Research Findings by Category
Treatment and Disease Management
Interventions related to treatment and management focused on investigating patient adherence to treatment (eg, visiting a doctor as planned) [1-6], adherence to medication [7-13], and disease management (particularly for diabetes [14-23] and asthma [24-26]), including coordinated health care interventions between health care providers and patients using communication technologies (mobile phone-based apps and SMS) for patients self-care of chronic diseases. The literature contains 28 cases with sample sizes ranging from 25 to 424. The interventions are described in Multimedia Appendix 1. Interventions in both developed countries (United States [1,16,17,22-24,27-31], Ireland [2,11], United Kingdom [5,25,26], Denmark [6], Spain [9], France [10], the Netherlands [12,13], South Korea [14,18,32], Austria [19], and Canada [20,33]), and developing ones (Peru [7,8], Kenya [3,34], Cameroon [35], and Brazil [36]) have explored the use of mobile phone-based software, voice and SMS, and personal digital assistants (PDAs). In these interventions, the technology was used to send automated reminders to patients, either by voice or text messages. In addition to reminders from health care units to patients, health care units may receive text message from patients.
In interventions regarding adherence to treatment and to medication, mobile technologies were used to send reminders so as to improve antiretroviral therapy (ART) in HIV-infected adolescents [1]; send at least one medication-specific dosage reminder for a chronic oral medication [31]; measure asthma medication use and symptoms [30]; and to reduce out-patient clinic nonattendance [5]. Reminders were sent 3 days prior to patients’ out-patient clinic appointment [2]; to HIV-positive patients with support content and enquire into how they are doing [3]; to patients to take their anti-asthmatic medication [6]; to soldiers to take their malaria chemoprophylaxis [10]; to patients to take antidepressant medication [11]; to patients with type 2 diabetes to take their oral antidiabetics [12,13]; to patients to take their oral antipsychotic medication [9]; and to take medications and provide additional support [34]. In addition, reminders were sent with instructions to patients reminding them to apply their morning and evening topical acne medication [28]; to support antiretroviral medication adherence [7,8]. Thus, motivational text message were sent to HIV-positive adults for adherence to ART [35]. In some interventions, patients received reminders 30 minutes before patients’ last scheduled time for a dose of medicine during the day [36]; received reminders and were asked to acknowledge receiving their messages after taking the vitamins [33], and were required to send event-based messages whenever they experienced asthma symptoms or took asthma rescue or controller medications, and they received time-based messages daily that prompted for a response about asthma medications or symptoms [37].
For disease management, interventions focused on the use of mobile phone-based apps and SMS. Interventions using mobile phone-based apps used the technology to transmit blood glucose levels using a mobile phone with a glucometer integrated into the battery pack on management of type 2 diabetes to the Internet-based glucose monitoring system [14]; transmit blood glucose meter readings using a mobile phone with a glucometer integrated to the Internet-based glucose monitoring system [22]; transmit blood glucose levels to secure servers and receive real-time feedback [27]; and transmit blood glucose values, diabetes medications, and lifestyle behaviors to a remote server and receive real-time educational and behavioral messaging [23]. The same apps are also used to transmit peak flow reading and symptom score to secure server with immediate feedback of control and reminder of appropriate actions in supporting asthma self-management [25,26], and transmit diabetes-related data with synchronization to the remote database at the monitoring center [19]. The SMS function was to send personalized medication, and appointment reminders and text messages were received from patients on adherence [16]; send tailored daily messages prompting patients with type 2 diabetes to enhance their diabetic self-care behavior [17]; send peak flow reading each day to a Web server and receive a text reminder if they did not send it by 11 AM [24].
In these interventions mobile phone-based apps and SMS were found to be acceptable to patients [11,16], practical and acceptable [1], feasible [10,16,17,24], effective [9,14], and cost-effective [5,19,38]. Patients had positive perceptions [6,8,15,19-21,25], positive impact on some clinical outcomes (eg, medication taking) [17,18,23,26,27], and were highly satisfied [32]. These apps and SMS improved patient adherence to medication [12,18,31,34], and to health behavior (taking vitamin C for preventive reasons) over a 1-month intervention [33]; and they also assisted in preserving higher rates of adherence over time [31]. In addition, their use increased adherence of HIV-infected women to ART drug-based treatment regimen [36], increased adherence to asthma-preventer inhaler [37], and significantly improved self-reported adherence to ART [29]. In particular, SMS reminders are a simple and cost-effective way to improve nonattendance [2]; and provided an ubiquitous, easy-to-use, and cost-efficient solution to assist diabetes patients on intensive insulin treatment [19].
SMS were not associated with significant differences in adherence to topical medications in patients with mild to moderate acne and had no significant effect on therapeutic response [28]. They also did not significantly improve adherence to ART [35].
In most cases, in the above literature, the mobile phones were used to send messages from a health care center to patients, most commonly reminders for taking medicine, visiting the doctor, etc. In some cases there was integrated data collection, for example, by integrating a glucometer into the battery pack on management of type 2 diabetes or transmitting data on asthma symptoms.
In 11 cases, the front-end mobile system was connected to some back-end system. Most commonly this was done by sending automated reminders based on some database (eg, with data collected from patient records) but in some cases also incoming data (from patients) were automatically inserted in a database, such as, into an Internet-based glucose monitoring system.
Data Collection, Reporting, and Disease Surveillance
On this topic the survey found 28 studies using mobile communication technologies with samples ranging from 8 to 648 participants, and eight studies using GIS technologies. The interventions are described in Multimedia Appendices 2 and 3. Interventions using mobile communication technologies in both developed countries (Sweden [39], Norway [40,41], USA [42-45], Germany [46], Canada [47,48], UK [49,50], Austria [51], Japan [52,53]), and developing ones (Ghana [54], Kenya [55-57], Peru [58-60], Angola [61], Swaziland [62], Malaysia [63], India [64,65], Iran [66], China [67]) have investigated the use of mobile phone-based apps, mobile phone functions (SMS and voice), and PDAs. In these interventions, the technology was used to collect or report health data (eg, influenza vaccination, tuberculosis, and HIV) and for disease surveillance (eg, tracking infectious disease, communicable disease, and respiratory infections).
For interventions using the SMS and or voice functions of mobile phone, one [54] evaluated the acceptability of using SMS for reporting postpartum hemorrhage data; one [39] compared the feasibility of using SMS and telephone in collecting self-reported data about influenza vaccination; two [62,63] evaluated the effectiveness of using SMS, the first for delivering laboratory results and the second for patients’ weekly symptoms reports. In addition, one [45] investigated the feasibility and acceptability of using two-way SMS texts communication to collect situational assessment data; one [64] provided a quantitative evaluation of data entry accuracy using SMS when compared with Internet and voice; one [65] investigated the effectiveness and efficiency gains in using mobile apps for detecting disease outbreaks in near-real-time; and one [49] tested the reliability, validity, acceptability, and practicability of SMS messaging for collecting patients’ infant feeding method and future feeding plans.
For interventions using PDAs, two studies [40,55] evaluated acceptability, two [40,55] data quality, one [55] usefulness, one [59] efficiency, three [46,56,60] effectiveness of a PDA-based system compared with paper-based system; one [40] assessed how PDAs performed as collection tools of patient-reported outcomes in clinical research compared to pen and paper diaries in terms of feasibility, protocol compliance, data accuracy, and subject acceptability. In addition, one [41] compared daily and weekly registrations of self-reported health status measures between PDA and paper-pencil (PP) format regarding scores, variation, and feasibility; one [42] feasibility of using PDA-based system for tracking and analysis of food intake for pregnant women; one [43] compared the completeness of data collection using a paper and PDA-based system. Other studies, assessed feasibility and patient acceptance of PDAs for collection of health data [68]; one [58] evaluated the quality of data on sexual behavior data collected with PDA-based system in comparison with paper-based questionnaires; and one [61] explored the acceptability of PDA for HIV/AIDS data collection and to identified potential barriers to acceptance.
For interventions using PDAs the technology was used to send individual’s usual food intakes to registered dieticians for analysis [52,53]. Some benefits of using PDA-based system or mobile phones (voice and/or SMS) include improved data quality [56,65], improved data completeness [43,56], reduction in staff work hours [59,60], led to reduction in processing time [60], reduced errors in data entry [60], positive feedback from users [41,58], and lower number of inconsistencies and missing values [58,62]. In addition, some studies have adopted the use of open-source tools, which contributes to cost effectiveness [58,60]. Mobile phones were also found to be a useful tool for communication in conjunction with infectious disease surveillance in areas hit by natural disasters [67].
Disease surveillance is a field where GIS technology has been much used. GIS for disease surveillance is an epidemiological practice that monitors the spread of disease in order to establish patterns of progression. Examples of diseases having been monitored in both developed countries (Canada [69], France [70], US [71,72], the Netherlands [73]), and developing ones (South Africa [74], Nicaragua [75], India [76], Vanuatu [77], Congo [78], Trinidad and Tobago [79]) using GIS include injury [74], respiratory and acute gastrointestinal illness [71], HIV/AIDS [72,73,76,78], malaria [77,80], rabies epidemic [79], dengue fever [75], West Nile virus [69], and communicable disease [70]. In these interventions, GIS contributed to assessing visit rates for common illnesses in a defined community and identified spatial variability over time [71]; provided an effective and efficient operational tool for rapidly defining spatial distribution of malaria [77]; provided a useful tool to track trends in HIV incidence, HIV prevalence, and related risk behavior in a vulnerable population of women [72]. In addition, GIS provided a tool for analyzing risk factors that increase HIV infections [78], to accurately identify areas with high incidences of mosquito infestation and interpret the spatial relationship of these areas with potential larval development sites, such as garbage piles and large pools of standing water [75]. GIS also facilitated the collection, localization, management, and analysis of monitoring data; it also allowed for the display of the results of analysis on maps, tables, and statistical diagrams [69]; and supported key elements of surveillance-response, including understanding epidemiological variation within target areas, implementing appropriate foci-specific targeted response, and consideration of logistical constraints and costs [80].
Health Support Systems
On this topic, the survey found 38 studies using mobile communication technologies with samples ranging from 5 to 5800, and 26 studies using GIS technologies. The interventions are described in Multimedia Appendices 4 and 5. Interventions using mobile communication technologies in both developed countries (Norway [81,82], France [83], UK [84-89], Spain [90], US [91-97], Sweden [98], Greece [99], the Netherlands [100], Italy [101], New Zealand [102-104], and South Korea [105]), and developing ones (Saudi Arabia [106], Tanzania [107,108], Peru [109-111], South Africa [112], Uganda [113], China [114,115], Trinidad and Tobago [116], Kenya [117], India [118]) have investigated the use of mobile phone-based apps (six studies); mobile phone functions (SMS, 20 studies), voice (three studies) and multimedia messaging service (MMS; two studies), and PDAs (10 studies).
Mobile phone-based apps were to design a mobile dietary management support system for people with diabetes [81], develop a smoking cessation support system [86], and support type 1 diabetes self-management [99]. These apps were also designed to support self-care process for patients with both diabetes and cardiovascular disease [116], and help individuals with weight problems to lose or maintain weight [93].
SMS-based technologies were used to integrate with an electronic medical record system on nonattendance rates in outpatient clinics [106]; support antimalarial stock management [107]; provide real-time collection and transmission of adverse events related with metronidazole administration for treatment of vaginosis among female sex workers [110]; provide tailored and stage-specific cessation messages to college smokers [94]; and provide on-going behavioral reinforcement for HIV-positive men who have sex with men [97]. In addition, the technology was used to develop a staff recall system for use after mass casualty incident [91] and to develop a support system to enhance self-efficacy, facilitate uptake of intensive insulin therapy and improve glycemic control in pediatric patients with type 1 diabetes [85]. The technology was also used to improve smoking cessation rates [87]; improve pain reporting, pain measurement, and adequate pain therapy for patients with cancer [100]; promote blood glucose monitoring [92]. Additionally, they were used to deliver tailored smoking cessation advice [88,96]; deliver individualized pharmaceutical care for medication compliance and safety [114]; deliver an automated support to young people with diabetes [89]; to collect, verify, and manage data on HIV/AIDS stigma and pregnancy in a rural area [117]; and transmit medical data collected and home by health care professionals [101].
PDA-based technologies were used to develop a PDA-based electronic system to collect, verify, and upload bacteriology data into an electronic medical record system [109]; develop a wireless clinical care management system [108]; and develop a data collection/entry system for public surveillance data collection [115]. In addition, they were used to display audio-visual animation for patient education in a clinical setting [84]; for medical professionals to access a centralized database system of patient data [105]; to assist tuberculosis-control programs to trace patients who interrupt treatment [112]; collect data from HIV patients and to support antiretroviral adherence [111]; and for dietary self-monitoring in patients with type 2 diabetes [95].
The use of mobile phone-based apps as health support systems doubled the self-reported quit rate in the short term [86] and improved patients’ self-management of type 1 diabetes mellitus [99]. The use of mobile phone functions (SMS, MMS, and voice) showed a positive effect on the reduction of the nonattended appointments [106]; provided visibility of antimalarial stock levels to support more efficient stock management [107]; was feasible, safe, did not alter quality of life, and was associated with a trend toward improved metabolic control [83]. The technologies also rapidly mobilized sufficient numbers of anesthesia personnel in response to a mass casualty incident [91]; improved self-efficacy and adherence to uptake of insulin therapy [85]; significantly improved smoking cessation rates [87]; provided patients with rapid, effective medication guidance and pharmaceutical care after discharge [114]; proved to be a productive channel of communication to promote behaviors in overweight adults [93], and was potentially efficacious and easily disseminated method for providing smoking cessation interventions to young adult smokers [94].
The use of PDA-based technologies as health support systems significantly decreased delays in processing and errors with a positive user experience [109]. They provided a fast and efficient data communication mechanism [105]; were a useful and user-friendly medical decision support system for nurses in home care [98]; showed promise as a tool for assisting those with type 2 diabetes in their efforts to manage their disease [95]; and reduced or eliminated data entry errors, performed better in timeliness of receipt and data handling that PP and provided a cost-effective alternative to the paper-based [115].
Interventions using GIS technology in both developed countries (Australia [119,120], UK [121], US [122,123], Canada [124,125], France [126]), and developing ones (Zambia [127], Vanuatu [77,128], Mexico [129], Saudi Arabia [130]) have used the technologies to identify optimal settings for cancer prevention and control [131]; deployment, monitoring, and evaluation of entomological interventions for malaria control [127]; assess environmental exposure [122]; share disease information [124]. Additionally, the GIS was used to support public health decision making for end-stage renal disease [126]; support malaria elimination [77,128]; estimate population catchment area around specific health services in rural and remote areas [125]; prevention and control of vector-borne diseases [129]; and evaluate the spatial distribution of hospital demand and for defining hospital service area [130].
The use of GIS has enabled detection of spatial trends of parasite prevalence following extensive deployment of front line vector control interventions; improved the tracking of entomological indicators: species characterization and insecticide resistance status, including falciparum malaria parasite prevalence and impact assessment of insecticide treated nets and indoor residual spraying (IRS) [127]. GIS was found to be a useful tool in displaying environmental risk factors and potentially associated health effects [122]; enabled cross-border visualization, analysis, and sharing of infectious disease information through interactive maps and/or animation in collaboration with multiple partners via a distributed network [124]; and provided an effective and efficient operational tool for rapidly defining the spatial distribution of target populations in designated malaria elimination zones [77]. In addition, it has empowered program managers at the provincial level to implement and asses the IRS intervention with the degree of detail required for malaria elimination [128]; and helped health planners on evaluating the spatial distribution of hospital demand and for defining hospital service area [130]. In special, using online analytical processing (OLAP)-GIS decision support system, tasks were completed more efficiently, with a higher rate of success, and with greater satisfaction [123].
Health Promotion and Disease Prevention
On this topic, the survey found 48 studies using mobile communication technologies with samples ranging from 5 to 5800, and 60 studies using GIS technologies. The interventions are described in Multimedia Appendices 6 and 7. Interventions using mobile communication technologies in both developed countries (US [132-154], Norway [155], Ireland [156,157], the Netherlands [158,159], Austria [160], New Zealand [161,162], Australia [163-165], and South Korea [166,167]), and developing ones (Kenya [168], Croatia [169], Singapore [170], Brazil [171], China [172-174], India [175-177], Malaysia [178,179]) have investigated the use of mobile phone-based apps, mobile phone voice call, SMS, and PDAs.
For interventions using mobile phone-based apps the technology was used to transmit patients’ self-reported outcomes [180]; transmit self-monitoring data to a website for review and analysis by clinicians, parents, and patients [134]; and ocate missing persons with dementia [145]. Patients were also able to transmit twice daily recording of symptoms, drug use, and peak flow with immediate feedback prompting action according to an agreed plan or paper-based monitoring [143].
For interventions using mobile phone functions the technologies were used to send SMS reminders to patients that enabled improving adherence to sunscreen app [132], and send immunization reminders to children aged 11 to 18 years that needed either or both meningococcal and tetanus-diphtheria-acellular pertussis immunizations [133]. Particularly, text messages were used to send result after genital chlamydia trachomatis infection tests [142]; send reminders about pediatric malaria case-management to health workers [168], and to women toward the end of her menstrual period to do breast self-examination [176]. In some cases, patients sent their peak expiratory flow results daily and received feedback from health center [169]; patients sent weekly self-monitoring data on exercise and eating behavior and their mood, and in return they received tailored feedback messages [158]; patients transmitted images of their psoriasis (chronic skin disease) lesions and received feedback message [160]; patients sent a weekly message regarding their bulimic symptomatology and mood states and received automatic feedback [146]; monitor symptoms in patients with asthma [170]; monitor the functional mobility of elderly subjects in an unsupervised environment [156]; transmit blood pressure measurement unit from patients to a remote server and send notification information to users if patient’s blood pressure is abnormal [173]; support educational intervention for patients with diabetes [166,167]; improve treatment results and reduce dropout rates in children with overweight [159]; remotely monitor the long-term mobility levels of elderly people in their natural environment [157]; monitor patients’ appetite ratings hourly over 7 consecutive days [135]; provide smoking cessation advice, support, and distractions for patients willing to quit smoking [161,162]; provide voice counseling sessions to HIV-positive population [137,138]; send tips on healthy eating and physical activity, as well as reminders to drink water and expressions of encouragement in a weight management program [139]; send sexual health education messages to young people aged between 16 and 29 years recruited from a music festival in Melbourne [163].
In particular, text messages were used as a tool to send reminders. Reminders were sent to promote receipt of influenza vaccination among children and adolescents [140]; to patients at pediatric clinic for appointments [149,151]; via text or call to patients after their missed clinic appointments [148,152]; via text or call to patients prior scheduled appointment [147,153,154,164,171,172,177-179]; and via text to patients after 7-days circumcision [141].
Some benefits of using mobile technologies as health support systems were improved attendance in return general ophthalmology clinic patients [147,150]; improved attendance rate in primary care [178]; improved attendance at the 7-day post-operative clinic visit following adult male circumcision [141]; improved immunization coverage in a low-income, urban population [133]; and improved and maintained health workers’ adherence to treatment guidelines for outpatient pediatric malaria [168]. In addition, the technologies have improved asthma control when added to a written action plan and standard follow-up [169]; improved attendance rates at a health promotion center [174]; improved levels of glycosylated hemoglobin and 2 hours post meal glucose in type 2 diabetes patients [166,167]; improved health knowledge and sexually transmitted infections testing [163]; and significantly improved follow-up adherence in pediatric cataract treatment [172]. Thus, the technologies reduced failure to attend rate at outpatient clinics [148,149,151,164,165,171]; reduced the number of failed appointments significantly [153,177]; offered a time-, labor-, and cost-efficient strategy for encouraging engagement with psychiatric outpatient services [154]; and offered an innovative, low-cost and effective method of improving adherence to sunscreen app [132]; saved staff time per month and reduced number of days to diagnosis [142].
In particular, SMS was cost-effective compared with voice call reminder [150,178]; was a cost-effective method for improving patient attendance at dental appointments [153]; reduced dropout rates from a pediatric lifestyle intervention [159]; reduced the financial burden on health care services by facilitating more efficient use of health care resources [157]; doubled quit rates at 6 weeks [162]; decreased symptoms of distress while increasing self-efficacy [138]; increased short-term self-reported quit rates [161]; increased rate of influenza vaccination [140]; increased the practice of breast self-examination [176]; and increased adherence of obese adolescents enrolled in a weight management program [136]. Routine SMS texting was a cost-effective means of reducing nonattendance rates [147], cost-effective approach for improving patient attendance [165], and more cost-effective compared with call reminders [174].
Not all trials have proven effective, however. Mobile technology did not improve asthma control or increase self-efficacy compared with paper-based monitoring, and there was no positive effect of SMS maintenance treatment on weight, eating behavior, or psychological well-being in obese children [158]. There was no significant reduction in nonattendance rates, as a result of texting appointment reminders to patients who persistently fail to attend their general practice appointments [148]. Also, the mobile technology was not cost-effective in one study [143]. As most interventions of these kinds in fact were effective it seems the reasons for not succeeding in some, relatively few, cases may have to do with local conditions.
The GIS technology in the context of health promotion and disease prevention was used for several purposes, including to measure distance between individuals’ area of residence and the location where each person used a computerized breast cancer education kiosk [131]; identify regional spots as potential territorial stations for a telemedicine service [181]; assess the neighborhood social and ecological contexts in mental health [182]; create a site selection strategy for the dissemination and pilot evaluation of a community-based fall prevention program for older adults [183]; and to analyze dental trauma using a GIS as a tool for integrating social, environmental, and epidemiological data [184]. In addition, GIS was used to discover the geographical variation of syphilis seeking clusters and hotspots [185]; plot measles cases on a digital map in real time [186]; visualize cancer risk patterns associated with incidence, mortality, and accessibility to care [187]; investigate factors associated with nosocomial transmission of resistant organisms [188]; and locate all out-of-hospital cardiac arrests (OHCAs) and identify clusters of OHCAs, as well as clusters of patients who did not receive bystander cardiopulmonary resuscitation [189]. In some studies, GIS was used to examine built environment characteristics and resident health behaviors as they relate to change in blood pressure [190]; quantify the effect of fish pond density on malaria occurrence [191]; identify geographic areas with elevated risk for the later development of amyotrophic lateral sclerosis among military personnel who served in the first Gulf War [192]; map the prevalence of malaria [193]; identify malaria hot spots [194]; create maps and charts displaying the geographic distribution of locations of injuries and their relationships with environmental and demographic parameters [195]; and examine sex-specific spatial patterns of overweight/obesity [196]. Some investigators, used GIS to explore the impact of the intervention coverage and the adherence to the intervention on malaria health outcome [197]; quantify the relationship between gonorrheal infection rates in California and a measure of poverty status and investigated how this relationship and the spatial dispersion of cases varied among the 4 dominant racial/ethnic groups [198]; develop spatial distribution maps of lymphatic filariasis in endemic areas [199]; and identify risk factors and affected areas of hantavirus infections in rodent hosts [200]. Furthermore, GIS was used to display the distribution of housing locations in relation to spatial dispersion, distress, stability, safety, and race/ethnic diversity for persons with psychiatric disabilities [201]; and assess the spatial distribution and associations for HIV testing and family planning use [202].
The use of GIS has enabled understanding of the interplay of psychological, social, environmental, area-level and sociodemographic influences on physical activity [203]; determination of actual travel time, and facilitation of the selection of community-based prevention program sites [183]. It has also enabled proving that space has an effect on outcome variables; mapping the prevalence of psychological distress, mental disorders, and use of mental health services and their correlates [182]; proving that there is significant variation in the occurrence of dental trauma [184]; enabled digital plotting cases of measles as they occurred in real time during the outbreak [186]; and finding significant relationships between the mapping of behavioral risk factors, health care services, transportation access, and policy advantages [187]. The technology was also used to demonstrated, by means of animated GIS, inappropriate patient placement for 19% of patients with methicillin-resistant Staphyloccocus aureus and insufficient time for hand hygiene in 14% (875/6248) of health care provider-patient contacts [188]; geographically map diabetes-risk scores and diabetes-screening rates [204]; and plot clusters of out-of-hospital cardiac arrests [189]. Through the mapping, fish pond density was found to be a significant predictor of malaria occurrence [191], and it was possible to see that service in particular locations of the Gulf was associated with an elevated risk for later developing amyotrophic lateral sclerosis, both before and after adjustment for branch of service and potential of exposure to chemical warfare agents in and around Khamisiyah, Iraq [192]. In addition, GIS identified 10 hot spots with extremely high risk of malaria and 14 hot spots with high risk of malaria [194]; enabled to create digital maps of injury spatial distribution and correlated injury type and location with patients’ clinical data [195]; enabled revealing marked geographical variation in overweight/obesity prevalence with higher values in the Northern and Atlantic health-regions and lower values in the southern and western health regions of Canada. Significant positive spatial autocorrelation was found for both males and females, with significant clusters of high values or hot spots of obesity in the Atlantic and Northern health regions of Alberta, Saskatchewan, Manitoba, and Ontario [196]; as indicated on the GIS maps, villages with malaria cases, lower intervention coverage, and lower adherence were identified. Although no malaria cases were detected in most villages with the best access to the district center, several cases were detected in the distal villages, where the intervention coverage and adherence to the intervention remained relatively lower [197]. The degree of spatial aggregation varied substantially among groups and was especially pronounced for African Americans with gonorrhea in the highest poverty category [198]; filaria monitoring visualization system maps demonstrated that filariasis remained unevenly distributed within districts [199]; land cover and elevation were found to be closely associated with the presence of hantavirus-infected rodent hosts [200]; maps displayed the distribution of housing locations in relation to spatial dispersion, distress, stability, safety, and racial/ethnic diversity and indicated that the developmental disabilities population in supportive housing was more spatially dispersed, and lived in less distressed, less unstable, more secure, but equally racially/ethnically diverse neighborhoods when compared with the psychiatric disabilities population in supportive housing [201]. Clustering among those using services is found as are spatial associations, indicating significant spatial variability in the utilization of health services [202].
Communication to or Between Health Care Providers
In this category the survey found 71 studies using mobile communication technologies with samples ranging from 8 to 4203, and 12 studies using GIS technologies. The interventions are described in Multimedia Appendices 8 and 9. Interventions using mobile communication technologies in both developed countries (Italy [205], US [1,92,206-228], UK [229-232], France [233], Canada [234-237], Japan [238], Australia [239], New Zealand [240], South Korea [241-245], and Denmark [246]), and developing ones (Thailand [247], Peru [248], Kenya [57,249,250], Taiwan [251,252], Israel [253-255], Uganda [256,257], Thailand [258], Singapore [259], Turkey [260], India [261], and South Africa [262]) have investigated the use of mobile phone-based apps, mobile phone voice call, SMS, and PDAs.
Interventions using mobile phone functions concerned providing automatic notification messages to the referring doctor and the consulted ophthalmologist on retinal diseases [205]; sending digital x-ray images via MMS [231,233,247]; and collecting patient diary information using an electronic peak flow meter linked to a mobile phone with an interactive screen to record current asthma symptoms transmitted to, and stored in, a server [229]. The video function was used to send reminders to assist with daily activities of persons with early dementia [230], and transmit teleconsultations, including clinical images of the amputated portion and stump as well as patient information between the physicians in the emergency room and the consultant plastic surgeon through Panasonic camera phones [251]. In addition, transmitting the 12-lead electrocardiography in an ambulance to the cell phone of the attendant emergency medical technician and then to the hospital and to cell phones of off-site cardiologists [252]. SMS was used to deliver diet, exercise, and behavior modification once a week to obese patients [241]. PDAs were used to track patient information during street outreach to the homeless in a major metropolitan area [208], and transmit radiological images to a remote physician [242].
Benefits of using mobile technologies include the possibility of identifying poor control more quickly and facilitating communication with health care professionals without the need for face-to-face consultation [229]. PDAs enabled clinicians to focus on building relationships instead of recreating documentation during patient encounters [208], and improve nursing work force, including accurate differential diagnosis and diagnostic reasoning, reduction of medication errors, reduction of health care costs, and development of effective treatment protocols [212]. A PDA-based technology providing behavioral messaging was an innovative, interesting, easy to use, educational, trustworthy, private, and nonjudgmental tool [248]. Teleconsultation using MMS is especially useful to improve remote management of orthopedic patients in local hospitals or for decisions of transfer when surgical treatment is needed [233]. SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals [249], and enhanced chronic disease management support and patient-provider communications beyond the clinic setting [214].
Interventions using GIS technology in developed countries (US [263-267] and UK [268,269]) have used the technologies to map cancer rates and communicate the findings effectively [263]. This technology has also identified risk and developed potential interventions to address perinatal health problems [264], and developed a perinatal GIS model that helped community members to decide where to focus interventions and in continued use of GIS for planning [264].
Medical Education
On this topic the survey found eight studies using mobile communication technologies with samples ranging from 30 to 366. The interventions are described in Multimedia Appendix 10. All interventions used PDAs in developed countries (Austria [270], Canada [271], and US [272-274]). In these interventions the technology was used to enhance students' pharmacological and clinical contextual knowledge in both clinical practice and nursing education [270], and to determine a patient’s stage of change, providing scripted motivational interviews targeted to their stage, and making relevant health behavior and stage-based interventions immediately accessible [273]. In addition, a PDA was primarily used for personal apps by students during their preclinical training and as drug references and clinical calculators during their clinical training [209].
The use of PDA led to significant increase in self-efficacy [271]; PDAs were easy to use and perceived students’ use as beneficial to their learning in the clinical area [270]. A PDA-based tool did not increase key smoking cessation counseling behaviors compared with a paper-based reminder [273].