusions: Most medical mobile phone apps lack expert involvement and do not adhere to relevant medical evidence.

  • 7 Minute Workout app screenshots.

    Low Quality of Free Coaching Apps With Respect to the American College of Sports Medicine Guidelines: A Review of Current Mobile Apps

    Abstract:

    Background: Low physical activity level is a significant contributor to chronic disease, weight dysregulation, and mortality. Nearly 70% of the American population is overweight, and 35% is obese. Obesity costs an estimated US$ 147 billion annually in health care, and as many as 95 million years of life. Although poor nutritional habits remain the major culprit, lack of physical activity significantly contributes to the obesity epidemic and related lifestyle diseases. Objective: Over the past 10 years, mobile devices have become ubiquitous, and there is an ever-increasing number of mobile apps that are being developed to facilitate physical activity, particularly for active people. However, no systematic assessment has been performed about their quality with respect to following the parameters of sound fitness principles and scientific evidence, or suitability for a variety of fitness levels. The aim of this paper is to fill this gap and assess the quality of mobile coaching apps on iOS mobile devices. Methods: A set of 30 popular mobile apps pertaining to physical activity programming was identified and reviewed on an iPhone device. These apps met the inclusion criteria and provided specific prescriptive fitness and exercise programming content. The content of these apps was compared against the current guidelines and fitness principles established by the American College of Sports Medicine (ACSM). A weighted scoring method based on the recommendations of the ACSM was developed to generate subscores for quality of programming content for aerobic (0-6 scale), resistance (0-6 scale), and flexibility (0-2 scale) components using the frequency, intensity, time, and type (FITT) principle. An overall score (0-14 scale) was generated from the subscores to represent the overall quality of a fitness coaching app. Results: Only 3 apps scored above 50% on the aerobic component (mean 0.7514, SD 1.2150, maximum 4.1636), 4 scored above 50% on the resistance/strength component (mean 1.4525, SD 1.2101, maximum 4.1094), and no app scored above 50% on the flexibility component (mean 0.1118, SD 0.2679, maximum 0.9816). Finally, only 1 app had an overall score (64.3%) above 50% (mean 2.3158, SD 1.911, maximum 9.0072). Conclusions: There are over 100,000 health-related apps. When looking at popular free apps related to physical activity, we observe that very few of them are evidence based, and respect the guidelines for aerobic activity, strength/resistance training, and flexibility, set forth by the ACSM. Users should exercise caution when adopting a new app for physical activity purposes. This study also clearly identifies a gap in evidence-based apps that can be used safely and effectively to start a physical routine program, develop fitness, and lose weight. App developers have an exciting opportunity to improve mobile coaching app quality by addressing these gaps.

  • Mobile phone mast in Uganda. Picture taken by Daniel Strachan, one of the authors.

    Potential Roles of Mhealth for Community Health Workers: Formative Research With End Users in Uganda and Mozambique

    Abstract:

    Background: Community health workers are reemerging as an essential component of health systems in low-income countries. However, there are concerns that unless they are adequately supported, their motivation and performance will be suboptimal. mHealth presents an opportunity to improve support for community health workers; however, most interventions to date have been designed through a top-down approach, rarely involve the end user, and have not focused on motivation. Objective: To use formative research to explore the views of community health workers in Uganda and Mozambique on the potential role of mHealth in their work delivering integrated community case management of children. Methods: We conducted 24 in-depth interviews and 5 focus group discussions with community health workers in Uganda and Mozambique. Data were collected on: current phone use, preferred phone and charger characteristics, and perceptions of a range of potential mHealth interventions. Interviews were conducted in the local language, were audio recorded and converted into expanded notes. Interviews were coded for key thematic areas using both deductive and inductive codes. Deductive codes included mHealth’s potential impact on motivation and performance. Results: The most salient roles of mHealth in improving performance and motivation were reducing the need for travel, improving efficiency and planning, receiving feedback and information, and improving communication with supervisors and other community health workers. This was mostly through improved voice and short message service (SMS) text communication. Specific components of mHealth interventions that participants felt could improve motivation included increasing their visibility and credibility through branding of phones; providing an SMS response to data submission; and sending SMS messages about the importance of their work and achievements, rather than just reminders or technical messages. Participants identified feasibility issues related to the language of SMS messages, network coverage, and the need for a balance between phone function and battery life. Phones with a dual SIM cards would ameliorate network problems but would reduce battery life. The provision of a solar charger was viewed as beneficial. Conclusions: Conducting formative research with end users is likely to improve mHealth interventions by: (1) identifying interventions that are likely to have the greatest impact and be the most acceptable, (2) developing salient SMS messages, and (3) identifying feasibility issues. mHealth interventions also could have an important impact on health worker motivation, which should be considered by intervention developers and in evaluations, especially as small modifications could have a significant impact. Our study suggests that using phones to improve direct communication should be considered, even when planners aim to focus on the provision of a specific application.

  • DEPIC.
©Kasemsak Jandee, Jaranit Kaewkungwal, Amnat Khamsiriwatchara, Saranath Lawpoolsri, Waranya Wongwit, Peerawat Wansatid.

    Effectiveness of Using Mobile Phone Image Capture for Collecting Secondary Data: A Case Study on Immunization History Data Among Children in Remote Areas of...

    Abstract:

    Background: Entering data onto paper-based forms, then digitizing them, is a traditional data-management method that might result in poor data quality, especially when the secondary data are incomplete, illegible, or missing. Transcription errors from source documents to case report forms (CRFs) are common, and subsequently the errors pass from the CRFs to the electronic database. Objective: This study aimed to demonstrate the usefulness and to evaluate the effectiveness of mobile phone camera applications in capturing health-related data, aiming for data quality and completeness as compared to current routine practices exercised by government officials. Methods: In this study, the concept of “data entry via phone image capture” (DEPIC) was introduced and developed to capture data directly from source documents. This case study was based on immunization history data recorded in a mother and child health (MCH) logbook. The MCH logbooks (kept by parents) were updated whenever parents brought their children to health care facilities for immunization. Traditionally, health providers are supposed to key in duplicate information of the immunization history of each child; both on the MCH logbook, which is returned to the parents, and on the individual immunization history card, which is kept at the health care unit to be subsequently entered into the electronic health care information system (HCIS). In this study, DEPIC utilized the photographic functionality of mobile phones to capture images of all immunization-history records on logbook pages and to transcribe these records directly into the database using a data-entry screen corresponding to logbook data records. DEPIC data were then compared with HCIS data-points for quality, completeness, and consistency. Results: As a proof-of-concept, DEPIC captured immunization history records of 363 ethnic children living in remote areas from their MCH logbooks. Comparison of the 2 databases, DEPIC versus HCIS, revealed differences in the percentage of completeness and consistency of immunization history records. Comparing the records of each logbook in the DEPIC and HCIS databases, 17.3% (63/363) of children had complete immunization history records in the DEPIC database, but no complete records were reported in the HCIS database. Regarding the individual’s actual vaccination dates, comparison of records taken from MCH logbook and those in the HCIS found that 24.2% (88/363) of the children’s records were absolutely inconsistent. In addition, statistics derived from the DEPIC records showed a higher immunization coverage and much more compliance to immunization schedule by age group when compared to records derived from the HCIS database. Conclusions: DEPIC, or the concept of collecting data via image capture directly from their primary sources, has proven to be a useful data collection method in terms of completeness and consistency. In this study, DEPIC was implemented in data collection of a single survey. The DEPIC concept, however, can be easily applied in other types of survey research, for example, collecting data on changes or trends based on image evidence over time. With its image evidence and audit trail features, DEPIC has the potential for being used even in clinical studies since it could generate improved data integrity and more reliable statistics for use in both health care and research settings.

  • Medication Application.

    The Prevalence and Characteristics of Emergency Medicine Patient Use of New Media

    Abstract:

    Background: Little is known about “new media” use, defined as media content created or consumed on demand on an electronic device, by patients in emergency department (ED) settings. The application of this technology has the potential to enhance health care beyond the index visit. Objective: The objectives are to determine the prevalence and characteristics of ED patients’ use of new media and to then define and identify the potential of new media to transcend health care barriers and improve the public’s health. Methods: Face-to-face, cross-sectional surveys in Spanish and English were given to 5,994 patients who were sequentially enrolled from July 12 to August 30, 2012. Data were collected from across a Southern Connecticut health care system’s 3 high-volume EDs for 24 hours a day, 7 days a week for 6 weeks. The EDs were part of an urban academic teaching hospital, an urban community hospital, and an academic affiliate hospital. Results: A total of 5,994 (89% response rate) ED patients reported identical ownership of cell phones (85%, P<.001) and smartphones (51%, P<.001) that were used for calling (99%, P<.001). The older the patient, however, the less likely it was that the patient used the phone for texting (96% vs 16%, P<.001). Income was positively associated with smartphone ownership (P<.001) and the use of health apps (P>.05) and personal health records (P<.001). Ownership of iPhones compared to Android phones were similar (44% vs 45%, P<.05). Race and ethnicity played a significant role in texting and smartphone ownership, with Hispanics reporting the highest rates of 79% and 56%, respectively, followed by black non-Hispanics at 77% and 54%, respectively, and white non-Hispanics at 65% and 42%, respectively (P<.05). Conclusions: There is a critical mass of ED patients who use new media. Older persons are less comfortable texting and using smartphone apps. Income status has a positive relationship with smartphone ownership and use of smartphone apps. Regardless of income, however, texting and ownership of smartphones was highest for Latinos and black non-Latinos. These findings have implications for expanding health care beyond the ED visit through the use of cell phones, smartphones, texting, the Internet, and health care apps to improve the health of the public.

  • Color design concepts of the My Interventional Drug-Eluting Stent Educational App: (A) Concept 3 and (B) Concept 4.

    My Interventional Drug-Eluting Stent Educational App (MyIDEA): Patient-Centered Design Methodology

    Abstract:

    Background: Patient adherence to medication regimens is critical in most chronic disease treatment plans. This study uses a patient-centered tablet app, “My Interventional Drug-Eluting Stent Educational App (MyIDEA).” This is an educational program designed to improve patient medication adherence. Objective: Our goal is to describe the design, methodology, limitations, and results of the MyIDEA tablet app. We created a mobile technology-based patient education app to improve dual antiplatelet therapy adherence in patients who underwent a percutaneous coronary intervention and received a drug-eluting stent. Methods: Patient advisers were involved in the development process of MyIDEA from the initial wireframe to the final launch of the product. The program was restructured and redesigned based on the patient advisers’ suggestions as well as those from multidisciplinary team members. To accommodate those with low health literacy, we modified the language and employed attractive color schemes to improve ease of use. We assumed that the target patient population may have little to no experience with electronic tablets, and therefore, we designed the interface to be as intuitive as possible. Results: The MyIDEA app has been successfully deployed to a low-health-literate elderly patient population in the hospital setting. A total of 6 patients have interacted with MyIDEA for an average of 17.6 minutes/session. Conclusions: Including patient advisers in the early phases of a mobile patient education development process is critical. A number of changes in text order, language, and color schemes occurred to improve ease of use. The MyIDEA program has been successfully deployed to a low-health-literate elderly patient population. Leveraging patient advisers throughout the development process helps to ensure implementation success.

  • Behavior Change Techniques (BCT) for alcohol apps. Copyright (cc-by) the authors..

    Identification of Behavior Change Techniques and Engagement Strategies to Design a Smartphone App to Reduce Alcohol Consumption Using a Formal Consensus Method

    Abstract:

    Background: Digital interventions to reduce excessive alcohol consumption have the potential to have a broader reach and be more cost-effective than traditional brief interventions. However, there is not yet strong evidence for their ability to engage users or their effectiveness. Objective: This study aimed to identify the behavior change techniques (BCTs) and engagement strategies most worthy of further study by inclusion in a smartphone app to reduce alcohol consumption, using formal expert consensus methods. Methods: The first phase of the study consisted of a Delphi exercise with three rounds. It was conducted with 7 international experts in the field of alcohol and/or behavior change. In the first round, experts identified BCTs most likely to be effective at reducing alcohol consumption and strategies most likely to engage users with an app; these were rated in the second round; and those rated as effective by at least four out of seven participants were ranked in the third round. The rankings were analyzed using Kendall’s W coefficient of concordance, which indicates consensus between participants. The second phase consisted of a new, independent group of experts (n=43) ranking the BCTs that were identified in the first phase. The correlation between the rankings of the two groups was assessed using Spearman’s rank correlation coefficient. Results: Twelve BCTs were identified as likely to be effective. There was moderate agreement among the experts over their ranking (W=.465, χ211=35.8, P<.001) and the BCTs receiving the highest mean rankings were self-monitoring, goal-setting, action planning, and feedback in relation to goals. There was a significant correlation between the ranking of the BCTs by the group of experts who identified them and a second independent group of experts (Spearman’s rho=.690, P=.01). Seventeen responses were generated for strategies likely to engage users. There was moderate agreement among experts on the ranking of these engagement strategies (W=.563, χ215=59.2, P<.001) and those with the highest mean rankings were ease of use, design – aesthetic, feedback, function, design – ability to change design to suit own preferences, tailored information, and unique smartphone features. Conclusions: The BCTs with greatest potential to include in a smartphone app to reduce alcohol consumption were judged by experts to be self-monitoring, goal-setting, action planning, and feedback in relation to goals. The strategies most likely to engage users were ease of use, design, tailoring of design and information, and unique smartphone features.

  • Image source: Lisa Brewster, FlickR, licensed under Creative Commons cc by-sa 2.0 https://www.flickr.com/photos/sophistechate/2670224692/in/photostream/.

    Doctors and the Etiquette of Mobile Device Use in Trauma and Orthopedics

    Abstract:

    Background: The etiquette surrounding the use of mobile devices, so-called "mobiquette," has been previously identified as a barrier to use in an educational context. Objective: To investigate the influence of mobile device use on patient and staff opinions in the trauma and orthopedics department at a teaching hospital in Wales. Methods: A survey of patients at the bedside and staff in their work environment was undertaken. Data included age, frequency of observed use, suspected main reason for use, and whether doctors’ use of a mobile device positively or negatively influenced participants' opinions of them as a professional and as a person. Results: A total of 59 patients and 35 staff responded. The modal age range was 40 to 54 years old. Most patients (78%) never see doctors using mobile devices in the workplace, compared with 3% of staff. The main reason for use was thought to be "communicating with colleagues" (48%) followed by "Internet use/applications for work reasons" (40%). Approximately 40% of patients' opinions of doctors were positively influenced by device use, compared with 82% of staff. This difference between patient and staff opinions was statistically significant for both professional (P<.001) and personal (P=.002) opinions. Conclusions: Patients are likely to have a negative opinion of doctors using mobile devices in the workplace. This can be balanced by the more positive opinions of colleagues. We advise doctors to remember "mobiquette" around patients.

  • Image

    Uptake and Acceptability of Information and Communication Technology in a Community-Based Cohort of People Who Inject Drugs: Implications for Mobile Health...

    Abstract:

    Background: Mobile phone and Internet-based technologies are increasingly used to disseminate health information and facilitate delivery of medical care. While these strategies hold promise for reducing barriers to care for medically-underserved populations, their acceptability among marginalized populations such as people who inject drugs is not well-understood. Objective: To understand patterns of mobile phone ownership, Internet use and willingness to receive health information via mobile devices among people who inject drugs. Methods: We surveyed current and former drug injectors participating in a longitudinal cohort study in Baltimore, Maryland, USA. Respondents completed a 12-item, interviewer-administered questionnaire during a regular semi-annual study visit that assessed their use of mobile technology and preferred modalities of receiving health information. Using data from the parent study, we used logistic regression to evaluate associations among participants’ demographic and clinical characteristics and their mobile phone and Internet use. Results: The survey was completed by 845 individuals, who had a median age of 51 years. The sample was 89% African-American, 65% male, and 33% HIV-positive. Participants were generally of low education and income levels. Fewer than half of respondents (40%) indicated they had ever used the Internet. Mobile phones were used by 86% of respondents. Among mobile phone owners, 46% had used their phone for text messaging and 25% had accessed the Internet on their phone. A minority of respondents (42%) indicated they would be interested in receiving health information via phone or Internet. Of those receptive to receiving health information, a mobile phone call was the most favored modality (66%) followed by text messaging (58%) and Internet (51%). Conclusions: Utilization of information and communication technology among this cohort of people who inject drugs was reported at a lower level than what has been estimated for the general U.S. population. Our findings identify a potential barrier to successful implementation of mobile health and Internet-based interventions for people who inject drugs, particularly those who are older and have lower levels of income and educational attainment. As mobile communication technology continues to expand, future studies should re-examine whether mHealth applications become more accessible and accepted by socioeconomically disadvantaged groups.

  • Interactive mock-up of the home screen.

    Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App

    Abstract:

    Background: The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children’s weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users’ engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process. Objective: The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community. Methods: The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app. Results: Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents’ capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents’ preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users’ preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app. Conclusions: Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users’ preferences to help maximize its engagement with the target population.

  • ©Behavior Imaging Solutions. Please cite as (http://mhealth.jmir.org/article/viewFile/4393/1/59594).

    A Novel System for Supporting Autism Diagnosis Using Home Videos: Iterative Development and Evaluation of System Design

    Abstract:

    Background: Observing behavior in the natural environment is valuable to obtain an accurate and comprehensive assessment of a child’s behavior, but in practice it is limited to in-clinic observation. Research shows significant time lag between when parents first become concerned and when the child is finally diagnosed with autism. This lag can delay early interventions that have been shown to improve developmental outcomes. Objective: To develop and evaluate the design of an asynchronous system that allows parents to easily collect clinically valid in-home videos of their child’s behavior and supports diagnosticians in completing diagnostic assessment of autism. Methods: First, interviews were conducted with 11 clinicians and 6 families to solicit feedback from stakeholders about the system concept. Next, the system was iteratively designed, informed by experiences of families using it in a controlled home-like experimental setting and a participatory design process involving domain experts. Finally, in-field evaluation of the system design was conducted with 5 families of children (4 with previous autism diagnosis and 1 child typically developing) and 3 diagnosticians. For each family, 2 diagnosticians, blind to the child’s previous diagnostic status, independently completed an autism diagnosis via our system. We compared the outcome of the assessment between the 2 diagnosticians, and between each diagnostician and the child’s previous diagnostic status. Results: The system that resulted through the iterative design process includes (1) NODA smartCapture, a mobile phone-based application for parents to record prescribed video evidence at home; and (2) NODA Connect, a Web portal for diagnosticians to direct in-home video collection, access developmental history, and conduct an assessment by linking evidence of behaviors tagged in the videos to the Diagnostic and Statistical Manual of Mental Disorders criteria. Applying clinical judgment, the diagnostician concludes a diagnostic outcome. During field evaluation, without prior training, parents easily (average rating of 4 on a 5-point scale) used the system to record video evidence. Across all in-home video evidence recorded during field evaluation, 96% (26/27) were judged as clinically useful, for performing an autism diagnosis. For 4 children (3 with autism and 1 typically developing), both diagnosticians independently arrived at the correct diagnostic status (autism versus typical). Overall, in 91% of assessments (10/11) via NODA Connect, diagnosticians confidently (average rating 4.5 on a 5-point scale) concluded a diagnostic outcome that matched with the child’s previous diagnostic status. Conclusions: The in-field evaluation demonstrated that the system’s design enabled parents to easily record clinically valid evidence of their child’s behavior, and diagnosticians to complete a diagnostic assessment. These results shed light on the potential for appropriately designed telehealth technology to support clinical assessments using in-home video captured by families. This assessment model can be readily generalized to other conditions where direct observation of behavior plays a central role in the assessment process.

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  • Development and Deployment of a Mobile App for Hypertension Management Based on Clinical Practice Guidelines: a Cohort Study

    Date Submitted: Jul 22, 2015

    Open Peer Review Period: Jul 23, 2015 - Sep 17, 2015

    Background: Hypertension is a chronic and lifestyle-related disease that requires continuous preventive care. Although there are many evidence-based clinical practice guidelines (CPGs) for hypertensio...

    Background: Hypertension is a chronic and lifestyle-related disease that requires continuous preventive care. Although there are many evidence-based clinical practice guidelines (CPGs) for hypertension management, applying them to daily management can be difficult for hypertension patients. A mobile app based on CPGs could help hypertension patients to manage their disease. Objective: This study aimed to develop a mobile app for hypertension management based on CPGs and evaluate its effectiveness in hypertension patients in terms of the perceived usefulness, user satisfaction, and medication adherence. Methods: The hypertension management app (HMA) was developed according to the Web-Roadmap methodology using planning, analysis, design, implementation, and evaluation phases. The HMA was provided to 29 hypertension patients who were recruited in person, and the perceived usefulness and user satisfaction were surveyed. Changes in medication adherence were measured in 19 hypertension patients between before and after using the HMA for 4 weeks. Results: The perceived usefulness score was 3.7 out of 5. The user satisfaction scores with regard to using the HMA for blood pressure recording, medication recording, data sending, alerting, recommending, and educating about medicine were 4.3, 3.8, 3.1, 3.2, 3.4, and 3.8 out of 5, respectively, in the 29 patients. Medication adherence as measured by the Modified Morisky Scale was significantly improved (p=0.001) in the 19 hypertension patients after they had used the HMA. Conclusions: This study showed that a mobile app for hypertension management based on CPGs is effective at improving medication adherence.

  • Smartphone use among medical residents: a cross sectional survey

    Date Submitted: Jul 15, 2015

    Open Peer Review Period: Jul 16, 2015 - Sep 10, 2015

    Background: Smartphones have great potential for medical education, as they allow health care providers and students to access resources efficiently at the right time at the point-of-care to help in i...

    Background: Smartphones have great potential for medical education, as they allow health care providers and students to access resources efficiently at the right time at the point-of-care to help in informed decision-making Objective: To evaluate the prevalence of smartphone usage among medical residents and to explore their attitudes, perceptions and challenges they experience when using Smartphones in their academic and clinical practices Methods: This study was performed using a cross sectional survey and was conducted on all 133 residents in 17 different specialties across two large academic hospitals, with a total of 800 beds, including out-patient clinics in Riyadh, Saudi Arabia. The outcomes were measured by a web-based validated questionnaire that included smartphones platforms preferences, and their uses in general and medical practice, and the perception of confidentiality and safety impact of using smartphones for communication and accessing patient’s data. Results: With a response rate of (101/133, 75.9%) and a mean age of 27.8 (SD 3.0) years, we found that (100/101, 99.05%) of participants were smartphone users with mean duration of use of 5.12 (SD 2.4) years, and a range from 1 to 12 years. A negative linear correlation was found between age and duration of age (P = 0.004). The most common operating system used by the participants was the iOS platform (55/101, 54.5%), and English was the most used language to operate residents’ smartphones (96/100, 96.0%). Further scrutiny determined that “phone calls (88/101, 87.1%)”, followed by chatting apps such as WhatsApp, LINE, were the most non-medical-practice communication, whereas medication references (83/101, 82.2%), medical references (80/101, 79.2%) and medical calculation (61/101, 60.4%) were the most commonly used medical-practice-related non-communication apps/tools among the respondents. Short battery life (84/92, 52.2%) was the most common technical difficulty, and distraction (28/92, 27.7%) was the most likely side effect of using a smartphone in medical practice. Conclusions: Smartphone use among medical residents in various medical specialties has become almost universal in healthcare settings. This should alert academic institutes about proper utilisation of these devices into the medical training and point-of-care decision-making, while at the same time ensuring patient’s confidentiality.

  • Mobile phone use and its association with sitting time and meeting physical activity recommendations in a Mexican American cohort

    Date Submitted: Jul 10, 2015

    Open Peer Review Period: Jul 11, 2015 - Sep 5, 2015

    Background: Physical activity (PA) benefits are well-documented. PA is influenced by mobile phones via promoting screen-based sedentary time or by providing entertainment during PA. It is not known ho...

    Background: Physical activity (PA) benefits are well-documented. PA is influenced by mobile phones via promoting screen-based sedentary time or by providing entertainment during PA. It is not known how mobile phone use is associated with PA and sitting time in Mexican-Americans, and how mobile phone users may differ from non-users. Objective: To examine this, 2,982 adults in the Mexican-American Mano A Mano cohort were interviewed regarding their mobile phone use and activity behaviors. Methods: Differences in meeting physical activity recommendations and sitting time between mobile phone users and non-users were examined using Chi-square and ANOVA tests. Logistic regression was used to examine associations between mobile phone use, PA and sitting. Results: Mobile phone users were more likely to be obese by Body Mass Index (BMI; ≥30 kg/m2), younger, born in the United States (US) and lived there longer, more educated, sit more hours per day but more likely to meet PA recommendations than non-users. Males (OR = 1.42, CI: 1.16, 1.74), use of text messaging (OR = 1.26; CI: 1.03, 1.56), and having a higher acculturation score (OR = 1.27; CI: 1.07, 1.52) were associated with higher odds of meeting PA recommendations. Sitting more hours per day was associated with being male, obese, US-born, a former alcohol drinker, and having at least a high school education. Among non-users, being US-born was associated with higher odds of more sitting time, and being married was associated with higher odds of meeting PA recommendations. Conclusions: Mobile phone interventions could be tailored to promote PA in Mexican-American mobile phone users. Clinical Trial: n/a

  • A National Survey of Health App Use among U.S. Smartphone Owners

    Date Submitted: Jul 10, 2015

    Open Peer Review Period: Jul 11, 2015 - Sep 5, 2015

    Background: Smart phone health applications, known as “health apps” may now seem to be ubiquitous, yet much remains unknown with regard to their usage. Information remains limited with regard to i...

    Background: Smart phone health applications, known as “health apps” may now seem to be ubiquitous, yet much remains unknown with regard to their usage. Information remains limited with regard to important metrics including percentage of the population that uses health apps, reasons for adoption/non-adoption, and reasons for non-continuance of use. Objective: The purpose of the current study was to examine health app use among smartphone owners in the United States. Methods: We conducted a cross-sectional survey of N=1,604 smartphone users throughout the U.S. The 36-item survey assessed sociodemographic characteristics, history of and reasons for health app use/non use, perceived effectiveness of health apps, reasons for stopping use, and general health status. Results: A little over one-half (58%) of smartphone users had ever downloaded a health-related mobile application. Fitness and nutrition were the most common categories of health apps used, with most respondents using them at least daily. Common reasons for not doing so were lack of interest, cost, and concern about apps collecting their data. Individuals more likely to use health apps tended to be younger, higher income, more educated, Latino/Hispanic, and with a BMI in the obese range (all p < 0.05). Cost was a significant concern among respondents with a large proportion indicating that they would not pay anything for a health app. Interestingly, among those who had downloaded health apps, trust in their accuracy and data safety was quite high, and most felt that the apps had improved their health. About half of respondents (46%) had stopped using some health apps, primarily due to high data entry burden, loss of interest, and hidden costs. Conclusions: These findings suggest that while many individuals use health apps, a substantial proportion of the population does not, and that even among those who use health apps many stop using them. These data suggest that app developers need to better address consumer concerns (such as cost, high data entry burden) and that clinical trials are necessary to test the efficacy of health apps to broaden their appeal and adoption.

  • A Qualitative analysis of eye care services in Kenya and the Acceptability, Usability, and views on deployment of Peek, a smartphone mHealth intervention for eye care.

    Date Submitted: May 22, 2015

    Open Peer Review Period: Jun 11, 2015 - Aug 6, 2015

    Background: The Portable Eye Examination Kit (Peek) is a smartphone based ophthalmic testing system that has been developed to perform comprehensive eye examinations. Peek offers a solution to overcom...

    Background: The Portable Eye Examination Kit (Peek) is a smartphone based ophthalmic testing system that has been developed to perform comprehensive eye examinations. Peek offers a solution to overcoming barriers of limited access to traditional ophthalmic testing methods and has been piloted on adults in Nakuru, Kenya and compared with traditional eye examination tools. Shortages in ophthalmic personnel, expensive and difficult to transport equipment have made it difficult to offer services particularly in rural areas. Objective: This qualitative study evaluated the acceptability and usability of Peek in addition to views regarding the adoption and nationwide deployment. Methods: A qualitative analysis of semi-structured interviews conducted with 20 patients, 8 Healthcare Care Providers (HCPs) involved in the pilot study and 4 key decision makers in ophthalmic service provision, who had been purposively sampled. The analytical approach used a framework analysis approach using pre-defined themes. Emerging themes relating to the objectives were also explored from the data. Results: Patients found Peek to be acceptable due to its benefits in overcoming the barriers to access ophthalmic services. Most thought it to be fast, convenient, and able to reach a large population. All patients expressed being satisfied with Peek. HCPs perceived it to satisfy the criteria for usability and found Peek to be acceptable based on the technology acceptance model. Peek was also found to have features required for strengthening ophthalmic delivery as a capabilities enhancer, opportunity creator, social enabler and knowledge generator. Some of the deployment related issues included; need for government and community involvement, communication and awareness creation, data protection, infrastructure development including capacity creation, training and maintenance support. Conclusions: According to all parties interviewed, Peek is an acceptable solution as it provides a beneficial service, supports patients’ needs, and fulfils HCPs’ roles, overall contributing to strengthening eye health.

  • The iPad® loaded with a survey application as a straightforward data collection tool: Advantages, limitations and experiences in a mixed-methods observational study.

    Date Submitted: May 17, 2015

    Open Peer Review Period: Jun 11, 2015 - Aug 6, 2015

    A straightforward iPad-based electronic data collection tool (Apple Inc., Cupertino, CA, USA) was created using the survey application iSurvey (Contact Software Ltd., Wellington, New Zealand, iSurveys...

    A straightforward iPad-based electronic data collection tool (Apple Inc., Cupertino, CA, USA) was created using the survey application iSurvey (Contact Software Ltd., Wellington, New Zealand, iSurveysoft.com) and applied during on-site observations and surveys in a mixed-methods observational study in an academic hospital. In this case report, we present our experiences with this data collection method and discuss its advantages, possible applications, and limitations in regard to international standards regulating human subject research. We can recommend this simple tool as an efficient and economical method to simplify data collection and utilization in studies not qualifying as human subject research.