Instead of being able to use their app to manage their care seamlessly, patients were bothered with having to think about whether an app was worth keeping. Another issue patients faced was the cost of these apps [ 25 ], especially in developing countries where some patients cannot afford them [ 62 ].
In addition, some patients were worried about purchasing data to use the app when they were not living in an area with available Wi-Fi [ 62 ]. Not being able to use apps consistently because of data issues deterred some patients from engaging with them for long.
An additional cost-related barrier was the fact that some apps charge patients a fee for obtaining full access to the app and for being advertisement-free [ 41 , 58 ]. Some patients would have to pay for using the full app, since some free versions provided only a few functions.
The financial issues arising therefore prevented some potential app users from fully optimizing the use of an app and engaging with it.
This study completes the model identifying the factors involved in the effective use of mHealth Apps for self-care purposes developed by Azhar and Dhillon [ 17 ]. In this model, the behavioral intention to use mHealth for self-care purposes is influenced by perceived usefulness, perceived ease of use, performance expectancy, social influence, self-efficacy, potential lack of privacy, and hedonic motives.
Some authors have portrayed eHealth internet and related technologies as an important means of achieving patient engagement [ 65 ], especially in the case of isolated people and those who are hard to reach or have difficulty in remaining engaged in care [ 16 ]. Even when patients are not physically in a health care setting, health care advice and guidance are within easy reach at all times. However, some studies based on other methods have shown that some patients are reluctant to use mHealth apps, which is paradoxically the case with adolescent patients because they want to separate their feelings of being a patient from those of being a teenager and make their illnesses and diseases invisible [ 66 ].
In addition, they find apps, especially those with push notifications, annoying, intrusive, and time consuming [ 66 ]. Patients also stated that although these technical health innovations have supported them in many different respects, they still view their providers as the first point of contact to be consulted for discussing the options available. Health apps serve only as back-up consultations when they are really needed; apps are simply available to support physician-patient relationships and do not replace a physician in any way.
Most of the studies included in this review suggest that patients feel empowered by the information provided by mHealth. According to the World Health Organization, adequate and understandable information is a necessary prerequisite for patient empowerment. Health care policymakers, politicians, and the media share the widespread idea that digital health technologies empower patients [ 9 ]. However, when faced with too much overwhelming information, users tend to feel more confused and possibly disempowered, which decreases the effectiveness of discussions with their physicians [ 67 ].
Users have also mentioned that the possible lack of validity of the information provided by apps makes it difficult to trust this information, which may make empowerment ambivalent.
The results presented here suggest that despite the many advantages of mHealth apps, barriers to their successful adoption persist. Patients are still reluctant to rely solely on these tools for reasons related to privacy and security and the validity of the information provided.
Other barriers to the optimal usage of apps are a lack of accessibility the cost and absence of access to Wi-Fi and issues concerning the technical and scientific validity of these tools. Many of the challenges could be met if there was more support on the part of health providers.
In addition, standards could be developed and implemented to ensure that these apps provide patients with accurate evidence-based information.
These standards could also address the security and privacy issues that many patients are concerned about as well as the compatibility of mobile apps with the technology with which existing health care systems are equipped. There is also a need for inexpensive quality apps and updates possibly financed by health insurance funds or other agencies that patients can easily afford. The levels of engagement and empowerment resulting from the use of mobile phone apps and tools have been found to depend on the users.
For example, one study showed that older adults were faced with barriers to adopting these tools because they were not as familiar with smartphones and tablets as younger people and had difficulty in using these technologies [ 70 ], whereas those who were digitally literate preferred to receive health information via tablets and electronic devices [ 70 ].
In addition, preference for the use of mobile devices can differ in some contexts. Although most authors focusing on developing countries discussed how mHealth apps help community health workers, few of them discussed the perspectives of patients using these apps.
As the infrastructures with which the large cities in developing countries are improving, their inhabitants are gaining greater access to mobile data and Wi-Fi [ 73 ]. Since only full-text articles available in English on PubMed were included in this review, many other studies have not been included because they were not written in English or were still in progress at the time of publication.
The papers included here deal mainly with developed countries and less with developing countries, which limits the general validity of the results presented here. It is therefore worth noting the perceptions of individuals inhabiting developing countries in order to establish how this technological advancement is liable to improve or limit their access to health care [ 77 ]. Although mHealth apps were considered a useful complementary tool by many of the patients studied, some major issues emerged with regard to the optimal use of mHealth technologies, such as the need for more highly tailored designs, their cost, the validity of the information they provide, and issues such as privacy and security.
Lastly, there is definitely a need for apps to be more personalized in order to meet the needs of individual users and their particular disease or condition, by designing apps that are easier to use, for example, by those who are not as digitally literate as others. Conflicts of Interest: None declared. National Center for Biotechnology Information , U.
Published online Jul Author information Article notes Copyright and License information Disclaimer. Corresponding author. Corresponding Author: Aline Sarradon-Eck rf. This article has been cited by other articles in PMC. Abstract Background Mobile phones and tablets are being increasingly integrated into the daily lives of many people worldwide.
Results A total of articles were selected for screening, and 43 of them met the inclusion criteria. Conclusions Although many of the patients included in the studies reviewed considered mHealth apps as a useful complementary tool, some major problems arise in their optimal use, including the need for more closely tailored designs, the cost of these apps, the validity of the information delivered, and security and privacy issues.
Keywords: mHealth, apps, mobile apps, qualitative studies, systematic review, mobile phone. Introduction Mobile health mHealth technology has been widely adopted in many countries worldwide. Methods Search Strategy Using relevant electronic databases PubMed and Web of Science , a systematic search was performed on the literature. Concept and keywords used in the search strategy.
Data Extraction and Analysis The titles and abstracts were scanned to retrieve the keywords and combinations of keywords mentioned above in order to identify relevant articles and exclude those that were not within the scope of this review. Results Study Selection Procedure The search conducted on the literature yielded articles, 43 of which met the inclusion criteria Figure 1.
Open in a separate window. Figure 1. Table 1 Characteristics of the selected studies. Summary of the emerging themes. Increasing Patient Engagement Improving the Accessibility to Information Apps are frequently used to make information accessible to users.
Peer Support Not only were patients able to engage with their providers more effectively, but they also stated that some apps facilitated conversation with other people who had undergone similar experiences, via forums or chat rooms.
Increasing Patient Empowerment Facilitating Self-Management Many patients approve of apps that can be used for self-monitoring and self-management of their health [ 25 ]. Gaining Greater Control and Autonomy Patients provided with a tool that gave them access to useful supplementary information and helped them engage with their providers declared that they felt more empowered and in control of their condition, disease, or regimen. Concerns of Trustworthiness Scientific Validity Most of the patients interviewed said they were in agreement with the concerns sometimes expressed about the validity of the information provided on mHealth apps.
Technical Validity The main issues mentioned by users in connection with these apps were those of privacy and security. Cultural and User Appropriateness Patients also stressed the need for apps to understand their users. The Need for Greater Personalization One of the most critical factors stressed upon by many participants in these studies was the need to personalize the content of mHealth apps to a greater extent.
Accessibility Issues In addition to the trustworthiness of the information and the appropriateness of the app, patients were also worried about a few issues related to their access to apps, such as the connectivity and cost.
Limitations Since only full-text articles available in English on PubMed were included in this review, many other studies have not been included because they were not written in English or were still in progress at the time of publication. Footnotes Conflicts of Interest: None declared. References 1. World Health Organization. International Telecommunication Union. Lupton D. Apps as Artefacts: Towards a critical perspective on mobile health and medical apps.
Empirical studies on usability of mHealth apps: a systematic literature review. J Med Syst. Yasini M, Marchand G. Toward a use case based classification of mobile health applications. Stud Health Technol Inform. M-health and health promotion: The digital cyborg and surveillance society. Soc Theory Health. Al Dahdah M. Use of m-Health in polio eradication and other immunization activities in developing countries.
Mobile apps in cardiology: review. Factors that influence the implementation of e-health: a systematic review of systematic reviews an update Implement Sci. Community health workers and mobile technology: a systematic review of the literature. PLoS One. Azhar F, Dhillon J. A systematic review of factors influencing the effective use of mHealth apps for self-care. IEEE; Pope C, Mays N.
Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Smith A. Jun 05, []. It acts as a programmable secondary memory. Care givers can program the device with all the key details like name, address and contact details to remind the patient when needed.
At normal times, it reminds patients of tasks such as taking medication at the prescribed time. In more advanced version it can detect fall and monitor the key health parameters such as heart rate, ECG, blood pressure, body weight, etc.
VESAG stores all the past medical history, current medications, specific allergies and the contact information of care givers which can be used during emergencies. Such a comprehensive system can provide a tremendous emotional relief to care givers by ensuring a constant round the clock digital monitoring.
Patients will benefit with the additional digital memory support and the freedom to move in the society. Regulatory issues, logistics, and the use of appropriate, need-based, customized solutions are some of the other concerns.
Karl Brown is Associate Director, Making the eHealth Connection but can he give me the more information about the eye ptosis General design challenges faced by all telemedicine systems include billing and usability," among a list of technical hardware and software, bandwidth, reliability, language, compatibility, and other logistical issues. Phone - Fax - General email info comminit. Skip to Content Skip to Navigation. July 13 - August 8 Click here to download this document in PDF format.
Related Summaries:. About More knowledge from. Login or register to post comments. Post new comment Login or Register to post comments. Previous Pause Next. Recent Classifieds View all. None of the trials were at low risk of bias for all quality criteria. There was no evidence of publication bias on visual and statistical examination of funnel plots. We report the effect estimates for primary outcomes and a summary of the effect estimates for secondary outcomes see Tables 8 — 12 for the secondary outcome effect estimates.
Medical education interventions: Of the nine knowledge outcomes reported, eight showed no statistically significant effects and one showed a statistically significant increase in knowledge Table 8. There were no statistically significant effects on the two reported outcomes regarding documentation. Clinical diagnosis and management support interventions: Seven trials [28] , [30] , [33] — [37] using application software to deliver support reported 25 outcomes relating to appropriate management, testing, referrals screening, diagnosis, treatment, and triage; of these, 19 outcomes showed benefits of which 11 were statistically significant Table 9.
The other six outcomes showed no clinically important or statistically significant direction of effect Table 9. Six outcomes showed negative effects in increasing time for processes or errors in data, of which three were statistically significant. One outcome had no clear direction of effect. Interventions to facilitate verbal or data communication between health care providers: The effect estimates are provided in Table 6.
One trial [44] using a mobile phone to facilitate communication between nurses and surgeons reported six outcomes; one showed statistically significant benefit. Two trials [40] , [43] using photos transmitted via mobile phones reported three outcomes showing negative effects of the interventions, with statistically significant reductions in fracture detection when compared to standard radiographic pictures, reductions in correct assessment of potential to perform re-implantation, and correct recognition of skin ecchymoses when compared to a gold standard assessment by a specialist evaluating ecchymoses in person.
One trial [42] reported a nonsignificant reduction in the ability of doctors to interpret endoscopy videos when viewed on a hand-held computer compared to a standard monitor. One trial [57] compared an ECG transmitted via mobile phone to an ECG transmitted by fax and reported statistically significant reductions for one of three outcomes regarding ECG quality.
The authors report there were no effects of this difference in quality on ECG interpretation but do not provided data on this. Of four reported outcomes regarding the time taken to transmit the ECG, none were statistically significant. Primary outcomes were reported in eight trials [47] — [54] that evaluated the effect of attendance reminders using SMS reminders versus no reminder and showed a statistically significant increase in attendance pooled relative risk [RR] 1.
The pooled effect for trials evaluating the effect of attendance reminder using text message against reminders that used other modes, such as postal reminder and phone calls, showed no significant change RR 0. Two trials [47] , [50] that evaluated the effects on cancellations of texting appointment reminders to patients who persistently fail to attend appointments showed no statistically significant change pooled RR of 1. Another trial [47] reported the effects on appointment cancellation of mobile phone reminders compared to postal mail RR 2.
One trial [52] evaluated the effect of appointment reminder by mobile phone call compared with a control group that received no reminder and showed a statistically significant increase in attendance RR 1. Forest plots of the effect of SMS reminders on appointments. Secondary outcomes were as follows: One trial [56] reported statistically significant reductions in mean time to communicating the diagnosis to the patient and the mean time from test to treatment, but no effects on mean time from first contact to treatment Table We identified 42 controlled trials that investigated mobile technology-based interventions designed to improve health care service delivery processes.
None of the trials were of high quality and nearly all were undertaken in high-income countries. Thirty-two of the trials tested interventions directed at health care providers. Of these trials, seven investigated interventions providing health care provider education, 18 investigated interventions supporting clinical diagnosis and treatment, and seven investigated interventions to facilitate communication between health care providers.
None of the trials reported any objective clinical outcome, and the reported results for health care provider support interventions are mixed.
There may be modest benefits in outcomes regarding correct clinical diagnosis and management delivered via application software, but there were mixed results for medical process outcomes regarding the time taken and completeness of or errors in reports or warning scores. For educational interventions for health care providers, there was no clear evidence of benefit. For interventions aiming to enhance communication between health care providers, one trial showed benefits in using the telephone functions of a mobile phone to enhance verbal communication between surgeons and nurses.
Two trials showed reductions in the quality of clinical assessment using mobile technology based photos when compared to a gold standard and one trial reported a reduction in quality of ECG print outs delivered via mobile phones. For the category of communication between health services and consumers, SMS reminders have modest benefits in increasing clinic attendance and appear similar in their effects to other forms of reminder. One trial [56] reported mixed results relating to time to treatment using SMS to notify patients of their test results.
To our knowledge, this is the first comprehensive systematic review of trials of all mobile technology interventions delivered to health care providers and for health services support to improve health or health services. We identified more than twice the number of trials of educational interventions and trials of PDA applications identified in previous reviews [11] , [58].
Our review findings are consistent with those of Krishna et al. Our systematic review was broad in its scope. We only pooled outcomes where the intervention function e. Here, findings in relation to clinical diagnosis and management and educational interventions are summarised, the individual trial results are reported in Tables 1 — It was not appropriate to pool these results as the interventions targeted different diseases and outcomes. Further, there are likely to be important differences in the intervention content of these interventions such as the behaviour change techniques used , even in those using the same mobile technology functions such as application software.
It was not possible to explore how different intervention components influenced outcomes as the intervention components were not described consistently or in detail in the authors' papers. It was not possible to explore how the intervention components targeting the disease and outcomes influenced the results. It was beyond the scope of our review to review internet or video-based interventions not specifically designed for mobile technologies.
We also excluded interventions combining mobile technologies with other interventions such as face-to-face counselling, which should be subject to a separate systematic review.
Factors influencing heterogeneity of effect estimates include low trial quality, in particular inadequate allocation concealment [60] , participant factors such as demographics or disease status, the setting hospital, primary care , the intervention features components, intensity, timing , the type of mobile technology device e. We were unable to statistically explore factors influencing heterogeneity because there were few trials of similar interventions reporting the same outcomes, resulting in limited power for such analyses.
It was not possible to statistically explore the mechanism of action of the interventions because there were too few similar interventions reporting the same outcomes. In addition, authors' descriptions of interventions were insufficiently detailed to allow mechanisms of action to be explored. It was outside the scope of this review to explore the cost-effectiveness of interventions with modest benefits such as appointment reminders.
At the request of the editors we re-ran our search on 1 November to any identify other trials eligible for this review published since our last search, and we identified eight trials. One high quality trial demonstrated that text message reminders increased Kenyan health workers' adherence to malaria treatment guidelines with improvements in artemether-lumefantrine management of Three trials reported statistically significant increases in clinic attendance with text message reminders OR 1.
These findings are similar to those reported in trials already included in the review [47] — [54]. One trial reported statistically significantly increased attendance with voice reminders compared to text message reminders [65]. One trial showed no effect on HIV viral load of a mobile phone-based AIDS care support intervention for community-based peer health workers [66]. One trial reported better performance in a cardiac arrest simulation for health care providers allocated to receiving a mobile phone application regarding advanced life support [67].
Trials of heath care provider support show some promising results for clinical management, appropriate testing, referral, screening, diagnosis, treatment, and triage. However, trials included in our review were subject to high or unclear risk of bias. In particular, only one of the 17 trials clearly reported that allocation was concealed and where there is no allocation concealment, the reported results may be an over-estimate of effects.
To date no trials have reported effects of mobile technology-based clinical diagnosis and management support on objective health outcomes. Most of the trials supporting health care providers in clinical diagnosis and management employed PDA devices and customised application software functions.
While PDA devices are no longer widely used, customised application software functions are now deliverable on smart phones or tablets. Mobile technology-based interventions may not be suitable for some clinical processes.
The data available for making clinical diagnoses or calculating early warning scores may be reduced and the time taken for medical processes may be increased.
There was no clear evidence of benefit of mobile technology-based educational interventions for health care professionals. For interventions using mobile technologies to communicate visual data, there were increases in time to diagnosis or ECG transmission or diagnostic errors.
Two trials using photos taken by mobile phone reduced diagnostic accuracy of fractures, skin ecchymoses, and potential to perform re-implantation when compared to a gold standard. However, the use of such technologies may be more relevant for settings where the gold standard is not available. Furthermore, the quality of photos on mobile phones has improved since these studies were completed.
Mobile technology-based diagnosis and management support may be most relevant to health care providers in developing countries where mobile phones potentially allow clinical support and evidence-based guidance to be delivered to health care professionals working remotely and in circumstances where senior health care professional support or other infrastructure is lacking [69].
SMS messages are modestly effective as appointment reminders. Their effects appear similar to other forms of reminder. Health care providers should consider implementing SMS appointment reminders because the cost of missed appointments in health services is high, the cost of providing SMS appointment reminders is low, and SMS reminders are cheaper than other forms of reminder e.
The effects of such support on the management of different diseases and on objective disease outcomes should be evaluated. It is imperative that future trials of clinical decision support, guidance, and protocol delivered via mobile technologies take place in low- and middle-income countries.
Many of the interventions evaluated to date are single component interventions of low intensity. The effects of higher intensity multi-component mobile technology interventions should be evaluated. Authors must describe the components of future interventions in detail so that mechanisms of action and the impact of different components on outcome can be explored. Trials should evaluate the effects of the use of photographic or video functions to support health care providers compared to standard care where gold standard options are not available.
As the technological capabilities of mobile phones improve, such as in photographic quality, further trials of the effects of using photos taken on mobile technologies on diagnostic accuracy may be a warranted.
Further research should evaluate the effects and cost-effectiveness of mobile technologies to increase the speed of communication between clinicians and patients, such as test results. Interventions combining elements delivered by mobile technology with other treatments such as clinics based counselling combined with text messages should be systematically reviewed. The reported effects of health care provider support interventions are mixed.
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