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Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits for both patients and health care providers, the overall adoption levels of mHealth tools by health professionals remain relatively low.
This study aimed (1) to investigate attitudes of health care providers and mHealth experts toward mHealth tools in the health context in general, and this study aimed (2) to test the acceptability and feasibility of a specific mHealth tool for patients with an eating disorder (ED), called TCApp, among patients and ED specialists.
To this purpose, we conducted an explorative qualitative study with 4 in-depth group discussions with several groups of stakeholders: our first focus group was conducted with 11 experts on mHealth from the Catalan Association of Health Entities; the second focus group included 10 health care professionals from the Spanish College of Doctors of Barcelona; the third focus group involved 9 patients with an ED who had used the TCApp over a 12-week period, and the fourth and last focus group involved 8 ED specialists who had monitored such ED patients on the Web.
The focus groups showed that health care providers and mHealth experts reported barriers for mHealth adoption more often than facilitators, indicating that mHealth techniques are difficult to obtain and use. Most barriers were attributed to external factors relating to the human or organizational environment (ie, lack of time because of workload, lack of direct interest on a legislative or political level) rather than being attributed to internal factors relating to individual obstacles. The results of the mHealth intervention study indicate that the TCApp was considered as easy to use and useful, although patients and the ED specialists monitoring them on the Web reported different adoption problems, such as the inability to personalize the app, a lack of motivational and interactive components, or difficulties in adhering to the study protocol.
In general, this paper indicates that both health professionals and patients foresee difficulties that need to be addressed before comprehensive adoption and usage of mHealth techniques can be effectively implemented. Such findings are in line with previous studies, suggesting that although they acknowledge their possible benefits and cost-effectiveness, health care providers are quite resistant and conservative about integrating mHealth technologies in their daily practice.
Over the last decade, the number of people who have obtained a mobile phone or some other portable electronic communication devices worldwide has increased exponentially [
mHealth has many different applications, such as the facilitation of data collection, the encouragement of health care consumers to adopt healthy lifestyles, the self-management of chronic conditions, such as pain, psychological distress, fatigue, and sleep [
Many factors influencing the acceptance, adoption, and usage of mHealth by health care professionals have been reported in the systematic review by Gagnon and colleagues [
Meanwhile, important barriers relating to mHealth characteristics were also mentioned in the same review [
Owing to the advantages of the use of mHealth technologies, it is important to determine what types of drivers and barriers are considered relevant by health professionals to adopt mHealth technologies efficiently. In this study, we will focus on the drivers and barriers for adoption of mHealth techniques in general health care delivery processes, and, more specifically, in an intervention using an mHealth tool specifically designed for patients with eating disorders (EDs) and the health care providers treating them.
According to Holmes and colleagues [
Health professionals treating patients with EDs might be an important group that could benefit from mHealth interventions, either as an adjunct to standard treatment or as a method to providing existing evidence-based treatments on the Web [
Furthermore, factors that facilitate or hinder the effective adoption of these tools by patients and clinicians need to be identified through qualitative research. In a systematic review of the literature by Anastasiadou and colleagues [
We conducted 4 separate in-depth focus groups for this study. The first was carried out with health care providers, and the second was carried out with mHealth experts. Both focus groups had the same structure, and both aimed at assessing important drivers and barriers, which these professionals perceived relating to mHealth adoption in different health care services. The third and fourth focus groups were based on data from a larger randomized controlled trial (RCT) assessing the effectiveness of an mHealth intervention (ClinicalTrials.gov Identifier: NCT03197519), and they sought to assess the user (patient and provider) experience of a specific mHealth tool, called TCApp, in supporting self-management for patients with an ED. Focus group discussions were performed in accordance with the generic inductive approach [
The TCApp is an mHealth tool specifically designed to bidirectionally connect patients with EDs and their therapists in the periods between medical consultations. The app has been designed and developed by the Spanish start-up company HealthApp. It offers 4 different language options (Spanish, Catalan, French, and English), and it is available through both Google Play and Apple Store markets, and it currently has more than 1000 patients as active users. Through the TCApp, patients can record their thoughts, actions, emotions, and whatever other information their therapists consider relevant for the therapy. The app can be customized for each patient according to therapy requirements. The main objective of the app is to replace paper self-records with Web-based records, as the former sometimes present a source of discomfort for patients [
A total of 11 experts on mHealth from the Catalan Association of Health Entities (Associació Catalana d‘Entitats de Salut, ACES) and 10 health care professionals from the Spanish College of Doctors of Barcelona (Colegio Oficial de Médicos de Barcelona, COMB) with a special interest in mHealth were invited to participate in focus groups organized by our research group at the Open University of Catalonia (Universitat Oberta de Catalunya, UOC). The generic inductive approach, on which the design of the study was based, required a purposive sampling. To better identify barriers and facilitators for mHealth adoption from the point of view of 2 different stakeholders’ groups, we considered it important to carry out the first focus group with experts on mHealth from ACES and the second with health care professionals from COMB. The approval of the Ethical Committee of the University leading the study (UOC) to conduct the focus groups was obtained on February 21, 2017. Inclusion criteria for both focus groups were professionals from several private medical centers in Barcelona (Spain) who were actively engaging in mHealth technique usage, including both health care providers as well as mHealth experts, such as technical staff (eg, data analysts, software developers), ICT management staff, marketing and communication managers, and human resources management staff.
The study’s population comprised a larger RCT for the mHealth intervention study, involving 8 public and private ED units in Spain. A total of 108 patients were recruited from this larger study, the protocol of which has been published elsewhere [
Inclusion criteria for the ED specialists’ group included having monitored their patients on the Web and having performed the following actions at least once a week: follow the patient’s daily self-records and generate personalized reports or graphs and communicate with him or her via the chat function. From a total of 21 patients who were invited to the focus group, 11 decided to participate, whereas 2 had to be excluded, as they did not meet all inclusion criteria. Next to that, all invited ED specialists from the 8 ED units took part in their respective group discussion. However, it is worth mentioning that only patients from 3 out of the 8 ED units involved in the larger study participated in the focus group study. The final focus group sample thus comprised 9 patients with an ED and 8 specialists who were monitoring such patients on the Web through the TCApp.
Description of patients.
Patient characteristics ( |
Values | |
Age (years), mean (SD) | 15 (0.50) | |
Body Mass Index (actual), mean (SD) | 19.55 (1.35) | |
Illness Duration (months), mean (SD) | 16.67 (8.75) | |
Male | 0 (0) | |
Female | 9 (100) | |
Primary | 7 (78) | |
Secondary | 2 (22) | |
Tertiary | 0 (0) | |
ANa-restrictive | 8 (89) | |
AN-purging | 1 (11) | |
BNb | 0 (0) | |
EDNOS | 0 (0) | |
Day Hospital | 1 (11) | |
Outpatient | 8 (89) |
aAN: anorexia nervosa.
bBN: bulimia nervosa.
cEDNOS: eating disorder not otherwise specified.
Description of eating disorder specialists.
ED specialist characteristics (N=8) | Values | |
Age (years), mean (SD) | 34.63 (7.21) | |
Male | 2 (25) | |
Female | 6 (75) | |
Psychiatry | 2 (25) | |
Psychology | 5 (63) | |
Nursing | 1 (12) | |
Public | 4 (50) | |
Private | 4 (50) | |
Duration actual employment status (years), mean (SD) | 6.19 (4.29) |
Qualitative data were collected through four in-depth focus groups, as previously indicated. The first comprised health care providers from the COMB, the second focus group was conducted with mHealth experts from the ACES, a third focus group with patients who had used the mHealth tool, TCApp, and a fourth with ED specialists who had monitored such patients on the Web.
The interviews carried out in the first 2 focus groups included open-ended questions designed to address the following topics relating to drivers and barriers of mHealth adoption:
Factors related to mHealth characteristics
Individual and professional factors
Human environment factors
Organizational environment factors: internal and external
Open-ended questions for the focus group were designed following previous work of our team [
For the third and the fourth focus group, the interviews with patients and ED specialists were completed 3 months after the study start date. When designing the questions, we were inspired by a multidimensional evaluation framework, called Model for ASessment of mHealth (MASH), previously described and implemented by a European project in which our team also participated, termed DoChange. The MASH model was constructed on the basis of the evaluation framework of the Model for ASsessment of Telemedicine methodology [
Domain 3 (both patients and ED specialists). Effectiveness.
To what extent did patients’ ED symptoms and quality of life improve when treated with TCApp as a complement to face-to-face treatment?
Domain 4 (both patients and ED specialists). User experiences.
Which were professionals’/patients’ needs in implementing the TCApp services in daily practice? Were users satisfied with the app/usability of the services offered by the TCApp? Which were the most important facilitators in implementing the TCApp in routine practice? Which were the most important barriers in implementing the TCApp in routine practice?
Domain 5 (ED specialists). Economic aspects.
Are you willing to pay for use of the TCApp from now on in your routine practice?
Domain 6 (both patients and ED specialists). Organizational aspects.
Participants had to think of a future ideal scenario in which decisions at their institution were made by them and describe the specific proposals they would make to their organization about a new service that implements, in an ideal way, the TCApp together with other new technologies.
Domain 7 (both patients and ED specialists). Sociocultural aspects.
Have any issues arisen regarding cultural accessibility (considering the different languages spoken by the users) and socioeconomic accessibility (different ages, users’ digital health literacy)?
First, for the focus groups with health care providers and mHealth experts, a formal invitation was sent to both institutions (COMB and ACES, respectively) by the principal investigator of the study, FL. Both focus groups, of 1 hour each, were conducted by FL at the headquarters of ACES and at the UOC, and they were audio recorded with permission. A second researcher, CF, was present during these events and transcribed the group discussions verbatim.
The study procedure of the mHealth intervention was described in detail elsewhere [
Patient information, including age, sex, diagnosis, illness duration, body mass index (BMI), degree of education, and employment status, was retrieved from the medical history of each patient, which was provided to the research team by the ED specialists responsible for each participating center.
Thematic content analysis was used to analyze the qualitative data from the 4 focus group discussions. [
The analyses of all descriptive data regarding participants’ sociodemographic and clinical characteristics, SUS, and CSQ-8 were carried out using SPSS 20.0 (SPSS Inc) [
In total, 4 domains and 16 key themes were identified and were then classified as barriers to or drivers for mHealth adoption. Most of these themes, 11 (69%), were classified by professionals as barriers, and only 5 (31%) were perceived as facilitators for mHealth adoption. The complete list of domains and themes, together with professionals’ most representative examples recounted during the focus groups, is shown in
Barriers relating to mobile health adoption by health care providers and mobile health experts.
Domain and key themes | Examples | |
Lack of time and workload (+++a) | “I had no time to integrate any changes in my work schedule”; “I know the theory...that you have to do a first push at the beginning in order to integrate changes, for example change to e-consultations, and then the workload will become less. But then in practice, it is difficult to implement due to our workload.” | |
Management: Lack of strategic plan to implement mobile health (+++) | “Leaders have to believe in innovation in order to promote the use of ICTb tools, otherwise projects testing their efficacy will not succeed.” | |
Health care policies and sociopolitical context: Lack of budget and direct interest (+++) | “Technology costs...There is a considerable lack of budget to support studies assessing the impact of mHealth tools”; “At a political and legislative level, there is not enough interest in mHealth. Doctors complain that they cannot reimburse mHealth”; “Technology is costly and it is difficult to verify its return. Often, the ideas we propose seem good, but when the budget is specified, people become more resistant, you see that the investment has a certain cost. In addition, technology evolves fast and you may not have time to recover the initial investment...Thus, inversions for mHealth should not only be innovative, but also timely and always updated.” | |
Insufficient training (++c) | “It is important to have a properly trained team...It is not enough to have an IT-department specialised and dedicated to this. All the staff has to be properly trained”; “It is essential to offer continuous training to ensure that students of health sciences acquire digital competences.” | |
Human resources: Lack of information technology support (++) | “There is a considerable lack of support by the technical staff of our institution when we integrate a new mHealth tool into our services...Due to this lack of support, users either use the new tools in the wrong way, or stop using them because they get frustrated when they do not know how to use them in a proper way.” | |
Age: Lack of familiarity and mobile health skills (+d) | “Age-based digital divide is present in the health sector...Young health professionals have more digital minds...Instead, for many professionals who are older in age, the handling of the Internet and other ICTs may seem complex and they prefer to do things in the traditional manner (paper-and-pencil methods)”; “I do not think that age has a significant impact on adoption...In my institution, older professionals do not have more negative attitudes towards ICTs than younger ones, neither do they perceive their utility and usefulness differently.” | |
Lack of agreement with mobile health: Resistance (++) | “Professionals are often resistant to change because of fear of the unknown and new.” | |
Risk-benefit assessment (perception; +) | “The value of face-to-face contact with our patients is inherent to all of us...sometimes we are afraid of losing this when introducing a new technology.” | |
Insufficient interaction: Patient-Health professional-information technology team (++) | “New technologies cannot be implanted unilaterally by the IT team. Health professionals are those who really know what patients need. There has to be an alignment of needs between IT team, patients and health professionals.” | |
Security and privacy issues (++) | “Sometimes bureaucracy is used as an excuse to stop the implementation of an innovation...Once patients sign their informed concern, there is freedom to conduct innovations”; “We have a very protectionist system...The new law on security / privacy of medical histories is very restrictive about which data from patients can be viewed and shared...this also obstructs the sharing of this information online using mHealth tools”; “It is important to approve Apps by an official authority taking into account both technological validation (must be useful) and functional validation (applicable to the context).” | |
Design and technical concerns (+) | “Technology can fail”...“Technical limitations of the mHealth tools” |
a+++: Very frequently mentioned (≥4 times).
bICT: Information and Communication Technology/ies.
c++: Frequently mentioned (2-3 times)
d+: Only occasionally mentioned, sometimes a debate was opened because of contradictory opinions (mentioned 1 time, or 2 contradictory opinions).
Drivers relating to mobile health adoption by health care providers and mobile health experts.
Domain and key themes | Examples | |
Quality standard (+++a) | “It is very important to achieve a proper quality control and approval of a mHealth tool by a certified institution” | |
Economic incentives for professionals (+b) | “If I personally had to implement a mHealth tool as complementary to my face-to-face visits and charge each visit by 2 euros more, I would think about it”; “I would rather offer training incentives to professionals as economic incentives in the public sector are not always realistic.” | |
Support and promotion of mobile health by colleagues (++c) | “All stakeholders should participate in the design of the mHealth tools (usability, acceptability, feasibility).” | |
Training (+++) | “Offer continuous training...Create awareness and empowerment of patient and professional before mHealth implementation.” | |
Management: Strategic plan to implement mobile health (+++) | “It’s a top-down approach...Leaders have to believe in innovation and push for its implementation.” |
a+++: Very frequently mentioned (≥4 times).
b+: Only occasionally mentioned, sometimes a debate was opened because of contradictory opinions (mentioned 1 time, or 2 contradictory opinions).
c++: Frequently mentioned (2-3 times).
Regarding barriers, the most recurrent themes pertained to the
Young health professionals have more digital minds...Instead, for many professionals who are older in age, the handling of the Internet and other ICTs may seem complex and they prefer to do things in the traditional manner -paper-and-pencil methods
However, others thought the opposite:
In my institution, older professionals do not have more negative attitudes towards ICTs than younger ones, neither do they perceive differently their utility and usefulness
In relation to the risk-benefit balance, some professionals believed that the fear of losing face-to-face contact with patients was a reality difficult to overcome (eg,
New technologies cannot be implanted unilaterally by the IT team. Health professionals are those who really know what patients need. There has to be an alignment of needs between IT team, patients, and health professionals
Finally, security and privacy concerns, as well as design and technical issues, all of which related to
Moreover, the option to offer economic incentives to professionals (eg,
First, as regards patients’ scores on the 2 self-report questionnaires administered after the group interview, the mean of the total CSQ-8 scale for the 9 patients was 16 (SD 4.69; Range=11-22), whereas the mean score for the SUS scale was 81.56 (SD 22.52; Range=27.50-100). This indicated moderate usability of and high satisfaction of patients with the tool.
Perceived advantages of the TCApp by patients.
Domain and Key themes | Patients who agree with example statements (N=9), n | Examples of patients´ statements | |
Perceived ease of use | 9 | “At the beginning I needed some instructions and guidance but then it was very easy to use.” | |
Perceived usefulness | 8 | “Paper food records are a source of discomfort because they can be lost or forgotten at home while online records are comfortable and useful”; “The option of taking photos of your meals and send them to your therapist was very useful”; “I would recommend the app to a friend with a similar problem.” | |
Design: App | 9 | “I found the online platform very attractive”; “I liked the colours and the personalized avatar.” | |
Satisfaction with content available: Motivational components | 2 | “I liked the option that we had to receive rewards a lot...I was looking forward to receiving prizes depending on my weekly performance and to comparing my ranking with others.” | |
Content appropriate for users (relevance) | 6 | “The app facilitated a better understanding of the contextual variables that surrounded my eating behavior...I am now more aware of what happens before, during and after the problematic behavior I would like to change...more than I used to be with paper records”; “It is a good company during your treatment process, especially when you feel lonely or with the urge to carry out a problematic behavior...The option to share your thoughts, emotions or actions and be sure that your therapist is going to read them, relieves stress and guilt.” |
Perceived disadvantages of the TCApp by patients.
Domain and Key themes | Patients who agree with example statements (N=9), n | Examples of patients´ statements | |
Privacy and anonymity concerns | 1 | “Sometimes I did not know who was going to read my messages, something that stopped me from using the chat option.” | |
Negative perception of usefulness | 2 | “It is not always useful to keep track of your problematic behavior and quantify it...I would have liked it more if the app had offered a free text option next to each question asking for the presence and frequency of several symptoms (vomiting, restriction, intensive exercise, laxative use, etc.) so that we could have the opportunity to write further explanations or observations of our behaviors.” | |
Problems with the design: App | 9 | “There was a word limit when I was using the chat, I could not finish my messages so I was sending them incomplete to my online therapist or split into 2 or 3 different messages”; “There was a 24-hour limit in the app; this means that you could not register your activity after 24.00 PM...that appeared as activity of the following day”; “I would prefer if the app collected information retrospectively, meaning that the day after you register what you did the day before. By doing so, you can gain a better insight of your behavior”; “It would have been nicer to change the design of the chat (each message as a new e-mail in your inbox) and make it similar to the chat of Facebook or Whatsapp, in order to see the whole history of conversations with your therapist or be able to see when he/she reads your messages, etc.” | |
Content inappropriate for users | 3 | “Patients receiving intensive treatment, i.e. day hospital, have enough of support and don’t want more monitoring of their symptoms. The content of the app is not appropriate for their needs. Then, as regards outpatients, when they are asked to complete self-records daily, they feel as if they retrocede in their treatment process. The app is not useful for them either”; “I think the app can be more appropriate for patients at their early treatment stages, when they are expected to gain awareness of their ED-related behaviors.” | |
Lack of satisfaction with content available: Lack of personalization | 9 | “It would have been better to personalize the app according to ED diagnosis, type of treatment that each patient is receiving and also treatment stage.” | |
Patient and therapist limited and not-personalized interaction | 3 | “The professional who was following me online was not the same with the one with whom a had face-to-face sessions...Sometimes I perceived a lack of understanding of my problems by my online therapist”; “Sometimes it took him/her a lot to answer to my online messages and when I finally received an answer, this was no longer useful to me”; “I would like to receive more immediate and personalized answers to my messages.” | |
Study design: Strict instructions | 1 | “There was a lot of pressure by researchers to use the app once a day, even if it was not always necessary.” | |
Negative benefit-risk balance | 1 | “It was easier for me to lie through the online records compared to the paper self-records...The app is more private, nobody (referring to her parents) has access to your records.” |
As regards patients’ perceptions about
It is a good company during your treatment process, especially when you feel lonely or with the urge to carry out a problematic behavior. The option to share your thoughts, emotions or actions, and be sure that your therapist is going to read them, relieves stress and guilt
On the other hand, negative comments (3 out of 9 patients) included the inability of the app to satisfy treatment needs of day-hospital patients and outpatients (see patients’ examples in
Perceived advantages of the TCApp by eating disorder specialists.
Domain and Key themes | ED specialists who agree with example statements (N=8), n | Examples of ED specialists’ statements | |
Perceived ease of use | 8 | “The platform (for professionals) is easy to use, very practical, quick and intuitive”; “Patients found it (TCApp) easy to use, simple, and they learned fast how to use its different functionalities. They have never asked for more explanations than those given at the beginning." | |
Perceived usefulness | 8 | “I value the immediacy of the instrument and the ability to advance visits when things were not going well a lot...I believe that the app can be a good tool for therapists. They can have information prior to their face-to-face visits.”; “The app facilitates our clinical practice a lot...The whole team feels more reassured with regard to each patient´s treatment”; “I value the possibility to give patients quick and valuable information (mostly resolve their doubts) during the time in between their regular sessions or advance visits, when there is something worrying in their records or messages...By doing so, we can also reduce the amount of visits of our patients to the emergency department”; “The online chat provides very valuable information as it facilitates contact with patients in-between sessions. However, it does require more time to explore and exploit the potential of these messages and how to use the information provided by each patient in face-to-face sessions.” | |
Design: Platform | 8 | “The platform is attractive and does not overload visually”; “The possibility to receive photographs of the patients’ meals is great!! I like how the food records described with words appear in the same screen next to the meal photographs.” |
Perceived disadvantages of the TCApp by eating disorder specialists.
Domain and Key themes | ED specialists who agree with example statements (N=8), n | Examples of ED specialists´ statements | |
Problems with the design: Platform | 8 | “A different new screen was opened for each of my patients...It was difficult for me to follow several patients at the same time.” | |
Technical problems | 1 | “In some cases, the application stopped working; this meant a lot of extra work without getting good results. Surely it depended on a user‘s smartphone model (Chinese), or it occurred due to the fact that they had downloaded another application that was interfering with the use of the TCApp.” | |
Lack of satisfaction with content available I: Inappropriate motivational components | 2 | “I would modify all content (she refers to the option offered to patients by the app to receive prizes and rewards according to their performance). Many patients with AN profile are stressed when receiving prizes; they want to be first in the list, corresponding to their high levels of perfectionism and competitiveness. It can be counterproductive for these patients”; “My patients decided not to share the awards received through social networks for confidentiality issues. They wanted to keep everything inside the application and not get out of this environment.” | |
Lack of satisfaction with content available II: Lack of personalization | 8 | “The app should be personalised according to patients’ clinical characteristics...for example, severe patients who presented a lack of consistency in their treatment in general, showed the same with the app”; “You cannot use the same instructions concerning the frequency of use of the app (once a day) for all patients. You should assess before whether this frequency is beneficial for them or not, according to the treatment stage, specific diagnosis, and other clinical characteristics of your patients”;“We should try to accommodate the therapeutic objectives offered by the app to the patient’s profile.” | |
Lack of satisfaction with content available III: Monotonous activity | 1 | “Patients’ online activity was monotonous...for example, emotions experienced during the day were static...a specific emotion felt at a specific moment during the day cannot represent the emotional status of the patient for the entire day...Some further specifications may be added, for example, next to each emotion, an objective for the following week or a further explanation of the context around emotions and their function could be provided, in order to make emotion records more motivating for them.” | |
Lack of satisfaction with content available IV: App was not interactive | 3 | “The app was not dynamic and interactive enough and its functionalities depended on the initiative demonstrated by the patient. Therefore, at times, when patients were feeling worse, they had no initiative to interact actively with the app and thus, they did not use it at all”; “The use of the app depended exclusively on each patient. For the most resistant and difficult patients, we had to follow-up a lot and remind them during sessions that they had to use the app regularly.” | |
Lack of appropriate collaboration among colleagues | 1 | “Lack of coordination among different health professionals participating in the study. Sometimes it was not clear who was doing what.” | |
Study design: Strict instructions | 1 | “Some of my patients felt frustrated and under pressure with the fact that they had to use the app at least once a day.” | |
Economic resources available | 2 | “In private institutions (ie, Dexeus), sometimes patients are willing to replace face-to-face sessions with their therapist with the chat option offered by the app There are economic reasons behind this...I think that in private hospitals, the app should be used differently; you cannot force a patient to have extra visits if you consider it important, as you would do in a public hospital”; “The implementation of the app in private practice is easier...You can charge each visit 2 euros more, for example, and offer patients complementary treatment with the app...In public hospitals this option does not exist at the moment, as there is a lack of budget and of direct interest in mHealth.” | |
Lack of time and workload | 6 | “Due to workload or need to attend emergencies and other priorities, sometimes patient monitoring through the app was postponed”; “Unfortunately, sometimes the symptom monitoring was not regular and constant (by us), as initially agreed when we were given the study protocol.” |
All of the clinicians reported that the TCApp was helpful in their treatment, and all preferred this method to keeping paper records. In terms of
The app facilitates our clinical practice a lot...The whole team feels more reassured with regard to each patient´s treatment.
The
The most frequently reported disadvantages of the app concerned (1) the lack of personalization of the app, (2) some problems with the design of the platform, and (3) the lack of time to regularly monitor patients because of workload. First, regarding the
The use of the app depended exclusively on each patient. For the most resistant and difficult patients, we had to follow-up a lot and remind them during sessions that they had to use the app regularly.
Contradictory opinions existed regarding whether the app would be more easily implemented in private institutions or public institutions. The fear of replacing face-to-face sessions by the chat option, which is of course less costly, was expressed by a therapist working in the private sector. Another therapist from a public hospital said that the implementation of the app should be easier in private practice, as there are more economic recourses available for the integration of a complementary service that includes the TCApp. The
I would modify all their content...Many patients with AN profile are stressed when receiving prizes; they want to be first in the list, corresponding to their high levels of perfectionism and competitiveness. It can be counterproductive for these patients.
Finally, other disadvantages related to mHealth characteristics and the organizational and human environment shown in
Personalize the app according to patients’ needs and specific characteristics.
Offer retrospective record keeping of the problematic behavior, in conjunction with real-time records. For example, a therapist commented on this saying the following:
Some of my patients would have preferred it if they had had the opportunity to register a problematic behavior (restriction, vomit, binge...) the day after its occurrence. Many of the patients from the control group that normally used paper records filled the record the day after the event or when they were feeling calmer or more distanced from the problematic behavior.
Adapt the TCApp to nutritionists’ needs. A therapist said the following:
I think the use of the app could be more appropriate for nutritionists and not for psychologists...an additional functionality assessing the caloric content of the meal records may be an option.
Add psychoeducational material and relaxation or mindfulness techniques in the form of modules that would be activated according to patients’ profile and evolution. Improve the gamified environment to make the app more interactive and motivating, for example, by including vodcasts with motivational messages by recovered patients or messages by therapists, personalized reminders, objectives, or coping strategies close to each problematic behavior.
Emerging literature on the field has shown that app-based treatment suggests promising results for enhancing the quality of mental health provision and treatment outcomes, whereas, at the same time, it can improve engagement with respect to different mental disorders, including depression, anxiety, stress, substance use, and symptoms of EDs [
The results showed that in the focus groups with health care providers and mHealth experts, most of the recurrent themes were classified as barriers, less so as facilitators, for mHealth adoption. This indicates that most professionals considered mHealth techniques as difficult to obtain and use. In addition, most barriers were attributed to external factors relating to the human or organizational environment rather than internal factors relating to individual, personal obstacles. More specifically, most health professionals reported a lack of time because of workload, a lack of strategic plan by leaders, lack of budget, and direct interest at a legislative or political level to support the implementation of mHealth. Other external barriers, which were less frequently reported, concerned the lack of specific ICT training for health professionals and the lack of communication and support among patients, health professionals, and information technology teams. In addition, individual factors, including the age-related digital divide and the fear of losing face-to-face contact with patients, generated contradictory opinions among professionals. These findings are in line with previous studies [
The results of the mHealth intervention study indicate that the TCApp was considered easy to use and useful, although patients and ED specialists monitoring patients on the Web reported different problems in adoption. Patients valued as highly positive the Web-based food records and the role these played in helping them gain a better understanding of their symptoms. In contrast, the problems reported most frequently concerned the lack of personalization of the app according to their needs (eg, diagnosis, type, and stage of treatment), as well as the overwhelming quantification of symptoms through the app (eg, presence or absence options) instead of a more qualitative evaluation of them on the basis of cognitive-behavioral chain analyses through Web-based free-text options. Similarly, a previous qualitative study with focus groups by Juarascio and colleagues [
In turn, ED specialists in this study highly appreciated the Web-based environment that was offered through the TCApp, especially the Web-based chat option, the usefulness of the tool outside and inside the therapeutic context, its immediacy, and the possibility to prepare for visits in advance when they felt this to be necessary. This partly runs counter to results found in the short message service text messaging intervention by Mazzeo and colleagues [
Both patients and health professionals of the mHealth intervention study experienced problems in complying with the study protocol at times. One of the reasons for this was the fact that patients, mostly those who were already receiving a demanding treatment at their hospital (day hospital), felt overloaded with the Web-based tasks that they had to perform on a daily basis. Another problem was that ED specialists, mostly those working in public hospitals, because of their workload or having to attend to emergencies and other priorities, tended to not give immediate responses to their patients’ Web-based messages. In fact, such responses were sometimes provided by other professionals who were available at that particular point in time, raising privacy and confidentiality issues with their patients. This somewhat contradicts the results found in the systematic review by Dowling and Rickwood [
One of the main strengths of this study is that we investigated how both health professionals and patients experience mHealth techniques, as well as what they consider important factors that need improving to use such techniques more frequently. Second, we focused this study on a heterogeneous sample of health care providers and mHealth experts who deal with health-related problems on a daily basis and who could benefit from mHealth techniques extensively. Selecting a group of professionals with such diverse backgrounds, we were able to obtain more generic views of mHealth adoption issues. In addition, by focusing on a specific mental health problem, ED, we were able to examine attitudes and ramifications of both patients and ED specialists regarding the implementation of a specific mHealth tool in their daily practice. As a result, we were able to gather a broad view of mHealth adoption issues among public and private health institutions in Spain for this type of condition.
The first limitation of this study is that there seemed to be a notable homogeneity among our sample of patients in terms of clinical representation, age, and gender. In fact, only female outpatients with AN decided to participate in the focus group, all of whom were adolescents and presented good adherence to face-to-face treatment (this can be also noticed by taking a look at the almost normal BMI of the participants). The impact of the exclusively AN sample on our findings may be that this group of patients, characterized by rigidity, compulsivity, and focus on detail [
In terms of future recommendations, all organizational, technological, and individual levels mentioned appear important for a correct mHealth implementation in clinical practice. For the individual aspect, hospitals may need to provide incentives and continuous training to encourage professionals to integrate mHealth techniques when carrying out their regular tasks. If professionals feel more empowered, skilled, and supported by their institution in adopting new technologies, they should be more willing to make use of the opportunity to try new innovations.
At an organizational level, there is a need for a strategic plan that establishes a common framework for evaluating mobile mental health apps, which allows clinicians and patients (and importantly, not only information technology teams) to identify and choose among high quality and safe mobile phone apps in accordance with their needs. Although a great number of mental health apps are readily available, and there seems to be a major potential for such apps in psychiatric assessment and interventions [
As regards mHealth characteristics, ED specialists recommended that the TCapp should be better personalized according to a patient’s clinical profile and that its gamified environment should be improved by integrating more useful motivational and interactive components. It was suggested that doing so would lead to improvements in engagement for the most difficult patients. A relapse prevention module should also be integrated into the TCApp for almost recovered patients who generally receive less regular visits to the hospital and who could benefit from some functionalities of the app (ie, online chat, symptoms monitoring). Other ideas for future improvement included the possibility to adapt the TCApp to nutritionists’ needs, add psychoeducational material, add relaxation or mindfulness techniques, and add a group chat functionality with a therapist who coordinates the group conversation. Last but not least, taking into account that family therapy for children and young people is the gold-standard treatment for AN [
In sum, this study shows that health professionals and patients foresee some issues that need to be resolved to increase adoption and usage of mHealth techniques in the near future. Owing to the possible benefits and cost-saving opportunities of mHealth techniques in health care [
Associació Catalana d‘Entitats de Salut
anorexia nervosa
body mass index
bulimia nervosa
cognitive behavioral therapy
Colegio Oficial de Médicos de Barcelona
Client Satisfaction Questionnaire
eating disorder
information and communication technology
Model for ASessment of mHealth
mobile health
randomized controlled trial
System Usability Scale
Universitat Oberta de Catalunya
The research leading to these results has received funding from RecerCaixa. The authors would like to thank Thjb Lubbers for his help with the English editing of the manuscript.
None declared.