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The current landscape of a rapidly aging population accompanied by multiple chronic conditions presents numerous challenges to optimally support the complex needs of this group. Mobile health (mHealth) technologies have shown promise in supporting older persons to manage chronic conditions; however, there remains a dearth of evidence-informed guidance to develop such innovations.
The purpose of this study was to conduct a scoping review of current practices and recommendations for designing, implementing, and evaluating mHealth technologies to support the management of chronic conditions in community-dwelling older adults.
A 5-stage scoping review methodology was used to map the relevant literature published between January 2005 and March 2015 as follows: (1) identified the research question, (2) identified relevant studies, (3) selected relevant studies for review, (4) charted data from selected literature, and (5) summarized and reported results. Electronic searches were conducted in 5 databases. In addition, hand searches of reference lists and a key journal were completed. Inclusion criteria were research and nonresearch papers focused on mHealth technologies designed for use by community-living older adults with at least one chronic condition, or health care providers or informal caregivers providing care in the home and community setting. Two reviewers independently identified articles for review and extracted data.
We identified 42 articles that met the inclusion criteria. Of these, described innovations focused on older adults with specific chronic conditions (n=17), chronic conditions in general (n=6), or older adults in general or those receiving homecare services (n=18). Most of the mHealth solutions described were designed for use by both patients and health care providers or health care providers only. Thematic categories identified included the following: (1) practices and considerations when designing mHealth technologies; (2) factors that support/hinder feasibility, acceptability, and usability of mHealth technologies; and (3) approaches or methods for evaluating mHealth technologies.
There is limited yet increasing use of mHealth technologies in home health care for older adults. A user-centered, collaborative, interdisciplinary approach to enhance feasibility, acceptability, and usability of mHealth innovations is imperative. Creating teams with the required pools of expertise and insight regarding needs is critical. The cyclical, iterative process of developing mHealth innovations needs to be viewed as a whole with supportive theoretical frameworks. Many barriers to implementation and sustainability have limited the number of successful, evidence-based mHealth solutions beyond the pilot or feasibility stage. The science of implementation of mHealth technologies in home-based care for older adults and self-management of chronic conditions are important areas for further research. Additionally, changing needs as cohorts and technologies advance are important considerations. Lessons learned from the data and important implications for practice, policy, and research are discussed to inform the future development of innovations.
As developed countries’ populations age and associated chronic health conditions increase, alternatives to hospital and institutional care are needed. The United Nations estimated that by 2050, the world population of older adults over 60 years will have doubled, while the age group over 80 will have tripled from 2013 statistics [
It is estimated that approximately one in four older adults have two or more chronic conditions and half of older adults (≥ 65 years) have three or more (ie, heart disease, diabetes, arthritis, chronic lower respiratory tract disease, stroke, chronic obstructive pulmonary disease [COPD], dementia, and hypertension) [
The field of mHealth, as defined by the World Health Organization (WHO) [
Despite these promising opportunities, the current literature supporting the use of mHealth primarily includes pilot and/or feasibility studies [
The purpose of scoping reviews includes comprehensively synthesizing evidence to map a broad, complex, or emerging field of study and to identify gaps with the intent to inform practice, policy, and future research [
To complete this scoping review, we followed the five-stage framework developed by Arskey and O’Malley [
The research question was identified from a preliminary scan of the literature and drawing on the expertise of the research team and several stakeholders. Rationale for the question arose from the lack of existing consensus in the academic literature on designing, implementing, and evaluating mHealth solutions in community-based settings, specifically as it pertains to older adults living at home with chronic conditions.
The team collaboratively planned and implemented a search strategy to identify relevant literature that was specific to mHealth solutions targeting chronic conditions and community-based care of older adults. Keywords and related subject headings were identified in consultation with research librarians in order to capture a comprehensive list of potential sources. Keywords were identified and combined to address three components of the research question: (1) mobile or electronic devices, (2) technology-based health care delivery, and (3) an aging population and/or chronic conditions (
Mobile/Electronic Device
Cellular Phone, Mobile Phone, PDA, Smartphone, Tablet
Mobile Health/Telehealth
Computer interface, Design, eHealth, Human factors, Implementation, Integration, mHealth, Mobile Health, Telecare, Telecommunication, Telehealth, Telemedicine, Usability, User-centred design, User-friendly
Condition/Population
Cerebrovascular Accident, Chronic Disease, Community, Disease Management, Health Program, Health Service, Healthcare Delivery, Home care, Inter-professional, Point-of-care, Quality of Life, Rehabilitation, Rehabilitation Care, Reintegration, Stroke
Two reviewers independently searched the titles and abstracts of the retrieved literature. Conflicts were resolved by a third reviewer and through team consensus. Inclusion criteria were mHealth technologies focusing on at least one of the following: (1) chronic conditions associated with aging populations, (2) HCPs providing home care, and/or (3) older adults living at home and/or their informal caregivers. Research articles using different methodologies (qualitative, quantitative, and systematic reviews) as well as theoretical papers were included and all papers had to be in English. The exclusion criteria were the following: (1) mHealth solutions being used for diagnostics/imaging, acute care, body and environment monitoring or support devices, or robotics; (2) technology pertaining to healthcare in developing countries; and (3) non-English language publications. Methodological quality of the published articles was not a criterion for exclusion/inclusion. This enabled the inclusion of a breadth of knowledge pertaining to the research question, as is consistent with scoping review practices [
Articles that potentially met inclusion criteria through abstract review were reviewed in full by team members. Meetings were held regularly to discuss reviewers' decisions specific to the inclusion and/or exclusion of articles. Both inclusion and exclusion criteria were revised as the search evolved, in order to best address the research question. Under the final revised criteria, only articles pertaining to older adults (>50 years old) with one or more chronic conditions living in their homes were included.
A descriptive-analytical narrative method was used to extract and chart the data from the selected articles [
In total, 1021 published articles were identified in the database search (
Of the 42 studies included (
Seven of the selected articles were theoretical papers (discussion and position papers). Four were descriptive reports of existing interventions, and 3 were case studies describing processes of mHealth implementation. Two articles described predictive modeling techniques for screening patients in use of technology. Three qualitative descriptive studies elicited opinions concerning mHealth. There were 13 papers in which mHealth solutions were evaluated; 6 controlled trials, 3 mixed-methods studies, and 4 qualitative studies. Three studies were cross-sectional surveys, 3 were systematic or scoping reviews, 2 were methods papers, and 1 paper focused on simulation.
Of the 42 articles, 17 focused on older adults with single chronic conditions: diabetes (n=4), stroke (n=5), heart condition (n=4), COPD (n=1), and dementia or cognitive impairment (n=3). Six articles involved older adults with any chronic condition or multiple chronic conditions. Conditions were not specified in 18 articles, in some cases referencing older adults (n=5) or home care patients (n=6) and caregiver burden (n=1).
The majority of mHealth solutions described were designed for use by both patients and HCPs (n=19), followed by HCPs only (n=7), patients only (n=5), caregivers, patients, and HCPs (n=4), and patients and caregivers (n=3); one mHealth solution was targeted exclusively at family caregivers. The remaining 3 articles were nonspecific.
Review article characteristics.
Article Location | Article Typea | Type of Article/ Study Design | Condition | Innovation | Innovation End-users |
Alpay et al (2010) Netherlands [ |
1 | Discussion paper | NSb | eHealth patient empowerment | Patients |
Bujnowska-Fedak & Mastalerz-Migas (2015) Poland [ |
4 | Cross-sectional survey | NS | Internet use for health by older adults | Patients |
Barakat et al (2013) USA [ |
2 | Qualitative descriptive | NS | eHealth competencies /HCPc workshop participants | HCP |
Blake (2008) UK [ |
1 | Discussion paper | Chronic disease | Mobile technology for monitoring & health promotion | Patients and HCP |
Bosl et al (2013) USA [ |
2 | Predictive modelling | NS | HCP screening for medication compliance at home | HCP |
Boulos et al (2011) UK [ |
1 | Discussion paper | NS | Mobile phones and app technology for mHealth | Caregivers, patients and HCP |
Chan et al (2012) Australia [ |
2 | Descriptive report | Diabetes | Web-based SMSd /mobile terminal | Patients and HCP |
Chiang et al (2012) Taiwan [ |
3 | Nonrandomized quasi- experimental design | Caregiver burden | Telemonitoring/phone counseling | Caregivers |
Chumbler et al (2012) USA [ |
3 | Single-blind RCTe | Stroke | Text messaging, phone, home visits | Patients and HCP |
Cicolini et al (2014) Italy [ |
3 | RCT | CVDf | Text messaging reminders | Patients and HCP |
Dale et al (2014) New Zealand [ |
3 | Mixed-methods survey; Pre-post test pilot | CVD | Mobile phone & Internet system | Patients and HCP |
Eland-de-Kok et al (2011) Netherlands [ |
5 | Systematic review | NS | eHeath vs usual home care | Patients and HCP |
Esser & Goossens (2009) Netherlands [ |
1 | Literature review/ |
NS | User-centered design framework | Patients and HCP |
Forducey et al (2012) USA [ |
3 | Controlled trials (2 randomized, 1 not) (pilot studies) | Cognitive impairment | Telehealth: text messaging, videophone, phone | Caregivers, patients and HCP |
Hall et al (2012) USA [ |
1 | Discussion paper | NS | Telemedicine and mHealth for older adults | Patients |
Hebert et al (2006) Canada [ |
1 | Implementation decision framework | Diabetes and chronic diseases | Telecare implementation | Patients and HCP |
Huang & Hsu (2014) Taiwan [ |
3 | Qualitative pilot | NS | Social networking & telehealth; tablets | Caregivers, patients and HCP |
Huijbregts et al (2009) Canada [ |
3 | Mixed methods | Stroke | Telehealth delivery system | Patients and HCP |
Joubert et al (2013) Australia [ |
5 | Literature review | Stroke | Telestroke | Patients and HCP |
Kim et al (2012) South Korea [ |
3 | Quasi-experimental design intervention study | COPDg | uHealth devices (monitoring, education/home visiting) | Patients and HCP |
Malinowsky et al (2014) Sweden [ |
3 | Case control | Cognitive impairment | Tech screening tool | Patients |
May et al (2011) UK [ |
2 | Qualitative descriptive | Chronic disease | Telecare implementation | Caregivers, patients, and HCP /managers |
McCullugh et al (2013) UK [ |
2 | Case review | NS | Telehealth evaluation framework | Patients and HCP |
Nielsen & Matthiassen (2013) Denmark [ |
2 | Case study | NS | mHealth implementation and home care | NS |
Nielsen & Mengiste (2014) Denmark [ |
2 | Case study | NS | Mobile health diffusion (social world theory) and home care | NS |
Nundy et al (2012) USA [ |
3 | Qualitative descriptive pilot | Diabetes | Text messaging with follow-up | Patients and HCP |
Nyborg et al (2013) Denmark [ |
2 | Descriptive report | NS | Mobile phone for nurses and home care | HCP |
Pandey et al (2013) USA [ |
4 | Cross-sectional survey | Stroke | Mobile phones and app technology | Caregivers and patients |
Paré et al (2011) Canada [ |
3 | Mixed methods | NS | Laptop computer software and home care | HCP |
Saywell et al (2012) New Zealand [ |
6 | Study protocol/mixed methods | Stroke | Telerehab program | Patients and HCP |
Stroulia et al (2012) Canada [ |
3 | Qualitative/ ethnography | NS | Mobile ICT and home care | HCP |
Townsend et al (2013) Canada [ |
2 | Qualitative descriptive | Chronic conditions (multiple) | Ethics of eHealth | Caregivers and patients |
Van Hoecke et al (2010) Belgium [ |
2 | Descriptive report | Diabetes and multiple sclerosis | Web-desktop with PDA interface | Patients and HCP |
Varnfield et al (2011) Australia [ |
2 | Descriptive report | CVD cardiac rehab | Mobile phone and internet video conferencing | Patients and HCP |
Varsi et al (2013) Norway [ |
3 | Qualitative descriptive | NS | Internet patient provider communication service | Patients and HCP |
Vuononvirta et al (2011) Finland [ |
2 | Qualitative descriptive | NS | TeleHealth compatibility | HCP |
Walters et al (2010) Australia [ |
6 | Study protocol/RCT | CVD cardiac rehab | Mobile phone platform | Patients and HCP |
Wang et al (2014) China [ |
5 | Integrative review | Chronic disease | Mobile phone apps | Patients |
Yellowlees (2005) USA [ |
1 | Position paper/ theoretical | NS | Principles of successful telemedicine | NS |
Zhang et al (2008) Japan [ |
6 | Simulation testing | NS | Mobile phone & Internet; Teleconferencing and home care | HCP |
Zhang et al (2014) UK [ |
2 | Predictive modelling | Dementia | HCP screening for use of video streaming by patients | Patients and HCP |
Zulman et al (2013) USA [ |
4 | Cohort study - sample survey | Chronic conditions | mHealth technology for out-of-home caregiving | Caregivers and patients |
aType of Article: 1=theoretical, 2=descriptive, 3=intervention study, 4=population/cohort study, 5=review, 6=other
bNS: nonspecific
cHCP: health care providers
d SMS: short message service
eRCT: randomized controlled trial
fCVD: cardiovascular disease
gCOPD: chronic obstructive pulmonary disease
Search strategy and results.
Results pertaining to mHealth solutions are organized under 3 phases of development: design, implementation, and evaluation. Given the iterative and cyclical nature of designing, implementing, and evaluating mHealth technologies, these categories are not discrete entities and inevitably overlap. The categorical terms were used to organize the review findings as commonly presented in the papers reviewed. Each section is discussed within thematic constructs derived from the analysis of the selected literature using an iterative process of qualitative content review.
Two thematic constructs emerged from the literature pertaining to practices and considerations in designing mHealth solutions: (1) user-centered design and (2) interdisciplinary/collaborative team approaches.
Recommendations from both research findings and theoretical perspectives are consistent regarding the need for end-user design. Multiple examples of end-user design approaches were provided within the literature [
Software/App Features
Graphs displaying patient-related trends (ie, glucose monitoring and medication) [
Notification system, which alerts agencies, case managers, and professionals of specific patient responses that require attention and follow-up [
Text messages (short message service, SMS), which contain motivational and educational information as well as reminders to improve treatment adherence in chronic diseases [
Video messaging (patients with dementia) [
Client management features: scheduling [
Aids for seniors: vision, hearing, memory [
Patient texting features for reporting health status [
Hardware/Mobile Devices
Mobile devices with large touch-screens and large virtual buttons (vs hard buttons) [
Mobile phones not requiring end-users to reboot the system frequently; minimizing pop-ups; remote, seamless maintenance [
Lighter tablets with a touch pen to suit the mobility of homecare providers [
Voice input function [
Cloud computing resources [
Smartphones and voice-over-Internet protocol software applications (eg, Skype) [
Esser and Goossens [
Reviewed literature consistently reported the use of interdisciplinary team-based approaches in the process of designing and developing mHealth solutions. The interdisciplinary team in this literature consisted of technology experts and health care professionals as well as end-users and other affected stakeholders [
In summary, continued engagement with end-users as well as collaborative team approaches that encourage multiple stakeholder involvement, are both essential in the successful design and development process for mHealth solutions. User-centered approaches enable researchers and engineers to prioritize an understanding of the context in which the solution will be used by a diverse group of end-users. It also helps to establish early on the specific app features and hardware considerations perceived to be acceptable, preferable, and compatible with the needs of the end-users. Integrating these features and hardware considerations throughout the design and development phase of the solution is imperative, as it influences end-users' response, engagement, uptake, and adherence. Collaboration among stakeholders ensures different interests are appreciated, and that knowledge transfer between content and technology experts is maximized.
Three thematic constructs emerged from the literature pertaining to successfully implementing mHealth solutions: (1) feasibility in relation to organizational and systems readiness, (2) acceptability of the mHealth solution, and (3) usability in relation to the different end-users. These factors were reported to either facilitate or hinder the implementation of mHealth solutions.
The need for health system readiness to adopt mHealth solutions was highlighted in much of the theoretical literature. At the institutional level, financial resources, policies, and workplace culture all play a key role in the successful adoption of mHealth technologies [
May et al reported how general uncertainties about policies and management systems were to blame for the lack of successful uptake of telecare services [
A lack of a clear reimbursement schedule was described as a barrier for clinicians to adopt mHealth technology [
The process of adoption and diffusion of an mHealth solution was reported in a case review from Denmark [
Delays in local adoption of mHealth technology were attributed to top-down approaches that neglect to address the impact on workload adjustments and practice preferences by the end-user workforce [
The perceived value and ease-of-use by the end-user was identified as a critical factor in successful adoption of an mHealth solution. End-user preferences and levels of technical literacy were felt to affect the way health care information is shared and accessed [
In addition, special consideration must be given to the varied types of information that are shared via different mobile devices; mobile phones are limited in the amount of information that can fit on a screen compared to computers [
In summary, factors that support or hinder implementation of mHealth solutions include the following: (1) institutional environment such as culture, policies, and readiness to change; (2) the availability of a comprehensive business plan; (3) personal factors of the different end-users including perceived value of the mHealth solution; and (4) factors related to the solution itself, for example, ease-of-use by different types of end-users. These data highlight the importance of researchers understanding the culture, values, and readiness of different stakeholders and end-users from project inception, and also to continue to monitor and address end-user and stakeholder feedback.
A variety of quantitative, qualitative, and mixed-methods designs were used to evaluate mHealth solutions for older adults living at home. Researchers were interested in evaluating aspects of application design and implementation (eg, feasibility, acceptability, and usability), as well as health outcomes experienced by clients receiving the interventions (
Constructs measured in mHealth studies
Domain | Construct | Measurement Tools |
End-User Satisfaction | ||
Usability | ||
Intervention Feasibility | Attendance/utilization rates [ |
|
Quality of Life/Well-being | Reintegration to Normal Living Index [ |
|
Condition-Specific Disease Severity | ||
Physical Function | Grip Strength (Jamar handheld dynamometer) [ |
|
Patient Treatment Adherence | Self-report [ |
|
Caregiver and Family Well-being | Caregiver Burden Inventory [ |
|
Goal Attainment | Goal Attainment Scaling [ |
|
Cost Effectiveness | EuroQol - 5D [ |
Studies that addressed design features with respect to acceptability and usability tended to use qualitative data collection strategies: focus groups, in-depth and semi-structured interviews [
Several methods and data collection strategies were used during pilot and small scale implementation studies to evaluate mHealth solutions used in the context of home and self-management for older adults. Studies investigating the adoption and implementation of mHealth solutions captured end-user utilization statistics through self-report [
Controlled trials assessing health outcomes associated with the use of mHealth solutions frequently incorporated standardized tools or scales designed for the specific health outcome or chronic condition of concern [
McCullagh et al discussed phases of evaluation: (1) formative evaluation, conducted during application design and prototype testing of mHealth solutions in the self-management of chronic conditions; (2) summative evaluation, conducted during limited launches and pilot phases; and (3) population outcome evaluations, applied to full implementation after pilot phases, to determine the impact of complex interventions embedded in health care delivery systems [
In summary, methods used to evaluate mHealth solutions varied across the literature, including a variety of quantitative and qualitative data collection strategies and tools. Standardized tools were used for targeted outcomes of interest, and were often tailored to the chronic condition or client population under study. Other outcomes were more specific to reported behaviors and body metrics. In most cases, studies were either feasibility or pilot investigations, offering limited knowledge concerning the impact of full-scale implementation [
The purpose of this scoping review was to identify current practices and recommendations in designing, implementing, and evaluating mHealth technologies to support older adults and their caregivers in managing their chronic conditions while living at home. Lessons learned from this review are highlighted in
Lessons learned in designing, implementing, and evaluating mHealth to support older adults with chronic conditions at home.
Design, Implementation, and Evaluation Domains | Recommendations |
A good understanding of the end-users’ context is critical | Engage end-users in activities such as personas and scenarios or simulations [ |
Less can be more on a mobile interface | Minimize navigation screens to two [ |
Develop a strategy for interprofessional collaboration (ie, health care and technical expertise) | Create interdisciplinary development teams that consist of technology experts and health care professionals along with end-users and other affected stakeholders [ |
System and service reliability is essential for successful implementation | Be aware that malfunctions can cause frustration and negative perceptions of the solution [ |
Look to business models for designing long-term maintenance and support | Carefully and realistically consider funds and timeline when planning for implementation [ |
Assemble a cohesive implementation team | Acknowledge that buy-in from both internal (end-users) and external (administrators/management) stakeholders is important [ |
An evaluation plan should be considered early on | Use an evaluation framework that incorporates all phases of mHealth application development [ |
The findings from this review have implications for all stakeholders including researchers, clinicians, homecare providers, software developers, patients, and their families. In one of the few widespread technology implementation studies in community health care, it was clear that the extent of technology adoption was related to the end-users’ perceived value or perceived risk of using the technology [
In only a few of the articles reviewed, were considerations and findings guided and presented within a theoretical framework [
There are considerable implications for the patient when mHealth solutions are deployed within the context of health care. Researchers noted end-user concerns about implementing solutions in health care related to the idea of technology replacing, rather than supporting, human contact [
Finally, there are policy implications at a population level. Mobile health has the potential to gather large amounts of health data that can be used to better inform interventions and care plans. However, there are many barriers to implementation and sustainability that limit the number of successful, evidence-based mHealth solutions that are implemented beyond the pilot or feasibility stage. For example, the additional costs of privacy / security testing, ongoing technology support/development, and software maintenance are a poor fit with government-supported funding cycles for research and development, where funds are typically delivered for a limited number of months or years [
While this scoping review highlights a number of key design principles and lessons learned for the development and implementation of mHealth solutions, there remain a number of gaps in the literature that should be addressed within future research priorities. First, there is little focus on sustainability of mHealth solutions, and few resources available for researchers to access when navigating the options and planning a sustainability plan. To address this, there may be opportunities for partnerships between industry and research to support the sustainability of an mHealth solution [
Researchers also need to consider the unanticipated consequences and risks of mHealth solutions, as well as the potential inequities that may be created given unequal access and use of technologies in society. Potential risks to be considered include the following: (1) the potential for breaches in patient privacy and confidentiality [
There is limited knowledge about the implementation science related to the adoption and acceptance of new technology in relation to home-based care for older adults. Researchers would benefit from a framework to evaluate the effectiveness of the process of implementing the mHealth solution. For example, where/when/how is support required by patients and their caregivers and how is this best addressed? More focused consideration needs to be given to patient empowerment using mHealth technology for self-management [
Various limitations concerning this review need to be considered. First, true to scoping review methods, a quality assessment of selected papers was not used to exclude articles, although all were peer-reviewed. Results from studies using a variety of study designs as well as author opinions were incorporated into the findings of this review. Second, mHealth is a rapidly advancing field. Application of the reported findings may need to be reappraised within the context of a changing landscape of innovation. Third, this scoping review addresses a broad area of content and contexts, that is, different mHealth solutions, goals, and implementation contexts; multiple applications; different users, communities, and countries; and different chronic conditions with rare separation of single conditions from the context of multiple chronic conditions. This may limit transferability of the results to a specific context and present as prime areas for future systematic and realist reviews. Fourth, grey literature is not included; sources for this review were limited to articles published in peer-reviewed journals. Unpublished yet related information on the most current trends in this field may have been missed.
Developing effective mobile technologies with minimized risk to the quality of health care offered to older adults is a current research priority. Despite the potential benefits that mHealth solutions could offer, there is limited use of these technologies in the home. Interdisciplinary mHealth development teams need to consider specific factors when designing, implementing, and evaluating such technologies that will ultimately fit within the unique context of older adults at home and their care providers. Whether the target of mHealth solutions is the patient, family and/or HCPs, it is imperative to be working
The question and selection criteria for this review allowed for a broad range of mHealth technologies to be considered that apply to a variety of chronic conditions associated with aging. This paper presents some commonalities across these different contexts using thematic constructs to inform interconnected processes of design, implementation, and evaluation when developing mHealth solutions best suited to the needs of older adults living at home. At a time of rapid technological innovation, guidelines for research and development in mHealth need to be adaptable to continuous change as new tools become available [
chronic obstructive pulmonary disease
cardiovascular disease
health care provider
mobile health
randomized controlled trial
short message service
World Health Organization
This work is part of a program of research (Aging, Community, and Health Research Unit) supported by the Ontario Ministry of Health and Long-Term Care Health System Research Fund Program (Grant #06669).
NMM and LH conceived of the scoping review and participated in the design and coordination. JP participated in the design and coordination of the scoping review and drafting the manuscript. LH, S Ibrahim, S Isaacs, and NMM participated in title, abstract, and article review/selection and drafting the manuscript. MMR, RV, and AG contributed to manuscript development and refinement.
None declared.