JMU JMIR Mhealth Uhealth JMIR mHealth and uHealth 2291-5222 JMIR Publications Toronto, Canada v11i1e45162 37351947 10.2196/45162 Review Review Influencing Factors to mHealth Uptake With Indigenous Populations: Qualitative Systematic Review Buis Lorraine Nair Uthara Camp Pat Al Al Goodman Andrew AdvDip 1
School of Public Health The University of Queensland 266 Herston Road Turrbal, Jagera Country, Herston, 4006 Australia 61 733655442 61 733655393 Andrew.Goodman@csiro.au
2 https://orcid.org/0000-0002-0385-1084 Mahoney Ray PhD 3 https://orcid.org/0000-0002-6183-4071 Spurling Geoffrey MBBS, PhD 4 https://orcid.org/0000-0002-3525-4663 Lawler Sheleigh PhD 1 https://orcid.org/0000-0002-5771-0551 School of Public Health The University of Queensland Turrbal, Jagera Country, Herston Australia Australian eHealth Research Centre (AEHRC) Commonwealth Scientific and Industrial Research Organisation (CSIRO) Turrbal, Jagera Country, Herston Australia College of Medicine and Public Health Flinders University Kaurna Country, Adelaide Australia General Practice Clinical Unit The University of Queensland Turrbal, Jagera Country, Herston Australia Corresponding Author: Andrew Goodman Andrew.Goodman@csiro.au 2023 23 6 2023 11 e45162 18 12 2022 8 2 2023 7 3 2023 21 4 2023 ©Andrew Goodman, Ray Mahoney, Geoffrey Spurling, Sheleigh Lawler. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 23.06.2023. 2023

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 Background

The advancements and abundance of mobile phones and portable health devices have created an opportunity to use mobile health (mHealth) for population health systems. There is increasing evidence for the feasibility and acceptance of mHealth with Indigenous populations. Providing a synthesis of qualitative findings of mHealth with Indigenous populations will gain insights into the strengths and challenges to mHealth use in Indigenous populations.

 Objective

This review aimed to identify and synthesize qualitative data pertaining to the experiences and perceptions of mHealth from the perspectives of end users (patients and service providers) living in the colonial settler democracies of Canada, Australia, New Zealand, the United States, the Pacific Islands, and the Sápmi region of northern Europe.

 Methods

In May 2021, systematic searches of peer-reviewed, scientific papers were conducted across the 5 databases of PubMed, CINAHL, Embase, PsycINFO, and Web of Science. Qualitative or mixed method studies were included where a mHealth intervention was the primary focus for responding to health challenges with Indigenous populations. Two authors independently screened papers for eligibility and assessed the risk of bias using a modified version of the Critical Appraisal Skills Programme. A meta-aggregative approach was used to analyze the findings of included studies.

 Results

Seventeen papers met the eligibility criteria, 8 studies with patients, 7 studies with service providers, and 2 studies that included both patients and service providers. Studies were conducted in Australia (n=10), Canada (n=2), New Zealand (n=2), Papua New Guinea (n=1), the United States (n=1), and Samoa (n=1). Our interpretation of these qualitative findings shows commonalities between Indigenous patients’ and service providers’ perceptions of mHealth. We summarize our findings in six themes: (1) mHealth literacy, (2) mHealth as a facilitator for connection and support, (3) mHealth content needed to be culturally relevant, (4) mHealth security and confidentiality, (5) mHealth supporting rather than replacing service providers, and (6) workplace and organizational capacity.

 Conclusions

This research suggests that mHealth can meet the needs of both patients and service providers when the mHealth intervention is culturally relevant, accounts for digital and health literacy, incorporates interactive components, is supported by workplaces, fits into health provider workflows, and meets security and confidentiality standards. Future mHealth research with Indigenous populations should partner with key representatives (eg, patients, service providers, and executive leaders) in the mHealth design appropriate to the purpose, people, setting, and delivery.

 mHealth Indigenous Canada Australia New Zealand United States Papua New Guinea Samoa qualitative systematic review feasibility acceptability users design workflow Introduction

The technological advancements and abundance of mobile phones and portable health devices have created a plethora of mobile health (mHealth) tools. mHealth is defined as “the use of mobile devices—such as mobile phones, patient monitoring devices, personal digital assistants and wireless devices—for medical and public health practice” [1]. These include mobile phone apps, text messages, portable monitoring devices and electronic patient information.

Systematic reviews globally have suggested mHealth is a broadly feasible and effective resource for a range of health conditions including; behavior change [2,3], noncommunicable disease management [4-9], perinatal care [10,11] medication adherence [12], and mental health well-being [13,14]. Likewise, health care workers suggest mHealth improves patient health outcomes and increases peer communication and care coordination [15,16].

There is a growing number of qualitative studies exploring the views and perceptions of mHealth from 2005 onward, resulting in a number of qualitative systematic reviews [16-21]. Findings from these reviews provide a collective insight into user perceptions and experience of mHealth to influence future research and implementation. These systematic reviews predominantly focus on non-Indigenous populations and fail to explore the user experiences of Indigenous people and their service providers. We need to ensure a space is kept privileging Indigenous worldviews as it pertains to mHealth. mHealth interventions are being explored with Indigenous populations with increasing interest [22-24]. Reviews examining the applicability of mHealth for Indigenous populations exist, and these indicate it is an acceptable health resource [23,24]. Yet, these reviews include qualitative data as only a peripheral focus and are inconsistent with the intervention type [23], and outcomes [24].

Providing a synthesis of qualitative findings of mHealth with Indigenous populations will gain insights to the strengths and challenges to mHealth use in Indigenous populations. This review aimed to identify and synthesize qualitative data pertaining to the experiences and perceptions of mHealth with Indigenous populations and the service providers that work with Indigenous populations.

 Methods Overview

A systematic search was conducted of peer-reviewed literature for this qualitative synthesis. A protocol of this qualitative synthesis was registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42021251861). We extracted qualitative data pertaining to the experiences and perceptions of both patients (Indigenous peoples) and service providers (either Indigenous or non-Indigenous health policy makers, health care professionals, and researchers) who work with Indigenous peoples from Canada, Australia, New Zealand, the United States, the Pacific Islands, and the Sápmi region of northern Europe. We define Indigenous Peoples as “distinct social and cultural groups that share collective ancestral ties to the lands and natural resources where they live, occupy or from which they have been displaced” [25].

 Search Strategy and Selection Criteria

A comprehensive list of search terms and strings were developed with the assistance of a librarian with expertise in systematic reviews. Systematic searches of peer-reviewed, scientific papers in English were conducted across 5 databases in May 2021: PubMed, CINAHL, Embase, PsycINFO, and Web of Science. Qualitative or mixed method studies were included where a mHealth intervention was the primary focus for responding to health challenges with Indigenous populations. As such, experimental and quasi-experimental studies were considered, as long as they met the following inclusion criteria:

Participants: Indigenous people of all ages from Canada, Australia, New Zealand, United States, the Pacific Islands, the Sápmi region of northern Europe; OR are service providers (either Indigenous or non-Indigenous) who work with Indigenous persons from Canada, Australia, New Zealand, the United States, the Pacific Islands, the Sápmi region of northern Europe; OR where participants are multicultural, outcomes for Indigenous persons are reported specifically.

Interventions: primary focus was a mHealth intervention delivered using a wireless device (eg, mobile or tablet app, website designed for mobile, messaging [SMS, voice, multimedia messaging system, etc]). The mHealth intervention aims to address a health challenge (eg, diagnosis of disease, substance use, health behaviors, quality of life, health knowledge, self-efficacy, caregiver support, etc).

Outcomes: studies reported on one or more outcomes including user; experiences, perceptions, barriers, and enablers via qualitative research methods (eg, interviews and focus groups).

A sample of the search strings using text words and subject heading keywords for PubMed can be found in Multimedia Appendix 1. The use of proximity operators, truncation, and phrase searching was used to widen the search to capture all iterations of both the mHealth and Indigenous themes. The 2 search strings were then combined to narrow the results—enabling discovery of all possible scientific papers, which capture mHealth interventions with Indigenous populations from Canada, Australia, New Zealand, the United States, the Pacific Islands, and the Sápmi region of northern Europe. The qualitative papers were then identified via screening by 2 researchers (AG and SL).

 Data Extraction and Quality Appraisal

Initial database searches and duplicate removal were conducted by 1 author (AG). Screening, review, and extraction were assisted by the web-based systematic review program Covidence (Veritas Health Innovation) [26]. Two authors (AG and SL) independently screened titles and abstracts against the inclusion criteria, and papers clearly not meeting the inclusion criteria were excluded.

Subsequently, 2 authors (AG and SL) screened the full-text papers independently and then discussed for comparison. Any differing views were resolved through discussion. Manual searches of reference lists were conducted on full-text papers included in the review. A final list of full-text papers and their citations which met inclusion criteria were downloaded and saved using Covidence software.

The quality of the included studies was appraised using a modified version of the Critical Appraisal Skills Programme (CASP) qualitative checklist [27]. An additional question from the Joanna Briggs Institute (JBI) was added that related to locating the researchers cultural or theoretical standpoint [28], improving the cultural rigor of this critical appraisal tool.

 Data Analysis and Synthesis

The data included in the analysis were all text included in the “Results” or “Findings” sections of the papers (excluding purely quantitative findings) and was extracted from the papers into NVivo 12 Plus software (QSR International) [29]. Characteristics of each study to be extracted for descriptive purposes included: Indigenous identification, study location (country), year, sample size, participant demographic characteristics (age, gender), data collection, and analysis methods.

A meta-aggregative approach was used to analyze the findings [30]. This analysis approach privileges the findings, presented as “themes” or “constructs” in qualitative research, as identified by the researchers (not the reviewer). This method helps ensure the expanse and breadth of cultural learnings identified by researchers conducting the original studies are not lost by the reviewers.

 Results Overview

From database searches, 2608 unique papers were identified; 2 additional papers were located by manual searches. In total, 2610 titles and abstracts were reviewed against the inclusion criteria, of which 2548 were excluded, leaving 62 papers for full-text review. Following the full-text review, 45 papers were excluded, leaving 17 studies included in this qualitative systematic review (Figure 1).

Preferred reporting items for systematic reviews and meta-analyses flow diagram of study selection.

 Description of Included Studies

All 17 studies included in this review were published between 2013 and 2021. Eight were studies specifically with Indigenous patients [31-38]. Seven studies were with service providers (either Indigenous or non-Indigenous) who work with Indigenous peoples [39-45]. Two studies involved both patients and service providers in data collection [46,47], so findings were considered for both.

Characteristics of the 17 studies are shown in Table 1. Ten papers involved Aboriginal and Torres Strait Islander peoples of Australia [31,36-38,40,42,44-47], 2 with the First Nations, Inuit, or Métis peoples of Canada [34,39], 2 with the Māori peoples of Aotearoa, New Zealand [33,35], 1 paper with the Indigenous peoples of Papua New Guinea [43], 1 paper with the Native Hawaiian and Pacific Islander peoples of Hawaii, the United States [41], and 1 paper with the Indigenous peoples of Samoa [48]. We were unable to identify any papers with Indigenous people of the Sápmi region of northern Europe that met the review criteria.

Characteristics of included studies.

Studies Indigenous peoples (country) Focus area of intervention Type of mHealtha delivery Participants (roles) Method CATb [27,28]
Indigenous patients
Kennedy et al [38] Aboriginal and Torres Strait Islander (Australia) Perinatal health care Appc 8 Indigenous patients Interviewsd 10
Tighe et al [37] Aboriginal and Torres Strait Islander (Australia) Suicide prevention Appe 13 Indigenous patients Interviewsd,f 8
Jongbloed et al [34] First Nations, Inuit, and Métis (Canada) Illicit drug use mHealth broad concept 130 Indigenous patients Questionnaireg 6
Peiris et al [36] Aboriginal and Torres Strait Islander (Australia) Smoking cessation Appe 15 Indigenous patients Interviewsh 8
Gasteiger et al [35] Māori (New Zealand) Pregnancy or perinatal health care mHealth broad concept Nine Indigenous patients Interviewsd,f,i 11
Te Morenga et al [33] Māori (New Zealand) Healthy lifestyle mHealth broad concept 21 Indigenous patients Focus group and “bus stop activity”d,i 9
McCool et al [48] Samoa Smoking cessation Text message 36 Indigenous patients Focus groupd,f 9
Povey et al [31] Aboriginal and Torres Strait Islander (Australia) Mental health well-being and suicide prevention Appe 9 Indigenous patients Focus grouph 10
Service providers
Akearok et al [39] Inuit (Canada) Social determinants view of health Appe 5 (health service recruitment and education staff) Interviews and surveyj 3
Raphiphatthana et al [42] Aboriginal and Torres Strait Islander (Australia) Mental health well-being Appe 57 (nurses, support workers, Indigenous health workers, psychologists, and alcohol and other drug workers) Interviewsd,h 10
Macniven et al [45] Aboriginal and Torres Strait Islander (Australia) Cardiovascular ECG attached to a mobile phone (iECG) 18 (Indigenous health workers, registered nurses) Interviewsd,f 10
Bennett-Levy et al [44] Aboriginal and Torres Strait Islander (Australia) Mental health well-being Appe 28 (consultant trainers, youth workers, Indigenous service workers, drug and alcohol worker, family development worker, well-being coordinator, Aboriginal health education officer, mental health support worker, and healthy lifestyle worker) Interviews and field notesd 9
Yazdanshenas et al [41] Native Hawaiian and Pacific Islander (United States) Hypertension Text message 20 (executive leader, church leader, community advocate, and health care providers) Interviewsh 7
Dingwall et al [40] Aboriginal and Torres Strait Islander (Australia) Mental health well-being Appe 15 (health professionals, managers, program coordinators, and an Aboriginal elder) Interviewsd 10
Kurumop et al [43] Papua New Guinea Malaria SMS Text message 17 (health workers) Focus grouph 9
Both Indigenous patients and service providers
Brown et al [46] Aboriginal and Torres Strait Islander (Australia) Mental health well-being mHealth broad concept 12 (8 Indigenous health workers, 4 Indigenous patients). Focus grouph,k 11
Houston et al [47] Aboriginal and Torres Strait Islander (Australia) Perinatal health care or parenting Appe and website 31 (21 administration staff, pediatricians, child health nurses, general practitioners, and Indigenous health workers; 10 Indigenous patients) Interviews and focus groupd 8

amHealth: mobile health.

bCAT: critical appraisal tool, maximum score is 11.

cmHealth interactive: integrated app used for access to health information or personal monitoring of health determinates that allows for information exchange (eg, peers and service providers).

dThematic analysis.

emHealth personal: autonomous app used for access to health information or personal monitoring of health determinates with no interactive capabilities.

fInductive analysis.

gRapid qualitative analysis.

hHybrid approach to qualitative analysis.

iKaupapa Maori approach.

jNarrative approach to qualitative analysis.

kYarning approach.

 Thematic Synthesis Overview

Our interpretation of these qualitative findings shows commonalities between Indigenous patients and service providers perceptions of mHealth. We have collectively termed both as “end users” hereafter unless explicitly stated otherwise. Common themes across end users were: the importance of mHealth or digital literacy, mHealth as a facilitator for connection and support, mHealth content that needed to be culturally relevant, and data security and confidentiality. Two themes emerged that were unique to service providers including the importance of mHealth supporting rather than replacing service providers, and the role of workplace champions and organizational capacity for influencing uptake and sustainability of mHealth.

 mHealth Literacy

Access to the required hardware (mobile or smartphones and touch screen tablets) and systems (network coverage and IT) was identified as an important influence to mHealth uptake by end users. Service providers noted barriers to accessing the mHealth hardware and systems with reasons including regionality and workplace restrictions [40,42,43,45,46]. Service providers held a perception that mobile phones were not prevalent or accessible to patients due to cost [46] and remote location [42]. However, Indigenous patients saw themselves as competent and confident users of technology and mobile phones for everyday life [31,33-38,46,47]. Yet, technology difficulties and lack of device access were still raised in several studies [31,34-36,46,47]. Some studies noted concerns end users had relating to the digital literacy required for mHealth [40,42,44].

Low levels of IT literacy pose a challenge to electronic mental health adoption. Unfamiliarity with different ways of using technologies impedes the utilization of the approach by both service providers and community members. Poor IT literacy within communities was attributed to limited access to technology…

42

Limited confidence in using new technology such as mHealth initiatives was identified as a barrier to uptake for service providers [40,44]. The investment of time and effort into appropriate mHealth training and ongoing support was suggested as a mitigation strategy for technical difficulties for end users [36,40].

Age and generational implications were raised as influential factors to the uptake of mHealth. Whether implicitly or explicitly, end users perceived mHealth would be more applicable and accepted by younger people [31,33,40-42,44,46]. Service providers perceived that older people have limited or no access to mobile phones and thus would have lower digital literacy [40,41,46]. Interestingly, these age-related barriers were not reflected by Indigenous patients in this Australian study.

Most older interviewees did not appear to have any major issues with knowledge on how to access phone features.

36

End users noted the importance of mHealth resources easy to understand and use for a confident user experience. A notable motivation for service providers to use a mHealth resource was for it to be uncomplicated and easy to use [39,40,45-47]. Likewise, Indigenous patients advised that if mHealth platforms were complex, slow, or used too much data, uptake and sustained use was less likely [31,33,35,38,46]. The importance of clear and concise language and the avoidance of jargon in mHealth messaging was noted to encourage comprehension for end users [31,37,38,41,43,47,48]. Service providers stated the importance of mHealth content being appropriate to the learning styles, health knowledge, and communication styles of their patients [39-41,43,44,46,47]. Indigenous patients were enthusiastic about the potential benefits mHealth provided in accessing relevant information for their health journey [33-35,37,38,46-48].

Participants spoke of parents being technologically savvy, and parents referred to accessing apps, YouTube clips, social media and the internet from their mobile phones for infant feeding information and support prior to the Growing healthy program.

47

The incorporation of visual and audio capabilities was suggested by end users to create a better understanding of the content [31,35-41,44,46-48]. mHealth may provide an appropriate tool to bridge health knowledge gaps [42] and enable education and empowerment for health care.

Several interviewees described how the iECG device provided unique opportunities to engage patients in education around AF and their heart, and to empower patients to find out more about their heart health.

45 mHealth as a Facilitator for Connection and Support

End users found mHealth an appropriate resource to facilitate engagement, connection, and support within health care systems. Indigenous patients appreciate that mHealth facilitated connection to support people, along with health care providers [31,33-38,47,48]. Likewise, service providers viewed mHealth as important for connection to patients with the added facility to connect with professional colleagues [40-42,46].

mHealth was found to provide a sense of reassurance and encouragement across a range of health journeys for Indigenous patients, including perinatal health [35,47], patients living with mental health challenges [34,37], and people on a smoking cessation journey [36,48]. Indigenous patients suggested mHealth could enable a web-based community to connect with others on similar health journeys [31,33-38,46]. Moreover, Indigenous patients appreciated the capability of mHealth to share health knowledge with family and support people in their lives [33,35,47,48].

Participants valued sharing advice and experience-based information with their families, partners or wider virtual communities, such as Facebook groups.

35

Service providers found that mHealth encouraged trust with patients while creating a collaborative environment with other health staff [40-42,46]. mHealth was found to provide professional peer support [40,46] while streamlining clinical communication and encouraging service provider collaborations [42].

Communication across services working with the same client may help to ensure nonoverlapping of interventions and resources.

42

Australian service providers noted mHealth broke down the barriers of patient engagement, “equalising the power imbalance often present in their relationships with clients” [40]. Service providers attributed this to the app acting as an impartial entity, encouraging person-centered care [40]. First Nations, Inuit, and Métis youth in Canada explained that having a mobile phone would enable them to connect with health professionals as well as on behalf of peers in emergency situations [34]. Youth in Australia found that mHealth provided connection to service providers while adding anonymity and privacy to the navigation of their mental health journey.

Some may have felt known in a small community or simply hesitant to engage a service because they felt uncomfortable. The app allowed them a choice in health care that was previously unavailable.

37 mHealth Content Needed to Be Culturally Relevant

End users stated the importance of mHealth including culturally relevant imagery and language to enable engagement, trust, and relatable connection. The inclusion of culturally relevant language and imagery was important for Indigenous patients to encourage engagement and build trust in mHealth content [31-33,37,38,46,47]. Likewise, service providers suggested the need for culturally applicable imagery and language in mHealth content in several studies [39-41,43,44,46,47]. End users suggested the translation of mHealth content to traditional language would enable comprehension of content as well as increase uptake [31,33,40,43,46].

…participants were keen to engage with apps that included Māori language, tikanga and knowledge.

33

Culturally relevant graphics, voices, animation, and optional short video clips may assist in engagement with the content, improve understanding, and overcome literacy issues.

31

Recommended features of a technology resource included a look and feel that was user-friendly, aesthetically pleasing (e.g., more visuals, Indigenous artwork and potentially Indigenous language for more remote communities), easy to read, quick to navigate, and interactive (e.g., notifications, touch screen, user online status shown).

46

Yet, the acknowledgment of diversity in cultural relevance was an important implication noted by Indigenous patients [31,33,38], namely, the tailoring of dialect [31,38] and that content be appropriate to the local cultural peoples [33], to ensure mHealth is not dismissive of cultural diversity.

Findings suggest mHealth can assist in developing cultural competence through gaining a better understanding of cultural diversity, histories, and traditional languages. In Australia, Indigenous patients advised the importance of including cultural determinants such as colonization, intergenerational trauma, and identity within mHealth content [31,38]. In Aotearoa, New Zealand, Māori patients chose to use traditional terminology in the thematic findings of mHealth exploration, acknowledging the importance of the cultural determinants of health [33,35]. mHealth was found to be an important resource to support culturally competent health care delivery for locum service providers in Canada.

Respondents expressed gratitude that the app now exists as an important tool for use in training and orienting new hires to Nunavut’s cultural and language context.

39 mHealth Security and Confidentiality

Security and privacy consistently emerged with Indigenous patients across several studies with differing views and implications [31,34,35,37,46]. Povey et al [31] found Indigenous patients were largely dismissive of privacy issues with regard to mHealth, noting that personal information held on phones such as photos, or emails being seen would worry them more. There were, however, concerns raised about the privacy and confidentiality of information being shared during group discussions embedded in mHealth [46]. In addition, Māori women felt a sense of intrusion when using their mobile phone to seek health advice [35]. This intrusion was due to third-party systems, not necessarily a mHealth resource.

…emphasised privacy concerns whereby they encountered personalised advertising on Google and Facebook that was based on previous searches done on the device.

35

Importantly, mHealth offered the opportunity of anonymous support for patients wishing not to engage with health services face to face [31,34,37]. Access to their own phone provided a sense of privacy and a safety net for Indigenous patients in Canada [34]. Likewise, Indigenous patients in Australia appreciated the facility of remote support seeking with the avoidance of unwanted in-person contact.

The ability to interact with the app privately, without anyone else needing to be present, meant that youth who may have been reluctant or afraid to speak to family members or health care professionals in a face-to-face setting could still access support.

37 mHealth Supporting Rather Than Replacing Service Providers

Service providers stated the importance of mHealth needing to support established workloads and practices rather than being an onerous addition to established workloads. Service providers raised uncertainties about the sustainability of mHealth, and how their roles and responsibilities may change with the implementation of mHealth [40-42,44,46]. The perceived “lack of fit” with established work practices was a professional barrier identified [40,42,44]. Service providers suggested that mHealth should be considered as a complementary resource in addition to “in person” and physical resources [40,41,46]. Service providers in Australia found mHealth may be more useful for staff lacking experience and confidence in health practice.

Gatekeepers less experienced in suicide prevention may find a resource more useful than more experienced or confident gatekeepers.

46

Service providers saw the benefit of mHealth as an educational tool to develop skills and knowledge. Service providers in Australia liked the health promotion opportunity a smartphone-enabled electrocardiogram (ECG) provided [45]. Service providers in Papua New Guinea valued the guidance capabilities mHealth provided them for clinical malaria treatment procedures [43]. Service providers in Australia identified mHealth as an appropriate resource to gain professional skills and knowledge in interviewing and counseling [40,44]. A smartphone-enabled ECG (ie, iECG) was found to have an indirect educational effect on service providers in Australia.

Some staff also spoke of how using the device for screening led them to want to learn more about AF and cardiovascular disease themselves in their professional role.

45 Workplace and Organizational Capacity

Workplace leadership, capacity, and strategic direction emerged as influencing factors to the uptake and sustainability of mHealth for service providers working with Indigenous populations [39,40,42,44,45].

Workplaces that have leaders and champions to drive and support mHealth were a central factor in enabling mHealth uptake. The presence of enthusiastic managers and eager IT champions had a positive effect on the workforce’s interest in mHealth resources with service providers in Australia [42,44]. Workplace leaders that did not perceive the need for or effectiveness of mHealth were often a barrier to the uptake by service providers [42,44]. The advocacy of mHealth from leadership was an influencing factor to acceptance:

Having leaders within the organization showing interest and providing direct support was perceived to facilitate uptake. It created incentives and provided opportunities for service providers to reflect and evaluate the utility of the electronic mental health approach.

42

Workplace staff capacity and retention contributed to the opportunities service providers had to commit to mHealth implementation [40,42,44]. High turnover of staff contributed to a lack of sustained mHealth knowledge and skill within the workplace [40,42,44]. The significance of investment into continued staff training and development was seen as important for mHealth success [40,42,45]. Limited workload capacity due to underresourcing impeded mHealth delivery [40,42,44] and restricted service providers’ capacity to engage in mHealth.

…in many services, demanding workloads left the workers with little or no opportunity to incorporate new skills into their existing work practices…

44

A workplace culture that supports and drives the use of health innovations was shown to positively impact service providers’ perception of mHealth. The absence of health innovation priorities in workplace strategies caused a sense of ambivalence and ineptness toward the need for mHealth among service providers [39,42,44]. Workplaces that invested in systems, valued innovation, and had supportive leadership, positively influenced service providers’ perception and engagement with mHealth tools [40,42,44]. Alignment of the health innovation with organizational principles was found to influence uptake.

Uptake of electronic mental health approaches was dependent upon the perceived fit of the innovation to the organization’s priorities.

42 Discussion Principal Results

This review found that both Indigenous patients and service providers are enthusiastic about the role that mHealth can play in health service delivery.

Common themes across end users were: importance of mHealth or digital literacy, mHealth as a facilitator for connection and support, mHealth content needed to be culturally relevant, and data security and confidentiality are a priority. Two themes emerged that were unique to service providers: the importance of mHealth supporting rather than replacing service providers and the role of workplace champions and organizational capacity for influencing the uptake and sustainability of mHealth.

In this review, most included studies stated the importance of relevant cultural imagery and language, which enabled greater comprehension of mHealth messaging and increased engagement by end users [31-33,37-41,43,44,46,47]. Cultural content needs to account for the heterogeneity of Indigenous peoples, appropriate to location, language, people, and knowledge systems. This creates a challenge for mHealth developers and researchers alike in having 1 product with the capability to be distributed to a culturally diverse audience. Regarding language, Varnfield et al [49] increased their scope of patient engagement with their mHealth app being “available in several different selected languages.” This demonstrates that mHealth has the potential to be adaptive with its content.

Similar to the included study findings of this review, mHealth has been shown to enable patients to engage with their health care providers more effectively as well as connect with peers on similar health care journeys [21]. Moreover, our findings support other reviews reporting health care providers who found mHealth improved communication between their patients and colleagues [15,16].

Our findings showed the importance of workplaces and their leadership in influencing the uptake of mHealth [39,40,42,44,45]. Likewise, Palacholla et al [50] found leadership and organizations that were supportive and facilitated digital health adoption in clinical settings. An important factor when implementing health service innovation is localized agenda setting being led by need, want, and appropriateness [51]. Within a mHealth context, Gagnon et al [52] found health professionals considered their workplace environment as one of the top contributing factors to adoption. Engaging health care organizations as a partner to support mHealth may offer the greatest opportunity for sustained uptake.

Other systematic reviews conducted to understand the influencing factors to mHealth uptake show a strong correlation with the findings presented here. Namely, the principal influencers for adoption are the mHealth design, personal perceptions of mHealth, and the workplace environment [16,21,52], which suggest that co-design may offer an effective methodology for sustained mHealth uptake with Indigenous populations and service providers that work with Indigenous populations.

Early engagement with the Indigenous community within eHealth research and implementation has shown to offer the greatest opportunity for acceptability, and local advocacy [22,23,53,54]. Moreover, this model of prioritizing community partnership and co-design is recommended by governing ethical guidelines on research with Indigenous peoples internationally to achieve beneficial research outcomes [55-58]. Despite this, Eyles et al [59] found a lack of co-design methods for minority and Indigenous groups internationally in the development of mHealth interventions. With the novelty of mHealth along with the cultural considerations involved in the study population, it would be practical to enter a colearning and cocreation relationship to achieve mutually beneficial outcomes.

In conclusion, there has been considerable growth in qualitative research exploring contextual factors in relation to mHealth uptake in non-Indigenous populations, yet less so for Indigenous populations. To our knowledge, this is the first review of qualitative studies that provides an understanding of the influential factors for both patients and service providers for Indigenous populations in relation to mHealth.

 Strengths, Limitations, and Future Directions

Having 2 reviewers from diverse cultural backgrounds and gender orientations independently screening improved the quality of this meta-synthesis. The authors are a multidisciplinary team with a breadth of expertise in this review focus (psychology, digital health, qualitative research, and Indigenous health). Using a meta-aggregative approach to analyze the findings ensured cultural learnings identified by researchers’ conducting the original studies were not lost by the reviewers. The quality appraisal tool used a modified version of the CASP qualitative checklist, with the additional question locating the researchers’ cultural or theoretical standpoint, improving the cultural rigor of this critical appraisal tool. Most studies were of medium to high quality, and the quality appraisal tool can be found in Multimedia Appendix 2.

Our review has some limitations; first, the searches were restricted to peer-reviewed literature published in 5 databases (PubMed, CINAHL, Embase, PsycINFO, and Web of Science). Second, publication bias may have occurred due to the subjective quantifying of studies reporting on one or more outcomes via qualitative research methods. Finally, the results of this study are based on the meta-synthesis of qualitative data, which is inherently subjective. There are studies included from all countries (except the Sápmi region), but there are still only a few studies in each country, and so more work is needed. Papers need to report not only on patients’ perspective but other end users to gain a full understanding of the perceptions of mHealth in supporting health care with Indigenous populations.

 Conclusions

This review used meta-aggregation to summarize the findings of 17 qualitative studies on the experiences and perceptions of mHealth with Indigenous populations and the service providers that work with Indigenous populations. mHealth end users are enthusiastic about the role that mHealth can play in Indigenous health service delivery. There is a need for mHealth design to center end users within a co-designed approach with Indigenous people. There is recent work driving this agenda in an Australian context [60]. Allowing end users to suggest localized agenda setting through co-design may provide an opportunity for ownership, championship, and mitigation of barriers in mHealth implementation. Future research should partner with key representatives (eg, patients, health care professionals, and executive leaders) in the mHealth design appropriate to the purpose, people, setting, and delivery.

Qualitative systematic review search string example.

CASP tool with additional JBI question.

 Abbreviations CASP

Critical Appraisal Skills Programme

 ECG

electrocardiogramJBI: Joanna Briggs Institute

 mHealth

mobile health

 PROSPERO

International Prospective Register of Systematic Reviews

To ensure a culturally inclusive lens, our authorship reflects a diversity of the background, career stage, gender, and race. Specific to the focus of the manuscript AG and RM are Indigenous, and GS and SL are non-Indigenous. AG is an Aboriginal PhD candidate from Iningai country in Central West Queensland, Australia. AG has spent more than 13 years as an Indigenous health worker in Queensland alongside rural and remote Aboriginal and Torres Strait Islander people in the discipline of cardiac and health care services. RM is Aboriginal, a descendant of the Bidjara people of Central Western Queensland, Australia. RM is an Aboriginal health leader and researcher and has worked extensively to implement best practice cardiovascular care, particularly for Aboriginal and Torres Strait Islander peoples. GS is a General Practitioner at the Inala Indigenous Health Service in Brisbane, Queensland, and a General Practice academic at The University of Queensland. SL is a public health academic, with research interests in broad reach interventions to improve health outcomes in priority populations. We thank The University of Queensland for the support of this review via an Indigenous higher degree by research Development Grant. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had full access to the full data in the study and accept responsibility to submit for publication.

 Data Availability

The search strategy is available in Multimedia Appendix 1. Any additional data are available upon request from the corresponding author.

AG and SL conceptualized the study design, retrieved, analyzed, and interpreted the research data on which the scholarly work is based. AG and SL prepared the manuscript with significant input and critical review from RM and GS. All authors have read and approved the manuscript.

None declared.

 Global difusion of eHealth: making universal health coverage achievable: report of the third global survey on eHealth WHO 2016 2023-05-30 Geneva World Health Organization https://www.who.int/publications/i/item/9789241511780 Free C Phillips G Galli L Watson L Felix L Edwards P Patel V Haines A The effectiveness of mobile-health technology-based health behaviour change or disease management interventions for health care consumers: a systematic review (m-health technology interventions for lay people) PLoS Med 2013 10 1 e1001362 10.1371/journal.pmed.1001362 Payne HE Lister C West JH Bernhardt JM Behavioral functionality of mobile apps in health interventions: a systematic review of the literature JMIR Mhealth Uhealth 2015 3 1 e20 10.2196/mhealth.3335 25803705 v3i1e20 PMC4376122 Hamine S Gerth-Guyette E Faulx D Green BB Ginsburg AS Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review J Med Internet Res 2015 17 2 e52 10.2196/jmir.3951 25803266 v17i2e52 PMC4376208 Whitehead L Seaton P The effectiveness of self-management mobile phone and tablet apps in long-term condition management: a systematic review J Med Internet Res 2016 18 5 e97 10.2196/jmir.4883 27185295 v18i5e97 PMC4886099 Xu H Long H The effect of smartphone app-based interventions for patients with hypertension: systematic review and meta-analysis JMIR Mhealth Uhealth 2020 8 10 e21759 10.2196/21759 33074161 v8i10e21759 PMC7605981 Hamilton SJ Mills B Birch EM Thompson SC Smartphones in the secondary prevention of cardiovascular disease: a systematic review BMC Cardiovasc Disord 2018 18 1 25 10.1186/s12872-018-0764-x 29415680 10.1186/s12872-018-0764-x PMC5803998 Gandhi S Chen S Hong L Sun K Gong E Li C Yan LL Schwalm JD Effect of mobile health interventions on the secondary prevention of cardiovascular disease: systematic review and meta-analysis Can J Cardiol 2017 33 2 219 231 10.1016/j.cjca.2016.08.017 27956043 S0828-282X(16)30931-X Marcolino MS Oliveira JAQ D'Agostino M Ribeiro AL Alkmim MBM Novillo-Ortiz D The impact of mHealth interventions: systematic review of systematic reviews JMIR Mhealth Uhealth 2018 6 1 e23 10.2196/mhealth.8873 29343463 v6i1e23 PMC5792697 Lee SH Nurmatov UB Nwaru BI Mukherjee M Grant L Pagliari C Effectiveness of mHealth interventions for maternal, newborn and child health in low- and middle-income countries: systematic review and meta-analysis J Glob Health 2016 6 1 010401 10.7189/jogh.06.010401 26649177 jogh-06-010401 PMC4643860 Overdijkink SB Velu AV Rosman AN van Beukering MD Kok M Steegers-Theunissen RP The usability and effectiveness of mobile health technology-based lifestyle and medical intervention apps supporting health care during pregnancy: systematic review JMIR Mhealth Uhealth 2018 20 4 e109 10.2196/mhealth.8834 29691216 Palmer MJ Machiyama K Woodd S Gubijev A Barnard S Russell S Perel P Free C Mobile phone-based interventions for improving adherence to medication prescribed for the primary prevention of cardiovascular disease in adults Cochrane Database Syst Rev 2018 1 54 10.1002/14651858.cd012675.pub2 Berrouiguet S Baca-García E Brandt S Walter M Courtet P Fundamentals for future mobile-health (mHealth): a systematic review of mobile phone and web-based text messaging in mental health J Med Internet Res 2016 18 6 e135 10.2196/jmir.5066 27287668 v18i6e135 PMC4920962 Wang K Varma DS Prosperi M A systematic review of the effectiveness of mobile apps for monitoring and management of mental health symptoms or disorders J Psychiatr Res 2018 107 73 78 10.1016/j.jpsychires.2018.10.006 30347316 S0022-3956(18)30828-8 White A Thomas DSK Ezeanochie N Bull S Health worker mHealth utilization: a systematic review Comput Inform Nurs 2016 34 5 206 213 10.1097/CIN.0000000000000231 26955009 PMC4860109 Odendaal WA Watkins JA Leon N Goudge J Griffiths F Tomlinson M Daniels K Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis Cochrane Database Syst Rev 2020 3 3 CD011942 10.1002/14651858.CD011942.pub2 32216074 PMC7098082 Carter DD Robinson K Forbes J Hayes S Experiences of mobile health in promoting physical activity: a qualitative systematic review and meta-ethnography PLoS One 2018 13 12 e0208759 10.1371/journal.pone.0208759 30557396 PONE-D-18-20417 PMC6296673 Hu R van Velthoven MH Meinert E Perspectives of people who are overweight and obese on using wearable technology for weight management: systematic review JMIR Mhealth Uhealth 2020 8 1 e12651 10.2196/12651 31929104 v8i1e12651 PMC6996738 Moore K O'Shea E Kenny L Barton J Tedesco S Sica M Crowe C Alamäki A Condell J Nordström A Timmons S Older adults' experiences with using wearable devices: qualitative systematic review and meta-synthesis JMIR Mhealth Uhealth 2021 9 6 e23832 10.2196/23832 34081020 v9i6e23832 PMC8212622 Slater H Campbell JM Stinson JN Burley MM Briggs AM End user and implementer experiences of mHealth technologies for noncommunicable chronic disease management in young adults: systematic review J Med Internet Res 2017 19 12 e406 10.2196/jmir.8888 29233804 v19i12e406 PMC5743925 Vo V Auroy L Sarradon-Eck A Patients' perceptions of mHealth apps: meta-ethnographic review of qualitative studies JMIR Mhealth Uhealth 2019 7 7 e13817 10.2196/13817 31293246 v7i7e13817 PMC6652126 Reilly R Stephens J Micklem J Tufanaru C Harfield S Fisher I Pearson O Ward J Use and uptake of web-based therapeutic interventions amongst indigenous populations in Australia, New Zealand, the United States of America and Canada: a scoping review Syst Rev 2020 9 1 123 10.1186/s13643-020-01374-x 32475342 10.1186/s13643-020-01374-x PMC7262751 Jones L Jacklin K O'Connell ME Development and use of health-related technologies in Indigenous communities: critical review J Med Internet Res 2017 19 7 e256 10.2196/jmir.7520 28729237 v19i7e256 PMC5544891 Hobson GR Caffery LJ Neuhaus M Langbecker DH Mobile health for first nations populations: systematic review JMIR Mhealth Uhealth 2019 7 10 e14877 10.2196/14877 31593537 v7i10e14877 PMC6803895 The World Bank Indigenous Peoples The World Bank 2023 2023-07-03 https://www.worldbank.org/en/topic/indigenouspeoples Covidence systematic review software Veritas Health Innovation 2023-05-25 https://www.covidence.org/ Critical Appraisal Skills Programme (CASP) Critical appraisal skills programme qualitative checklist Qual Res checklist 2017 31 13 449 10.7717/peerj.12951/table-2 The Joanna Briggs Institute The joanna briggs institute critical appraisal tools for use in JBI systematic reviews Checklist Qual Res 2017 9 Supplement e025789 10.11124/01938924-201109481-00003 NVivo (Version 12) QSR International 2018 2023-05-25 https://qsr-nvivo.software.informer.com/12.2/ Pearson A Balancing the evidence: incorporating the synthesis of qualitative data into systematic reviews JBI Reports 2004 2 2 45 64 10.1111/j.1479-6988.2004.00008.x Povey J Mills PPJR Dingwall KM Lowell A Singer J Rotumah D Bennett-Levy J Nagel T Acceptability of mental health apps for aboriginal and torres strait islander australians: a qualitative study J Med Internet Res 2016 18 3 e65 10.2196/jmir.5314 26969043 v18i3e65 PMC4825593 McCool J Dobson R Whittaker R Moving beyond the individual: mHealth tools for social change in low-resource settings BMJ Glob Health 2018 3 6 e001098 10.1136/bmjgh-2018-001098 30498591 bmjgh-2018-001098 PMC6254750 Te Morenga L Pekepo C Corrigan C Matoe L Mules R Goodwin D Dymus J Tunks M Grey J Humphrey G Jull A Whittaker R Verbiest M Firestone R Ni Mhurchu C Co-designing an mHealth tool in the New Zealand Māori community with a “kaupapa māori” approach Altern Int J Indig Peoples 2018 14 1 90 99 10.1177/1177180117753169 Jongbloed K Pearce ME Thomas V Sharma R Pooyak S Demerais L Lester RT Schechter MT Spittal PM Cedar Project Partnership The cedar project - mobile phone use and acceptability of mobile health among young indigenous people who have used drugs in British Columbia, Canada: mixed methods exploratory study JMIR Mhealth Uhealth 2020 8 7 e16783 10.2196/16783 32716311 v8i7e16783 PMC7427984 Gasteiger N Anderson A Day K Rethinking engagement: exploring women's technology use during the perinatal period through a Kaupapa Māori consistent approach J (New Zealand Coll Midwives) 2019 55 55 20 26 Peiris D Wright L News M Rogers K Redfern J Chow C Thomas D A smartphone app to assist smoking cessation among aboriginal Australians: findings from a pilot randomized controlled trial JMIR Mhealth Uhealth 2019 7 4 e12745 10.2196/12745 30938691 v7i4e12745 PMC6538311 Tighe J Shand F McKay K Mcalister TJ Mackinnon A Christensen H Usage and acceptability of the iBobbly app: pilot trial for suicide prevention in aboriginal and torres strait islander youth JMIR Ment Health 2020 7 12 e14296 10.2196/14296 33258782 v7i12e14296 PMC7738247 Kennedy M Kumar R Ryan NM Bennett J Fuentes GLH Gould GS Codeveloping a multibehavioural mobile phone app to enhance social and emotional well-being and reduce health risks among aboriginal and torres strait islander women during preconception and pregnancy: a three-phased mixed-methods study BMJ Open 2021 11 11 e052545 10.1136/bmjopen-2021-052545 34819285 bmjopen-2021-052545 PMC8614130 Akearok GH Tabish T Cherba M Cultural orientation and safety app for new and short-term health care providers in Nunavut Can J Public Health 2020 111 5 694 700 10.17269/s41997-020-00311-8 32219728 10.17269/s41997-020-00311-8 PMC7501330 Dingwall KM Puszka S Sweet M Nagel T “Like drawing into sand”: acceptability, feasibility, and appropriateness of a new e-mental health resource for service providers working with aboriginal and torres strait islander people Aust Psychol 2020 50 1 60 69 10.1111/ap.12100 Yazdanshenas H Bazargan M Jones L Vawer M Seto TB Farooq S Taira DA Engaging gatekeeper-stakeholders in development of a mobile health intervention to improve medication adherence among African American and pacific islander elderly patients with hypertension JMIR Mhealth Uhealth 2016 4 4 e116 10.2196/mhealth.5905 27784651 v4i4e116 PMC5103104 Raphiphatthana B Sweet M Puszka S Whitty M Dingwall K Nagel T Evaluation of electronic mental health implementation in northern territory services using the integrated "promoting action on research implementation in health services" framework: qualitative study JMIR Ment Health 2020 7 5 e14835 10.2196/14835 32452812 v7i5e14835 PMC7284395 Kurumop SF Bullen C Whittaker R Betuela I Hetzel MW Pulford J Improving health worker adherence to malaria treatment guidelines in papua New Guinea: feasibility and acceptability of a text message reminder service PLoS One 2013 8 10 e76578 10.1371/journal.pone.0076578 24116122 PONE-D-13-17792 PMC3792049 Bennett-Levy J Singer J DuBois S Hyde K Translating E-Mental health into practice: what are the barriers and enablers to E-Mental health implementation by aboriginal and torres strait islander health professionals? J Med Internet Res 2017 19 1 e1 10.2196/jmir.6269 28077347 v19i1e1 PMC5266824 Macniven R Gwynn J Fujimoto H Hamilton S Thompson SC Taylor K Lawrence M Finlayson H Bolton G Dulvari N Wright DC Rambaldini B Freedman B Gwynne K Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in aboriginal adults Aust N Z J Public Health 2019 43 4 313 318 10.1111/1753-6405.12905 31141280 Brown K Toombs M Nasir B Kisely S Ranmuthugala G Brennan-Olsen SL Nicholson GC Gill NS Hayman NS Kondalsamy-Chennakesavan S Hides L How can mobile applications support suicide prevention gatekeepers in Australian indigenous communities? Soc Sci Med 2020 258 113015 10.1016/j.socscimed.2020.113015 32559573 S0277-9536(20)30234-3 Houston A Laws R Askew D Saldanha T Denney-Wilson E Exploring the cultural appropriateness and usefulness of a mHealth promotion program for infant feeding in an urban aboriginal health service: a qualitative study Aust Indig Health Bull 2017 17 3 1 10 McCool J Tanielu H Umali E Whittaker R Assessing the cross-cultural adaptation and translation of a text-based mobile smoking cessation program in samoa (TXTTaofiTapaa): pilot study JMIR Mhealth Uhealth 2018 6 8 e173 10.2196/mhealth.9033 30170994 v6i8e173 PMC6138826 Varnfield M Redd C Stoney RM Higgins L Scolari N Warwick R Iedema J Rundle J Dutton W M♡THer, an mHealth system to support women with gestational diabetes mellitus: feasibility and acceptability study Diabetes Technol Ther 2021 23 5 358 366 10.1089/dia.2020.0509 33210954 PMC8080933 Palacholla RS Fischer N Coleman A Agboola S Kirley K Felsted J Katz C Lloyd S Jethwani K Provider- and patient-related barriers to and facilitators of digital health technology adoption for hypertension management: scoping review JMIR Cardio 2019 3 1 e11951 10.2196/11951 31758771 v3i1e11951 PMC6834226 Fox A Gardner G Osborne S A theoretical framework to support research of health service innovation Aust Health Rev 2015 39 1 70 75 10.1071/AH14031 25513878 AH14031 Gagnon MP Ngangue P Payne-Gagnon J Desmartis M m-Health adoption by healthcare professionals: a systematic review J Am Med Inform Assoc 2016 23 1 212 220 10.1093/jamia/ocv052 26078410 ocv052 PMC7814918 Verbiest MEA Corrigan C Dalhousie S Firestone R Funaki T Goodwin D Grey J Henry A Humphrey G Jull A Vano M Pekepo C Morenga LT Whittaker R Mhurchu CN Using codesign to develop a culturally tailored, behavior change mHealth intervention for indigenous and other priority communities: a case study in new zealand Transl Behav Med 2019 9 4 720 736 10.1093/tbm/iby093 30388262 5155648 Kip H van Gemert-Pijnen L Sanderman R Kelders SM eHealth Research, Theory and Development: A Multidisciplinary Approach. 1 ed 2018 Milton Park, Abingdon, Oxfordshire Routledge Keeping research on track II: A companion document to Ethical conduct in research with Aboriginal and Torres Strait Islander Peoples and communities: guidelines for researchers and stakeholders National Health and Medical Research Council 2018 2023-05-25 Canberra Commonwealth of Australia https://www.arts.unsw.edu.au/sites/default/files/documents/keepingresearchontrack.pdf Code of ethics for Aboriginal and Torres Strait Islander research Australian Institute of Aboriginal and Torres Strait Islander Studies 2020 2023-05-25 https://aiatsis.gov.au/sites/default/files/2020-10/aiatsis-code-ethics.pdf Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, Canadian Institutes of Health Research Natural Sciences and Engineering Research Council of Canada Social Sciences and Humanities Research Council, Editor Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada and Social Sciences and Humanities Research Council 2018 2023-05-25 https://ethics.gc.ca/eng/policy-politique_tcps2-eptc2_2018.html Pūtaiora Writing Group Te Ara Tika: Guidelines for Māori Research Ethics: A Framework for Researchers and Ethics Committee Members 2010 Auckland Health Research Council of New Zealand Eyles H Jull A Dobson R Firestone R Whittaker R Te Morenga L Goodwin D Mhurchu CN Co-design of mHealth delivered interventions: a systematic review to assess key methods and processes Curr Nutr Rep 2016 5 3 160 167 10.1007/s13668-016-0165-7 Chelberg GR Butten K Mahoney R eHRCATSIH Group Culturally safe eHealth interventions with aboriginal and torres strait Islander people: protocol for a best practice framework JMIR Res Protoc 2022 11 6 e34904 10.2196/34904 35687420 v11i6e34904 PMC9233256