ArticleLiterature Review

Developing a Theoretical Framework for Evaluating the Quality of mHealth Apps for Adolescent Users: A Systematic Review

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Abstract

Objective: To assess adolescents' preferred mobile app features and to propose a framework for evaluating health-related mobile apps for adolescents. Methods: PubMed, CINAHL, PsycINFO, ERIC, HealthIT.gov, and ClinicalTrials.gov were systematically searched in August 2017. Studies pertaining to app development, feasibility, or usability that reported preferred app features and rating criteria on mHealth (mobile health) apps intended for adolescents were included. Quality assessment was performed using the Mixed Methods Appraisal Tool. Qualitative synthesis was performed to develop themes reflecting best practices for evaluating the quality of mHealth apps for adolescents. Using a grounded theory approach, we constructed a theoretical framework of rating criteria that can be used to inform development of an evaluation tool for mHealth apps targeted to adolescents. Results: Thirteen articles were included. Most commonly preferred features include ability to track test results or self-management progress, connect to social media, and gain points or prizes through app gamification. Common rating criteria include degree of app customizability, ease of use, visual appeal, and interactivity. Five emerging dimensions were used in the theoretical framework: Technical Quality; Engagement; Support System; Autonomy; and Safety, Privacy, and Trust. Conclusions: We found that adolescents prefer mHealth apps that are customizable, offer peer support through social media, sustain engagement via gamification, and support the ability to visualize health trends via simplified graphs. Findings may help in the development of mHealth apps that are preferred by adolescents, as well as the development of a quality evaluation tool for mHealth apps targeted to this population.

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... Reviews of existing literature show that mobile apps are an effective method for reaching teenagers when it comes to health promotion [16], and specifically for self-monitoring of health-related behaviors [17]. This is facilitated by increasing levels of smartphone accessibility among teenagers, and their familiarity and ease with new technologies [16,18]. ...
... Reviews of existing literature show that mobile apps are an effective method for reaching teenagers when it comes to health promotion [16], and specifically for self-monitoring of health-related behaviors [17]. This is facilitated by increasing levels of smartphone accessibility among teenagers, and their familiarity and ease with new technologies [16,18]. The acceptability of smartphone use in different social settings for teenagers also contributes to their comfort level in their use for self-monitoring [7]. ...
... Current literature on the development of teen-oriented mHealth apps offers important insights into their assessment. A recent systematic review on the quality of mHealth apps for teenagers identified common rating criteria, including ease of use, visual appeal, interactivity, and degree of customizability [16]. Such criteria are commonly explored under the umbrella concepts of feasibility (ie, suitability to perform the intended tasks) and usability (ie, quality of user experience) [7,18]. ...
Article
Background Mobile apps are not only effective tools for promoting health to teenagers but are also useful for engaging teenagers in participatory research on factors that influence their health. Given the impact of food marketing messages on teenagers’ food attitudes and consumption choices, it is important to develop effective methods for capturing the food advertisements targeted at this population to assess their content. Objective The aim of this study was to test the feasibility and usability of a mobile app, “GrabFM!” (“Grab Food Marketing!”), designed for teenagers to facilitate monitoring of self-identified targeted food marketing messaging. Methods A mixed methods approach, including quantitative user response rates and qualitative focus group discussion feedback, was used in the evaluation process. Results A total of 62 teenagers (ages 13-17) completed GrabFM! app pilot testing over a 7-day data collection period. Teenagers submitted a total of 339 examples of food marketing, suggesting high feasibility for the app. Participants also took part in focus group discussions about their experience, providing positive feedback on usability, including ease of use and design aesthetic appeal. Conclusions The GrabFM! app had high feasibility and usability, suggesting its efficacy in capturing accurate data relevant to the teenage population’s experience with food marketing messaging.
... New evaluation frameworks. Most of the papers in this category 70% (7/10) presented new frameworks developed by the study authors, and the methods adopted in their creation varied: from reviews of related literature and preexisting app evaluation frameworks [84], [86], [89] to more empirical methods such as engaging an expert panel of key stakeholders [87] and analysis of mHealth applications [85]. ...
... Most of the studies in this category 60% (6/10) focused on overall evaluation of mHealth apps, including quality assessment [86], [89], review of official frameworks such as APA [5], and frameworks to support decision-making in choosing mHealth apps for research purposes [87]. ...
... Based on the information extracted, we classified evaluation frameworks by three stages of the mHealth app lifecycle that they could be applied at: development, testing, and adoption or recommendation (Table 3) 11 Early stage, development. Ensuring the security and privacy of sensitive medical data in health apps [85] or providing "a theoretical framework of rating criteria" that can be used to inform development of an evaluation tool for mHealth apps [86] were common objectives of the frameworks (Table 3, green colour). Target users here are app developers. ...
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While digital health or mHealth applications (apps) have become accessible resources for the support of personal health, the privacy and security of users’ data have been the subject of concern and controversy. As large numbers of mHealth apps are created and are increasingly widely used by people with various health conditions, it is crucial to have clear and valid methods for evaluating the data practices within them. Recent regulatory initiatives such as the European Union’s General Data Protection Regulation (GDPR) and California Consumer Privacy Act (CCPA) have had the effect of raising awareness and establishing a minimal set of expectations. However, they do not in themselves address the issue of the development of systems which meet privacy and security requirements. There is a growing body of research on evaluation techniques and frameworks to support the assessment of the privacy and security of health apps, and guidelines to support their design. However, it can be challenging to navigate this space and choose appropriate techniques for a given context. Addressing this issue, this paper examines the recent literature on security and privacy of m-Health applications, using a scoping review methodology. It analyses data security and privacy evaluation techniques and frameworks that have been proposed for mHealth applications, as well as relevant research-based design recommendations. This work consolidates recent research on the topic to support researchers, app designers, end users, and healthcare professionals in designing, evaluating, recommending and adopting mHealth applications.
... Of the papers identified in Category 1, One proposed a methodology to evaluate the quality of both mHealth apps and health websites [29]. Five proposed methodologies solely to evaluate the quality of mHealth apps [30][31][32][33][34]. The coverage of Nouri's mHealth app evaluation criteria [27] found in methodologies within this Category can be viewed in Table 2. ...
... Behaviour change technique is not an explicit quality criteria proposed Nouri et al but the WHO recognises the importance of health outcome based measures [87]. This review identified its considerations in four of the generic methodologies [30,31,33,34]. The ACDC construct and that proposed by Jeminiwa et al included behaviour change as a singular point of consideration [30,32]. ...
... This review identified its considerations in four of the generic methodologies [30,31,33,34]. The ACDC construct and that proposed by Jeminiwa et al included behaviour change as a singular point of consideration [30,32]. In contrast, the MARS construct and Enlight suite included a section dedicated to the topic [29,33]. ...
Preprint
BACKGROUND There has been a rapid growth in the availability and use of mobile health (mHealth) apps around the world in recent years. However, consensus regarding an accepted standard to assess the quality of such apps does not exist. Differing interpretations of quality add to this problem. Consequently, it has become increasingly difficult for healthcare professionals to distinguish apps of high quality from those of lower quality. This exposes both patients and healthcare professionals to unnecessary risk. Despite progress, limited understanding of contributions by those in low- and middle- income countries (LMIC) on this topic exists. As such, the applicability of quality assessment methodologies in LMIC settings remains unexplored. OBJECTIVE The objectives of this rapid review are to; 1) Identify current methodologies within the literature to assess the quality of mHealth apps. 2) Understand what aspects of quality these methodologies address. 3) Determine what input has been made by authors from LMICs. 4) Examine the applicability of such methodologies in low- and middle- income settings. METHODS The review is registered with Prospero (CRD42020205149). A search of PubMed, EMBASE, Web of Science and Scopus was performed for papers relating to mHealth app quality assessment methodologies, published in English between 2005 and the 28th of December, 2020. A thematic and descriptive analysis of methodologies and papers was performed. RESULTS Electronic database searches identified 841 papers. After the screening process, 53 papers remained for inclusion; 6 proposed novel methodologies which could be used to evaluate mHealth apps of diverse medical areas of interest; 8 proposed methodologies which could be used to assess apps concerned with a specific medical focus; 39 used methodologies developed by other published authors to evaluate the quality of various groups of mHealth apps. Authors of 3 papers were solely affiliated to institutes in LMICs. A further 8 papers had at least one co-author affiliated to an institute in a LMIC. CONCLUSIONS Quality assessment of mHealth apps is complex in nature and at times, subjective. Despite growing research on this topic, to date an all-encompassing, appropriate means for evaluating the quality of mHealth apps does not exist. There has been engagement with authors affiliated to institutes in LMICs, however limited consideration of current generic methodologies for application in a LMIC settings have been identified.
... Medline Complete, CINAHL Complete, PubMed, Embase, Scopus, Google, and Google Scholar were searched from January 2018 to April 2020, reflecting the period after the latest systematic reviews found from a preliminary search. 9,10,12,13,17 The reference lists of the systematic and narrative reviews identified from the systematic database search were screened. 6,[9][10][11][12][13]17,18 No limitation was applied for the publication year for this backward searching. ...
... 9,10,12,13,17 The reference lists of the systematic and narrative reviews identified from the systematic database search were screened. 6,[9][10][11][12][13]17,18 No limitation was applied for the publication year for this backward searching. Overall, the time frame covered by this review was from 2011 to April 2020. ...
... 91 Other studies did not elaborate on their scaling method (n ¼ 23). 2,[4][5][6][9][10][11][12][13]17,[92][93][94][95][96][97][98][99][100][101][102][103][104] For the scoring modalities, the most popular approach taken was the calculation of mean or average scores (n ¼ 22 studies, 23% of the total number of studies) (Figure 4; Supplementary Appendix S4). 20,21,27,30,32,33,35,[37][38][39]41,43,45,46,50,54,56,70,71,81,98 Thirteen (13%) studies presented their scores as a sum or total, and 11 (11%) studies used a mixed of mean, median, interquartile range, percentage, or total scoring. ...
Article
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Objective The study sought to review the different assessment items that have been used within existing health app evaluation frameworks aimed at individual, clinician, or organizational users, and to analyze the scoring and evaluation methods used in these frameworks. Materials and Methods We searched multiple bibliographic databases and conducted backward searches of reference lists, using search terms that were synonyms of “health apps,” “evaluation,” and “frameworks.” The review covered publications from 2011 to April 2020. Studies on health app evaluation frameworks and studies that elaborated on the scaling and scoring mechanisms applied in such frameworks were included. Results Ten common domains were identified across general health app evaluation frameworks. A list of 430 assessment criteria was compiled across 97 identified studies. The most frequently used scaling mechanism was a 5-point Likert scale. Most studies have adopted summary statistics to generate the total scoring of each app, and the most popular approach taken was the calculation of mean or average scores. Other frameworks did not use any scaling or scoring mechanism and adopted criteria-based, pictorial, or descriptive approaches, or “threshold” filter. Discussion There is wide variance in the approaches to evaluating health apps within published frameworks, and this variance leads to ongoing uncertainty in how to evaluate health apps. Conclusions A new evaluation framework is needed that can integrate the full range of evaluative criteria within one structure, and provide summative guidance on health app rating, to support individual app users, clinicians, and health organizations in choosing or recommending the best health app.
... In fact, many apps gather (sensitive) personal data, and the more data, the more precise the customization to individual needs, which supports successful treatment processes. Hence, highly customizable apps require a trade-off between information privacy and comfort or customization (Jeminiwa et al., 2019;Iwaya et al., 2020;Hensher et al., 2021;Grundy, 2022). Information privacy refers to the degree of autonomous and self-directed disclosure of private information (Smith et al., 2011). ...
... App-based data therefore has a high economic value and needs far-reaching protection. From a user-centered design perspective, establishing transparent privacy policies and data security measures is paramount (Azhar and Dhillon, 2016;Adjekum et al., 2018;Jeminiwa et al., 2019). Moreover, from an end-user perspective, it is important to trust data security protocols, and a lack of trust can impede uptake and continued use of digital health technologies, such as apps (Schnall et al., 2015;Azhar and Dhillon, 2016). ...
Article
Full-text available
Introduction Privacy concerns are an important barrier to adoption and continued use of digital technologies, particularly in the health sector. With the introduction of mobile health applications (mHealth apps), the construct of app information privacy concerns has received increased attention. However, few validated measures exist to capture said concerns in population samples, although they can help to improve public health efforts. Methods Using a cross-sectional survey of German adults (mean age = 35.62; 63.5% female), this study examined psychometric properties of the app information privacy concerns scale (AIPC). Analyses comprised confirmatory factor analysis, factorial validity (exploratory factor analysis), internal consistency, convergent validity (i.e., correlations with privacy victimhood, and app privacy concerns), and discriminant validity (i.e., daily app use, adoption intentions, and attitudes toward COVID-19 contact tracing app use). Results The analysis did not support the proposed three-factor structure of the AIPC (i.e., anxiety, personal attitude, and requirements). Instead, a four-factor model was preferable that differentiated requirements regarding disclosure policies, and personal control. In addition, factors mirroring anxiety and personal attitude were extracted, but shared a significant overlap. However, these factors showed good reliability, convergent and discriminant validity. Discussion The findings underline the role of app information privacy concerns as a significant barrier to mHealth app use. In this context, anxiety and personal attitudes seemed particularly relevant, which has implications for health communication. Moreover, the observed differentiation of external (disclosure) and internal (control) requirements aligns with health behavior change models and thus is a promising area for future research.
... With the rise of mobile health (mHealth), wearable technologies have offered unique opportunities to assess and shape health behaviors among adolescents [8][9][10]. For this age group specifically, researchers have long touted the importance of feasible, at-home collection of sleep information using devices that are acceptable to adolescents, in part due to PSG-related alterations to sleep (eg, diminished sleep quality) that occur for youth in clinic or laboratory settings [11]. ...
... Wearable sleep EEG devices provide a potential opportunity to expand access to sleep evaluations for adolescents in both research and clinical settings, which may in turn allow for the acceleration of sleep-based mHealth apps in this age group. As mentioned above, interest in developing user-friendly, efficacious mHealth apps among adolescents is increasing at a rapid pace [8][9][10], in part due to adolescent engagement and facility with emerging technologies [38]. Incorporation of sleep EEG assessment via wearables may allow for refinement of mHealth apps targeting sleep in this age group-for example, by helping to identify adolescents most likely to benefit from sleep-based mHealth and/or to aid in monitoring sleep improvements resulting from such interventions. ...
Article
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Background Adolescence is an important life stage for the development of healthy behaviors, which have a long-lasting impact on health across the lifespan. Sleep undergoes significant changes during adolescence and is linked to physical and psychiatric health; however, sleep is rarely assessed in routine health care settings. Wearable sleep electroencephalogram (EEG) devices may represent user-friendly methods for assessing sleep among adolescents, but no studies to date have examined the feasibility and acceptability of sleep EEG wearables in this age group. Objective The goal of the research was to investigate the feasibility and acceptability of sleep EEG wearable devices among adolescents aged 11 to 17 years. Methods A total of 104 adolescents aged 11 to 17 years participated in 7 days of at-home sleep recording using a self-administered wearable sleep EEG device (Zmachine Insight+, General Sleep Corporation) as well as a wristworn actigraph. Feasibility was assessed as the number of full nights of successful recording completed by adolescents, and acceptability was measured by the wearable acceptability survey for sleep. Feasibility and acceptability were assessed separately for the sleep EEG device and wristworn actigraph. Results A total of 94.2% (98/104) of adolescents successfully recorded at least 1 night of data using the sleep EEG device (mean number of nights 5.42; SD 1.71; median 6, mode 7). A total of 81.6% (84/103) rated the comfort of the device as falling in the comfortable to mildly uncomfortable range while awake. A total of 40.8% (42/103) reported typical sleep while using the device, while 39.8% (41/103) indicated minimal to mild device-related sleep disturbances. A minority (32/104, 30.8%) indicated changes in their sleep position due to device use, and very few (11/103, 10.7%) expressed dissatisfaction with their experience with the device. A similar pattern was observed for the wristworn actigraph device. Conclusions Wearable sleep EEG appears to represent a feasible, acceptable method for sleep assessment among adolescents and may have utility for assessing and treating sleep disturbances at a population level. Future studies with adolescents should evaluate strategies for further improving usability of such devices, assess relationships between sleep EEG–derived metrics and health outcomes, and investigate methods for incorporating data from these devices into emerging digital interventions and applications. Trial Registration ClinicalTrials.gov NCT03843762; https://clinicaltrials.gov/ct2/show/NCT03843762
... Getting the text wording correct for the target audience was also a continuous improvement process to facilitate culturally appropriate narrative engagement via text. Frequent use of commonly agreed-upon abbreviation dialects in texting results in these abbreviations being rapidly absorbed into the language and automatically (linguistically) recognized as words [91], reflecting how humans socially adapt to a technology (and its constraints). On the basis of the first focus group with the advisory board, the following modifications were made for the second 4-week session: ...
... In the paper by Pettifor et al [13], titled Adolescent Lives Matter, they argue that "adolescents should be involved throughout the process from design to implementation." This is supported by a recent systematic review of mHealth apps for adolescent users and concluded that there is a fundamental difference between adult and adolescent preferences in apps, where apps for adolescents need features that support decision making [91]. In summary, a quote by Glasgow et al [96] echoes the spirit of this paper's intent: ...
Article
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Background: African American adolescent females are disproportionately affected by STIs and HIV. Given the elevated risk of STIs and HIV for African American women, there is an urgent need to identify innovative strategies to enhance adoption and maintenance of STI and HIV preventive behaviors. Texting is a promising technology for creating preventive maintenance interventions (PMIs) that extend the efficacy of the original intervention. However, little guidance in the public health literature is available for developing this type of application. Objective: We describe a formative pilot study that incorporates user experience (UX) methods to design and test PMI texts for Afiya, an original evidence-based intervention (EBI) specifically designed for African American adolescent females. The purpose of this study is to describe the adaptation process of the health educator-lead phone calling to text-based communication. Methods: The formative process followed the ADAPT-ITT framework for adapting EBI and using them in a new setting, for a new target population, or a modified intervention strategy. This study presents the details of how the phases of the ADAPT-ITT framework were applied to the design of the adaptation. An advisory board (AB) from the target population was constituted, consisting of six African American women ages of 18 - 24 years, participating in formative activities for 12 weeks, involving components of the PMI design. As Afiya included a telephone-based PMI, developers of the original Afiya consultation scripts crafted the initial design of the SMS-based text and texting protocol. The AB participated in the one-day Afiya workshop, followed by 4 weeks of texting PMI messages, a mid-course focus group, followed by 4 more weeks of texting PMI messages, ending with a final focus group. At the advisory board's request, this phase included an optional, additional week of text-based PMI messages. Results: The methods provided a rich source of data and insights into the fundamental issue involved when constructing SMS-based PMI for this target population, and for this EBI. Prior contact and context are essential, as the health educator was identified as a key persona in the process and the messages were situated in the original (workshop) context. Narrative adaptations for personas emerged from AB discussions. Suggestions on how to expand the PMI to current, specific social contexts indicated the use of narrative analysis is warranted. Conclusions: The use of existing EBI incorporating telephone-based PMI scripts facilitated the initial design of the texts, with subsequent narrative analysis of the AB data providing additional adjustments given the actual context. Post-analysis revealed that personas would offer insight and opportunities for persona-specific modification of texting narratives. Clinicaltrial:
... However, including features such as tips and suggestions to support consumers' decisions or sending notifications [59] to notify users of new products or restaurants could improve the user app experience, growth of the app community, and app competitiveness. To increase user enjoyment and participation, meal planner, food product, and restaurant apps should perhaps include features such as rewards, goal-setting options, challenges, and leader boards, which have been recognized as effective tools in past studies [60][61][62], especially in adolescent populations, where game competition can motivate users to participate [63]. Finally, features such as feedback and self-monitoring, which have been demonstrated in previous studies to be effective in increasing users' motivation [32,58] and health behavior [64,65], should be available in apps focused on self-managing food allergies or intolerances; however, only 2 of the 14 apps included in the present systematic search offer these features. ...
Preprint
BACKGROUND Food allergies and intolerances, as adverse reactions to the ingestion, contact or inhalation of a specific food, derivate or additive, are increasing worldwide, whereas mobile phone applications (Apps) are emerging as a promising tool in the management of food allergies and/or intolerances. OBJECTIVE The aim of this review is to systemically search and integrate the information of Apps present in Apple App Store (iOS) and Google Play Store (Android) about food allergies and/or intolerances, and to evaluate their quality through the Mobile App Rating Scale (MARS) tool. METHODS Apps were searched through specific keywords translated in English, Spanish and Italian language (“food allergy”, “food intolerance” and “allergens”). Inclusion criteria were: ≥ 3/5 minimum users’ star rating as a tool to evaluate Apps’ quality; ≥ 1000 reviews as an indicator of reliability; and last update up to 2017. Eligible Apps were evaluated and searched on PubMed to check if already present in scientific articles. Apps’ features were distinguished into input and output ones, depending on whether the contents were inserted by users or automatically generated. The included Apps were divided according to their function (“food products”, “restaurants” and “meal planners” Apps) and evaluated through the MARS tool comprising: 1) App classification category, collecting general and technical information; 2) App quality category, divided into “objective” (including four sections: engagement, functionality, aesthetics, and information) and “subjective” quality; and 3) App specific section, as optional section to evaluate the perceived impact of the App. Only App quality category and App specific section were rated for the quality assessment. For each section, mean±standard deviations (SD), statistical significance between-sections and between Apps’ function were evaluated. RESULTS Fourteen Apps were included: n=12 related to food allergies and intolerances, detecting from 2 to 15 food allergens; and n=2 related to gluten intolerance only. From the MARS quality assessment: a) objective quality scored 3.8±0.4 points (mean± SD of 5 maximum points); b) subjective quality scored 3.5±0.6 points; and c) App specific section scored 3.6±0.7 points. Therefore, Apps resulted in overall acceptable quality, considering ratings ≥ of 3points. From a between-sections comparison, engagement obtained lower scores than functionality, aesthetics and information sections. However, comparing Apps by function, “meal planners” Apps presented higher scores for the engagement section (4.1±0.4 points), than “food products” (3.0±0.6) and “restaurants” Apps (3.2±0.3 points) (P<.05). CONCLUSIONS The present review integrates information of 14 Apps to help consumers to avoid food allergies and/or intolerances, providing suggestions for future Apps. Specifically, the analysed Apps have acceptable quality despite the MARS engagement section should be further improved in “food products” and “restaurants” function Apps. Additionally, for Apps recommendation, their effectiveness in detecting food allergens should be tested in scientific trials.
... In this paper, we first discuss six strategies that have shown promise for increasing engagement in DHIs and increasing its likelihood of being perceived as useful, relevant and "youth focused" among adolescents and young adults. These components include use of theory in DHI development, tailoring, provision of self-monitoring and feedback, fostering social support from peers and providers, including "push factors" (reminders, notifications) and inclusion of game-based elements (12,(25)(26)(27)(28)(29)(30). We then highlight how these components have been operationalized by providing concrete examples from five DHIs being evaluated for efficacy in iTech (19)(20)(21)(22)(23)(24). ...
Article
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Background: Youth participating in mobile health (mHealth) intervention trials often engage with the technologies [e.g., applications (app) or mobile-optimized websites] only partially, often prematurely discontinuing use altogether. Limited engagement can impact the interventions effect on behavior change and compromise researchers' ability to test and estimate the true efficacy of their interventions. While mHealth interventions have been shown to be feasible and acceptable to youth, across diverse health conditions, strategies to increase engagement have been less well studied. Specifically, within HIV prevention and care mHealth interventions, there is not consensus as to which components represent the "key ingredients" to support maximal engagement of youth. Further, successful intervention evaluation requires the ability to systematically track users' engagement with intervention components (i.e., paradata) to evaluate its effects on behavior change. Methods: As part of the Adolescent Medicine Trials Network UNC/Emory Center for Innovative Technology (iTech) portfolio of HIV/AIDS Interventions, we present diverse strategies used across five mHealth protocols seeking to promote youth engagement, track and measure engagement through paradata, and incorporate these components into mHealth intervention evaluations. Results: We describe the importance of defining and measuring engagement using case studies from iTech to illustrate how different research teams select mHealth features to promote youth engagement over time, taking into account features embedded in the technology design, key mechanisms of change and trial outcomes (e.g., HIV testing, pre-exposure prophylaxis uptake and adherence, HIV treatment adherence). Finally, we discuss how the research teams plan to evaluate engagement's role on their intervention's outcomes. Conclusions: Based on this synthesis, we discuss strategies to enhance mHealth engagement during intervention development and design, ensure its monitoring and reporting throughout the trial, and evaluate its impact on trial outcomes.
... 48,57,58 This co-design process is also important, as young people are digital natives and may have preferences that are different from those of adult users. 59 Finally, it is important for researchers to consider carefully the unique e-mental health needs and preferences of all young people and to ensure that disadvantaged and rural youth are represented in the design process. 60 ...
Article
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E-mental health programmes have great potential to provide young people with access to mental health support. However, it is commonly reported that adherence to these programmes is low. Low adherence can be problematic, particularly if young people do not receive the full benefits of a programme. In a research trial setting, non-adherence to treatment recommendations can prevent researchers from drawing strong conclusions about effectiveness. Although adherence has been recognised as an issue in need of attention, many of the reviews available are focused on adults and lack clear direction towards what strategies to employ. This paper presents a broad review of the adherence literature, focusing on factors associated with improving adherence to e-mental health among youth. Our view on the key elements to improve adherence identified from the existing literature are presented, and key recommendations for e-mental health intervention design are provided. These include: developing and communicating adherence guidelines based on individuals’ needs and symptom severity, including customisable features to provide a tailored experience and promote a sense of agency, including engagement checks and adopting a user-centred approach by utilising strategies such as co-design. This paper provides guidance to intervention designers and researchers by outlining recommendations and considerations for intervention development and research design.
... However, including features such as tips and suggestions to support consumers' decisions or sending notifications [59] to notify users of new products or restaurants could improve the user app experience, growth of the app community, and app competitiveness. To increase user enjoyment and participation, meal planner, food product, and restaurant apps should perhaps include features such as rewards, goal-setting options, challenges, and leader boards, which have been recognized as effective tools in past studies [60][61][62], especially in adolescent populations, where game competition can motivate users to participate [63]. Finally, features such as feedback and self-monitoring, which have been demonstrated in previous studies to be effective in increasing users' motivation [32,58] and health behavior [64,65], should be available in apps focused on self-managing food allergies or intolerances; however, only 2 of the 14 apps included in the present systematic search offer these features. ...
Article
Background: Food allergies and intolerances are increasing worldwide, and mobile phone apps could be a promising tool for self-management of these issues. Objective: This study aimed to systemically search and assess food allergy or intolerance apps in app stores using the multidimensional Mobile App Rating Scale (MARS) to rate the objective and subjective quality and to identify critical points for future improvements. Methods: This systematic search identified apps through the keywords "food allergy," "food intolerance," and "allergens" in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ≥3 (of 5 stars) to limit the selection to the most highly rated apps; ≥1000 reviews as an indicator of reliability; and the most recent update performed up to 2017. Then, the apps were divided according to their purpose (searching for allergen-free "food products," "restaurants," or recipes in "meal planners") and evaluated on a scale of 1 to 5 points using the MARS in terms of (1) app classification category with a descriptive aim; (2) app subjective and objective quality categories comprised of engagement, functionality, esthetics, and information sections (Medline was searched for eligible apps to check whether they had been tested in trials); and (3) an optional app-specific section. Furthermore, the output and input features were evaluated. Differences between MARS sections and between app purposes and correlations among MARS sections, star ratings, and numbers of reviews were evaluated. Results: Of the 1376 apps identified, 14 were included: 12 related to food allergies and intolerances that detect 2-16 food allergens and 2 related only to gluten intolerance. The mean (SD) MARS scores (maximum 5 points) were 3.8 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5 (SD 0.6) for subjective quality; and 3.6 (SD 0.7) for the app-specific section. Therefore, a rating ≥3 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1, SD 0.6), esthetics (mean 4, SD 0.5), and information (mean 3.8, SD 0.4). However, when the apps were compared by purpose, critical points were identified: meal planner apps showed significantly higher engagement (mean 4.1, SD 0.4) than food product (mean 3.0, SD 0.6; P=.05) and restaurant (mean 3.2, SD 0.3; P=.02) apps. Conclusions: In this systematic search of food allergy or intolerance apps, acceptable MARS quality was identified, although the engagement section for food product and restaurant purpose apps should be improved and the included apps should be tested in trials. The critical points identified in this systematic search can help improve the innovativeness and applicability of future food allergy and intolerance apps.
... Trophies mathematically correlate with the same thresholds that match moving from entry to intermediate to advanced levels in our exercise training curriculum. These elements can be effective motivational tools, as patients find it easier to assess movement toward a positive goal when their progress can be quantified [29][30][31][32]. Questionnaire data reflecting the patient's overall mood are also collected to see how that relates to physical activity participation and later measured fitness outcomes. ...
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Children and adolescents with congenital heart disease often do not have the opportunity, inclination, or education to participate in safe and effective exercise. The consequences of this behavioral pattern affect not only cardiopulmonary parameters, but also psychosocial factors, especially when lack of participation in peer activities or sports leads to isolation and further sedentary behaviors. Importantly, unlike cardiac rehabilitation programs for adults with atherosclerotic disease, the goal for congenital heart disease patients was less about “rehabilitation” and more about promotion of optimal fitness. We thus developed a comprehensive “Cardiac Fitness Program” at Boston Children’s Hospital to promote exercise training, enhanced self-confidence, and motivation for patients with congenital heart disease. Since much of sustained fitness relates to consistency and behavior change, we crafted a progressive, goal-oriented exercise curriculum and augmented it with a self-learning workbook of targeted positive mindset practices to develop self-efficacy, an app for motivation and data collection, and exercise videos to demonstrate mechanics and to reiterate a positive message. We now report our experience including program structure and framework, navigating insurance, curriculum development, and outcome measures. Methods employed and barriers encountered in the initial development and execution of this program are reviewed. Key take-aways and further considerations including virtual and home-based programs are discussed.
... Several systematic reviews and meta-analyses conclude that mHealth interventions that are informative and motivating, support goal setting and prompt self-monitoring short-term, can positively affect adolescents' health behaviour change (Fedele et al., 2017;Loescher et al., 2018;Shin et al., 2019). However, mHealth interventions also need to be tailored to support adolescents' engagement in healthy behaviours long-term (Jeminiwa et al., 2019;Shin et al., 2019). ...
Article
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Health promotion interventions delivered via mobile phones (mHealth) need to be carefully tailored to end-users to optimize engagement and effects on health outcomes. However, tailoring requires an in-depth understanding of the users’ context and under which circumstances end-users are willing to engage. The aim of this study was to identify and describe how high school students perceive health behaviour change and how mobile phones are used in the process of change. Thematic analysis was used to analyse data collected through 6 focus groups with 21 Swedish high school students (16–19 years). The results showed that behaviour change among adolescents were promoted by having an open approach, being able to be independent, and self-accepting. Mobile phones can provide resilience in long-term behaviour change. These findings may be useful in the development of mHealth interventions, but also for professionals in promoting healthy behaviours among adolescents.
... Involving adolescents in the creation is vital for a user-based perspective to ensure it is appealing and engaging. A recent systematic review in 2019 reviewed adolescents' preferences for app features in health-related applications and identified an ability to customise, enhanced engagement through gamification, social media linking and observing their health trends were important to this population [62]. To our knowledge, only five studies over the last five years have reviewed adolescents' preferences for content and features of health technology in asthma (Table 1) [4,5,26,63,64]. ...
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Asthma is one of the most common chronic diseases worldwide, with a substantial proportion of the asthma population being children and adolescents. Self-management is recognized as a key component to asthma management, with multiple international guidelines emphasizing the need for adequate self-management skills for good asthma control. Unfortunately, the uptake amongst young people and adolescents is low, with often suboptimal engagement to self-management education and skills contributing to poor adherence to medication as well as poor perception of asthma symptoms. Innovative solutions to deliver education and self-management to adolescents are clearly needed. mHealth is the use of mobile devices such as smartphones and tablet devices to improve healthcare and has been used in multiple chronic diseases. This review articles explores the current use of mHealth in asthma, specifically smartphone and tablet applications as a generation-appropriate, accessible delivery modality for provision of asthma education and self-management interventions in adolescents. Current evidence gaps are also highlighted, which should be addressed in future research.
... Adherence-promoting features included those explicitly used by the authors to improve adherence or those that fit within the following categories: supported use defined as use that involves support, encouragement or guidance from a person, reminders, rewards, gamification, social or peer support, tailoring defined as the capacity to tailor content to meet an individual's requirements, personalized feedback including system-generated personalized feedback, customization of visual features such as avatars and color schemes, and interactive content defined as content requiring active inputs from the user. These categories were derived from past literature that endorsed supported use as an effective adherence promoter [44] and systematic reviews of user preferences [24,45]. Supported use was further categorized into autonomous, supported, or intervention-led blended, using the definitions provided by Fairburn and Patel [46] (Table 1). ...
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BACKGROUND Digital, self-guided cognitive behavioural therapy (CBT) interventions circumvent many barriers to in-person therapy for young people; although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. OBJECTIVE This systematic review synthesizes the literature on digital CBT interventions for depression and anxiety in young people to describe (i) how appropriate use has been defined and communicated to users as instructions for use; (ii) how adherence has been measured; and (iii) to determine the associations between adherence and treatment outcomes. METHODS A systematic review was conducted with two reviewers extracting data independently. Four electronic databases (Embase, Medline, PsycINFO and The Cochrane library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12-24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioural-only interventions were excluded. Methodological quality was assessed using the using the Cochrane Risk of Bias Tool (ROB) and the Integrated Quality Criteria for the Review of Multiple Study designs (ICROMS). RESULTS There were 32 manuscripts that met inclusion criteria, of which 28 were unique studies (total N=16 578 youth). Definitions of appropriate use varied between the different interventions in terms of intended recipients, duration and frequency of use, and the features employed to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies were inconsistent with no study systematically describing components of appropriate use nor providing information on how recommendations for use were relayed to users. Most often definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the nine studies that examined this. CONCLUSIONS Definitions of appropriate use are unique to each digital CBT intervention. Yet, statements of appropriate use are not systematically reported in the literature. Further, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We propose a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence. CLINICALTRIAL This protocol was registered with PROSPERO [CRD42020208668].
... En la misma línea, Edwards et al. (2016) en su estudio confirmaron la efectividad de la gamificación para promover y mantener dichas conductas saludables. Asimismo, Jeminiwa et al. (2019) ponen de relieve que la población joven prefiere aplicaciones móviles de salud que mantengan el compromiso por medio de la gamificación. ...
Article
Las aplicaciones móviles que incorporan contenidos relacionados con la salud han sido de los recursos tecnológicos que más se han extendido en los últimos años, sobre todo a raíz de la situación provocada por el coronavirus. En España, muchas ya han sido sometidas a procesos de regulación de calidad y fiabilidad a través de iniciativas acreditadoras. Además, se ha comprobado que la gamificación en este tipo de tecnología es efectiva para generar conductas saludables en la población joven. Este estudio se centra en conocer cuáles de ellas cuentan con una certificación de calidad en nuestro país y están orientadas a la promoción de hábitos saludables en niños/as y jóvenes. Se ha llevado a cabo una revisión exhaustiva de los portales de salud de carácter gubernamental y no gubernamental en los cuales quedan recogidos los sellos, los distintivos o las etiquetas de calidad como iniciativas acreditadoras en el campo de la salud. Entre los resultados, resaltar que el número de aplicaciones destinadas a menores y a adolescentes, que además integren elementos ludificados y certificadas, es muy escaso y menor en comparación con aquellas dirigidas a adultos, y ello, a pesar de la relevancia que pueden tener para su salud y bienestar.
... Adherence-promoting features included those explicitly used by the authors to improve adherence or those that fit within the following categories: supported use defined as use that involves support, encouragement or guidance from a person, reminders, rewards, gamification, social or peer support, tailoring defined as the capacity to tailor content to meet an individual's requirements, personalized feedback including system-generated personalized feedback, customization of visual features such as avatars and color schemes, and interactive content defined as content requiring active inputs from the user. These categories were derived from past literature that endorsed supported use as an effective adherence promoter [44] and systematic reviews of user preferences [24,45]. Supported use was further categorized into autonomous, supported, or intervention-led blended, using the definitions provided by Fairburn and Patel [46] (Table 1). ...
Article
Background: Digital, self-guided cognitive behavioral therapy (CBT) interventions circumvent many barriers to in-person therapy for young people (aged 12-24 years), although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. As such, many young people may not self-administer these interventions appropriately or receive the optimal degree of treatment. Objective: This systematic review aims to synthesize the literature on digital CBT for depression and anxiety in young people to describe how appropriate use has been defined and communicated to users as instructions for use, to describe how adherence has been measured, and to determine the associations between adherence and treatment outcomes. Methods: A systematic review was conducted with 2 reviewers (SHL and MRA) extracting data independently. Overall, 4 electronic databases (Embase, MEDLINE, PsycINFO, and Cochrane Library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12 and 24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioral-only interventions were excluded. Methodological quality was assessed using the Cochrane Risk of Bias Tool and the Integrated Quality Criteria for the Review of Multiple Study Designs. Results: There were 32 manuscripts that met the inclusion criteria, of which 28 (88%) were unique studies (N=16,578 youths). Definitions of appropriate use varied among the different interventions in terms of intended recipients, duration and frequency of use, and the features used to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies was inconsistent, with no study systematically describing components of appropriate use or providing information on how recommendations for use were relayed to users. Most often, definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the 9 studies that examined this. Conclusions: Definitions of appropriate use are unique to each digital CBT intervention. However, statements of appropriate use are not systematically reported in the literature. Furthermore, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We proposed a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence. Trial registration: PROSPERO CRD42020208668; https://tinyurl.com/4bu2yram.
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Theoretical principles As technology use increasingly expands, the opportunity to capitalize on it for healthcare education, monitoring, and assessment has grown rapidly, especially among adolescent patients. As apps are developed, consideration should be given to self-management theory concepts. Phenomena addressed The proliferation of mobile health (mHealth) applications allows adolescents to access healthcare information in new, innovative ways. Many health applications focus on health promotion, fitness, and nutrition and others help persons with chronic disease. This article offers a compelling case for incorporating mHealth into teen healthcare by reviewing current data on teens' technology use, showing how mHealth aligns with self-management theory concepts, and offering a case scenario on mHealth-enhanced self-management care. Research linkages The ability to combine accurate and immediate healthcare information with continual social support could radically improve teen's self-management behaviors, especially when mHealth apps use connectivity, a feedback loop, and concepts known to enhance self-management behaviors.
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Evidence-based therapies have proven effective in treating the mental health of adolescents. However, these interventions are not without shortcomings: therapies are costly and not accessible for everyone who needs them; psychologists are scarce, with more adolescents needing support than therapists available. We contribute to mental health support tools with a digital robot agent that delivers micro-interventions to adolescents. Our key insight is that translating therapies traditionally provided in a physical workbook format to an interactive robot uncovers therapeutic mechanisms that promote healing. We present our translation process from workbook to robot-mediated therapy, which include the co-design of a robot with adolescents and heuristic evaluations with evidence-based clinical psychologists. This work presents a preliminary study with adolescents in which they used both the workbook (traditional medium) and the digital robot (interactive medium) during two consecutive weeks. Results show both a preference for the robot and more engagement of this treatment delivery option.
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Mobile health applications (mHealth apps) have the potential to support youth with type 1 diabetes (T1D) as they transition to independence, but require sustained user-engagement if long-term health benefits, such as improved metabolic control, are to be observed. As such, it is important for mHealth apps to be developed using an evidence-based framework, with early involvement of end-users. Although financial incentives may further promote app engagement and improve health outcomes, few mHealth apps for youth with TID have incorporated principles of behavioural economics into their design. In this hypothesis-generating, mixed-methods pilot study, we conducted focus groups with youth, parents, and healthcare providers (HCPs) to identify challenges related to self-management that could potentially be overcome by an innovative mHealth app offering user-selected financial rewards for youth participation in self-management behaviours. We developed and piloted the functionality of and satisfaction with a prototype of the Canadian Diabetes Incentives and Technology (CanDIT) app. Though rewards were earned and redeemed, and feedback on existing features was positive, we were unable to fully meet the needs of our target population. We present a summary of findings and discuss design features that app developers should consider in the future to optimize app usability and uptake by youth with T1D.
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Adolescence is associated with heightened vulnerability to symptoms of depression and anxiety. In-person and computerised cognitive behavioural therapy (CBT) are effective treatment options, yet uptake and engagement remain low. Smartphone delivery of CBT offers an alternative, highly accessible method of delivering CBT. However, there is no freely available CBT smartphone application (app) specifically designed to reduce depression and anxiety symptoms in adolescents. The aim of this study was to design a new CBT smartphone app (ClearlyMe) that targets depressive and anxiety symptoms in adolescents. We engaged in a rigorous co-design process with adolescents ( n =36), parents ( n =15), and mental health professionals ( n =32). Co-design involved: (1) discovery of users’ needs, views and preferences by conducting focus groups, (2) defining app features through ideation workshops and user consultations, (3) designing therapeutic CBT content and visual features, and (4) testing prototypes. Users were involved at every step and the process was iterative, with findings carried forward to ensure continued refinement of concepts and features. We found a preference for vibrant, cheerful colours and illustrations and non-endorsement of gamification and chatbots, which contrasted with findings from other studies. Preferences were largely consistent between the three user groups. However, adolescents preferred an app that could be used autonomously without professional support, whereas mental health professionals desired a product for use as a therapy adjunct to support CBT skill development. The importance of co-design, and particularly the inclusion of all stakeholders throughout the entire co-design process, is discussed in relation to the design of ClearlyMe. Key learning aims (1) To understand the co-design process that underpins the development of a new CBT smartphone app for youth with elevated symptoms of depression and anxiety. (2) To understand adolescent, parent and mental health professionals’ key preferences regarding the features and functionality of a CBT smartphone app for adolescents with elevated symptoms of depression and anxiety. (3) To understand how ClearlyMe has been designed as both a therapy adjunct and stand-alone program, and how it can be incorporated into day-to-day clinical practice.
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Young people (YP), defined as individuals aged between 10 and 24 years, are a vulnerable population. Leveraging digital platforms to reach YP is essential in identifying protective and risk behaviors among this population. The objectives of this study were to (1) examine the user-inclusive development process of a theory-based digital platform to reach YP, (2) describe aspects of the digital application prototype, and (3) provide preliminary findings from the utilization of the app. We present the five-step design process for building the app. The app, known as the REACH-AYA survey, consisted of 98 closed-ended questions with built-in skip-logic algorithms and took approximately 7 min to complete. The survey questions centered on behavioral, lifestyle, and psychosocial factors, which were adopted from different validated instruments, thereby addressing 10 different domains. During the pilot phase, participants utilized the app, critiqued its features, and provided iterative feedback. We used respondent-driven sampling to recruit participants in Nairobi, Kenya, the leading county in high-speed data connectivity. Once recruited, each participant completed the survey and later sent it to their peers until the desired sample size was achieved. The REACH-AYA app prototype was guided and developed by the design thinking approach with an initial pilot sample of 33 YP for pre-testing. The end-user pre-testing assessed for functionality, time, and adaptability. The app was then launched initially through social media, reaching 1101 YP, with approximately eighty percent (n = 887) having completed the survey by the close of the study. The majority of the participants were male (59%), and approximately (69%) of the participants were aged between 15 and 24 years. This is one of the few studies that demonstrate user-centric methodologies of app development and real-life application in identifying protective and risk factors for the wellbeing of YP. Methodologies and lessons learned from this research may benefit other disciplines using digital technology to reach YP or other difficult-to-reach populations.
Article
Topic: Mobile Health (mHealth) stands as a potential means to better reach, assess, and intervene with teens with socially complex needs. These youth often face overlapping adversities including medical illness and a history of experiencing adverse childhood experiences (ACEs). Clinicians are faced with navigating ethical decisions when developing mHealth tools for teens who have socially complex needs. Many tools have been developed for adults from the general population. However, despite the development of thousands of mHealth interventions, developers tend to focus on designing for usability, engagement, and efficacy, with less attention on the ethical considerations of making such tools. Purpose: To safely move mHealth interventions from research into clinical practice, ethical standards must be met during the design phase. In this paper we adapt the Four Box Model (i.e., medical indications, preferences of patients, quality of life, and contextual features) to guide mHealth developers through ethical considerations when designing mHealth interventions for teens who present with a medical diagnosis and a history of ACEs. Sources: A review of language, inclusive features, data sharing, and usability is presented using both the Four Box Model and potential scenarios to guide each consideration. Conclusions: To better support designers of mHealth tools we present a framework for evaluating applications to determine overlap with ethical design and are well suited for use in clinical practice with underserved pediatric patients.
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The number of children and adolescents with chronic health conditions (CHCs) has doubled over the past two decades. Medication adherence is a key component of disease management within these groups. Low adherence to prescribed medications is a known problem in adolescents with CHCs and is related to health outcomes, including quality of life, disease complications, and mortality. Adolescence is a critical time to create routines and health behaviors that optimize disease self-management and transition to adult care. The mounting interest in the development and use of mobile health tools provides novel opportunities to connect patients, particularly adolescents, with their providers outside of the clinic and to improve health outcomes. There is growing evidence to support the efficacy of technology-based approaches, in particular text-messaging and mobile apps, to improve adherence behavior in adolescents, although cost-effectiveness and long-term health benefits remain unclear. In this short viewpoint article, we review some important considerations for promoting medication adherence in adolescents with CHCs using technology-based approaches.
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Background: The extensive availability and increasing use of mobile apps for nutrition-based health interventions makes evaluation of the quality of these apps crucial for integration of apps into nutritional counseling. Objective: The goal of this research was the development, validation, and reliability testing of the app quality evaluation (AQEL) tool, an instrument for evaluating apps' educational quality and technical functionality. Methods: Items for evaluating app quality were adapted from website evaluations, with additional items added to evaluate the specific characteristics of apps, resulting in 79 initial items. Expert panels of nutrition and technology professionals and app users reviewed items for face and content validation. After recommended revisions, nutrition experts completed a second AQEL review to ensure clarity. On the basis of 150 sets of responses using the revised AQEL, principal component analysis was completed, reducing AQEL into 5 factors that underwent reliability testing, including internal consistency, split-half reliability, test-retest reliability, and interrater reliability (IRR). Two additional modifiable constructs for evaluating apps based on the age and needs of the target audience as selected by the evaluator were also tested for construct reliability. IRR testing using intraclass correlations (ICC) with all 7 constructs was conducted, with 15 dietitians evaluating one app. Results: Development and validation resulted in the 51-item AQEL. These were reduced to 25 items in 5 factors after principal component analysis, plus 9 modifiable items in two constructs that were not included in principal component analysis. Internal consistency and split-half reliability of the following constructs derived from principal components analysis was good (Cronbach alpha >.80, Spearman-Brown coefficient >.80): behavior change potential, support of knowledge acquisition, app function, and skill development. App purpose split half-reliability was .65. Test-retest reliability showed no significant change over time (P>.05) for all but skill development (P=.001). Construct reliability was good for items assessing age appropriateness of apps for children, teens, and a general audience. In addition, construct reliability was acceptable for assessing app appropriateness for various target audiences (Cronbach alpha >.70). For the 5 main factors, ICC (1,k) was >.80, with a P value of <.05. When 15 nutrition professionals evaluated one app, ICC (2,15) was .98, with a P value of <.001 for all 7 constructs when the modifiable items were specified for adults seeking weight loss support. Conclusions: Our preliminary effort shows that AQEL is a valid, reliable instrument for evaluating nutrition apps' qualities for clinical interventions by nutrition clinicians, educators, and researchers. Further efforts in validating AQEL in various contexts are needed.
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Background: Many adolescents and young adults with chronic illness or disability often fail to develop the self-management skills necessary to independently handle medical and self-management routines. In light of these needs, we are developing iMHere 2.0 (Interactive Mobile Health and Rehabilitation), a mobile health (mHealth) system to support a self-management program. Objective: Our objective was to gather data from persons with brain and spinal cord anomalies (BSA) and their caregivers to better understand how mHealth would be most helpful in supporting them to proactively manage daily self-care routines and to access medical care as needed. The specific purpose was not only to gather feedback and to gain increased insight into the design of the new version of iMHere, but also to gather perspectives of new groups, namely adolescents as young as 12 years and their parents and/or caregivers. Methods: Our project employed focus group sessions and surveys to collect data from participants with BSA, as well as their caregivers. A total of six focus group sessions were conducted on four separate occasions until the data gathered reached saturation. The objectives of our focus group sessions were to better understand ways to develop mHealth systems to support self-management, to promote independence, to motivate long-term system use, and to prevent medical problems that lead to hospitalizations and emergency room visits for youth and young adults with BSA. Results: A total of 16 youth and young adults with BSA and 11 caregivers participated in the sessions. Within and among our groups, the following five overarching themes emerged from the data: (1) make it easy, (2) engage, (3) educate and prepare, (4) motivate and support, and (5) personalize. Participants shared their perspectives and detailed information about mHealth apps that would be important for independence in self-care and self-management. Conclusions: Our findings suggest that most individuals keep their mobile phones with them at all times and typically use a mobile phone for social media, music, photos, and texting. Our qualitative analysis indicates that youth and young adults with BSA, as well as their caregivers, acknowledge the importance of being actively engaged in developing and using mHealth apps that monitor and manage their health care needs. Information gleaned from these focus group sessions and surveys have provided data to refine the iMHere 2.0 mHealth prototype platform that we have developed.
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Background: Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient's condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care. Objectives: The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs. Methods: We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis. Results: A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app. Conclusions: We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis.
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Background There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years. Methods The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years. Results A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate. Conclusions Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed.
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Background Nutrition and diet apps represent today a popular area of mobile health (mHealth), offering the possibility of delivering behavior change (BC) interventions for healthy eating and weight management in a scalable and cost-effective way. However, if commercial apps for pediatric weight management fail to retain users because of a lack of theoretical background and evidence-based content, mHealth apps that are more evidence-based are found less engaging and popular among consumers. Approaching the apps development process from a multidisciplinary and user-centered design (UCD) perspective is likely to help overcome these limitations, raising the chances for an easier adoption and integration of nutrition education apps within primary care interventions. Objective The aim of this study was to describe the design and development of the TreC-LifeStyle nutrition education app and the results of a formative evaluation with families. Methods The design of the nutrition education intervention was based on a multidisciplinary UCD approach, involving a team of BC experts, working with 2 nutritionists and 3 pediatricians from a primary care center. The app content was derived from evidence-based knowledge founded on the Food Pyramid and Mediterranean Diet guidelines used by pediatricians in primary care. A formative evaluation of the TreC-LifeStyle app involved 6 families of overweight children (aged 7-12 years) self-reporting daily food intake of children for 6 weeks and providing feedback on the user experience with the mHealth intervention. Analysis of the app’s usage patterns during the intervention and of participants’ feedback informed the refinement of the app design and a tuning of the nutrition education strategies to improve user engagement and compliance with the intervention. Results Design sessions with the contribution of pediatricians and nutritionists helped define the nutrition education app and intervention, providing an effective human and virtual coaching approach to raise parents’ awareness about children’s eating behavior and lifestyle. The 6 families participating in the pilot study found the app usable and showed high compliance with the intervention over the 6 weeks, but analysis of their interaction and feedback showed the need for improving some of the app features related to the BC techniques “monitoring of the behavior” and “information provision.” Conclusions The UCD and formative evaluation of TreC-LifeStyle show that nutrition education apps are feasible and acceptable solutions to support health promotion interventions in primary care.
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Background: Although the prevalence of mental illness among young people with asthma is known to be twice the rate of the wider population, none of the asthma apps reported have acknowledged or attempted to include psychological support features. This is perhaps because user involvement in the development of asthma apps has been scarce. User involvement, facilitated by participatory design methods, can begin to address these issues while contributing insights to our understanding of the psychological experience associated with asthma and how technology might improve quality of life. Objective: The goal of this participatory user research study was to explore the experience, needs, and ideas of young people with asthma while allowing them to define requirements for an asthma app that would be engaging and effective at improving their well-being. Methods: Young people aged 15-24 years with doctor-diagnosed asthma were invited to participate in a participatory workshop and to complete a workbook designed to elicit their thoughts and ideas about living with asthma, technology use, and the design of an app. Participants generated a number of artifacts (including collages, concept maps, and paper prototypes) designed to reify their ideas, tacit knowledge, and experience. Results: A total of 20 participants (mean age 17.8 years; 60%, 12/20 female) representing a range from inadequately to well-controlled asthma completed a workbook and 13 of these also took part in a workshop (four workshops were held in total), resulting in 102 participant-generated artifacts. Theoretical thematic analysis resulted in a set of personal needs, feature ideas, and app characteristics considered relevant by young people for an asthma support app. The data revealed that psychological factors such as anxiety, and impediments to autonomy, competence, and relatedness (as consistent with self-determination theory [SDT]), were considered major influences on quality of life by young people with asthma. Furthermore, the incorporation of features pertaining to psychological experience was particularly valued by participants. Conclusions: In addition to practical features for asthma management, an app for young people with asthma should include support for the mental health factors associated with lived experience (ie, anxiety, lack of autonomy, and social disconnectedness). We show how support for these factors can be translated into design features of an app for asthma. In addition to informing the development of asthma-support technologies for young people, these findings could have implications for technologies designed to support people with chronic illness more generally.
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Objectives As young patients with cystic fibrosis (CF) grow up, they are expected to take increasing responsibility for the treatment and care of their disease. The aim of this study was to explore the disease-related challenges faced by young adults with CF and their parents, when they leave home. Materials and methods A questionnaire survey of Danish patients with CF aged 18–25 years and their parents was conducted. The questionnaires were based on focus-group interviews with young adults with CF and their parents, and addressed challenges faced in the transition phase between childhood and adulthood, including different areas of disease management in everyday life. Results Among all of the patients invited, 62% (n=58/94) of young adults and 53% (n=99/188) of their parents participated in the study. In total, 40% of the 18- to 25-year-olds were living with their parents, and the parents continued to play an active role in the daily care of their offspring’s disease. Among the young adults who had left home, both the patients and their parents reported many difficulties regarding disease management; the young adults reported difficulties in contacting social services and in affording and preparing sufficient CF-focused meals, and their parents reported difficulties in answering questions concerning social rights and CF in general, and in knowing how to give their offspring the best help, how much to interfere, and how to relinquish control of managing their offspring’s disease. Conclusion Young adults with CF who have left home have difficulties in handling the disease and their parents have difficulties in knowing how to give them the best help. There is an urgent need for holistic CF transitional care, including ensuring that young adults master the essential skills for self-management as they leave their parents.
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Background: mHealth apps hold potential to provide automated, tailored support for treatment adherence among individuals with chronic medical conditions. Yet relatively little empirical research has guided app development and end users are infrequently involved in designing the app features or functions that would best suit their needs. Self-management apps may be particularly useful for people with chronic conditions like cystic fibrosis (CF) that have complex, demanding regimens. Objective: The aim of this mixed-methods study was to involve individuals with CF in guiding the development of engaging, effective, user-friendly adherence promotion apps that meet their preferences and self-management needs. Methods: Adults with CF (n=16, aged 21-48 years, 50% male) provided quantitative data via a secure Web survey and qualitative data via semi-structured telephone interviews regarding previous experiences using apps in general and for health, and preferred and unwanted features of potential future apps to support CF self-management. Results: Participants were smartphone users who reported sending or receiving text messages (93%, 14/15) or emails (80%, 12/15) on their smartphone or device every day, and 87% (13/15) said it would be somewhat or very hard to give up their smartphone. Approximately one-half (53%, 8/15) reported having health apps, all diet/weight-related, yet many reported that existing nutrition apps were not well-suited for CF management. Participants wanted apps to support CF self-management with characteristics such as having multiple rather than single functions (eg, simple alarms), being specific to CF, and minimizing user burden. Common themes for desired CF app features were having information at one's fingertips, automation of disease management activities such as pharmacy refills, integration with smartphones' technological capabilities, enhancing communication with health care team, and facilitating socialization within the CF community. Opinions were mixed regarding gamification and earning rewards or prizes. Participants emphasized the need for customization options to meet individual preferences and disease management goals. Conclusions: Unique capabilities of emerging smartphone technologies (eg, social networking integration, movement and location detection, integrated sensors, or electronic monitors) make many of these requests possible. Involving end users in all stages of mHealth app development and collaborating with technology experts and the health care system may result in apps that maintain engagement, improve integration and automation, and ultimately impact self-management and health outcomes.
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Computer systems cannot improve organizational performance if they aren't used. Unfortunately, resistance to end-user systems by managers and professionals is a widespread problem. To better predict, explain, and increase user acceptance, we need to better understand why people accept or reject computers. This research addresses the ability to predict peoples' computer acceptance from a measure of their intentions, and the ability to explain their intentions in terms of their attitudes, subjective norms, perceived usefulness, perceived ease of use, and related variables. In a longitudinal study of 107 users, intentions to use a specific system, measured after a one-hour introduction to the system, were correlated 0.35 with system use 14 weeks later. The intention-usage correlation was 0.63 at the end of this time period. Perceived usefulness strongly influenced peoples' intentions, explaining more than half of the variance in intentions at the end of 14 weeks. Perceived ease of use had a small but significant effect on intentions as well, although this effect subsided over time. Attitudes only partially mediated the effects of these beliefs on intentions. Subjective norms had no effect on intentions. These results suggest the possibility of simple but powerful models of the determinants of user acceptance, with practical value for evaluating systems and guiding managerial interventions aimed at reducing the problem of underutilized computer technology.
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The goal was to improve immunosuppressant adherence for pediatric patients with orthotopic liver transplants by using text messaging (TM). A prospective study of sending TM reminders to the primary medication administrator (patient or caregiver) for pediatric transplant recipients was performed. Patient records were reviewed, comparing the year before and the year of the study. The SD of serum tacrolimus levels was used as an indicator of adherence. Forty-one patients provided consent. The median age was 15 years (range: 1-27 years), and the median age at the time of transplantation was 2 years (range: 4 months to 23 years). Fourteen patients (34%) were male. In 29 of 41 cases, the medications were self-administered by the patient. The mean duration of study was 13 +/- 1.5 months. Twenty-two patients were receiving 1 immunosuppressant, 14 were receiving 2, and 5 were receiving 3. Thirteen patients (37%) stopped the study after 4 months. The mean tacrolimus level SD decreased from 3.46 microg/L before the study to 1.37 microg/L (P < .005). The number of immunosuppressants taken and patient self/caregiver medication administration did not significantly affect the results. The number of acute cellular rejection episodes decreased from 12 to 2 during the study. Risk factors for rejection were older age (17.67 vs 13.28 years) and administration of >1 immunosuppressant. We observed significant improvement in medication adherence and a reduction in rejection episodes with TM reminders for pediatric recipients of liver transplants.
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Home peak expiratory flow (PEF) measurement is recommended by asthma guidelines. In a 16-week randomized controlled study on 16 subjects with asthma (24.6 6.5 years old, asthma duration small ze, Cyrillic 6 months), we examined Global System for Mobile Communications (GSM) mobile telephone short-message service (SMS) as a novel means of telemedicine in PEF monitoring. All subjects received asthma education, self-management plan, and standard treatment. All measured PEF three times daily and kept a symptom diary. In the study group, therapy was adjusted weekly by an asthma specialist according to PEF values received daily from the patients. There was no significant difference between the groups in absolute PEF, but PEF variability was significantly smaller in the study group (16.12 +/- 6.93% vs. 27.24 +/- 10.01%, p = 0.049). forced expiratory flow in 1 second (FEV1; % predicted) in the study group was slightly but significantly increased (81.25 +/- 17.31 vs. 77.63 +/- 14.80, p = 0.014) and in the control group, unchanged (78.25 +/- 21.09 vs. 78.88 +/- 22.02, p = 0.497). Mean FEV1 was similar in the two groups both before and after the study. Controls had significantly higher scores for cough (1.85 +/- 0.43 vs. 1.42 +/- 0.28, p < 0.05) and night symptoms (1.22 +/- 0.23 vs. 0.85 +/- 0.32, p < 0.05). There was no significant difference between the groups in daily consumption of inhaled medicine, forced vital capacity, or compliance. Per patient, per week, the additional cost of follow-up by SMS was Euros 1.67 (equivalent to approximately $1.30 per 1 Euro), and SMS transmission required 11.5 minutes. Although a study group of 40 patients is needed for the follow-up study to achieve the power of 80% within the 95% confidence interval, we conclude that SMS is a convenient, reliable, affordable, and secure means of telemedicine that may improve asthma control when added to a written action plan and standard follow-up.
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To create Parent and Adolescent Medication Barriers Scales (PMBS and AMBS) for assessing perceived barriers to medication adherence in adolescent transplant recipients. These scales were developed and initially validated with 78 families. Participants responded to questions concerning perceived barriers to medication adherence. To assess validity, data on contextual factors (e.g., family functioning) and adherence measures were collected. A principal components factor analysis resulted in the following subscales for the PMBS and AMBS: (a) Disease Frustration/Adolescent Issues, (b) Regimen Adaptation/Cognitive Issues, (c) Ingestion Issues, and (d) Parent Reminder (PMBS only). Significant associations were found between barrier scale scores, contextual factors, and adherence. The PMBS and AMBS are brief and psychometrically promising scales for assessing perceived barriers to adherence in adolescent transplant recipients.
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Objective: To identify the availability and quality of apps supporting Dietary Approaches to Stop Hypertension (DASH) education. Methods: The researchers identified DASH apps over 1 month in the Apple App Store. Five registered dietitians used the App Quality Evaluation (AQEL) to evaluate app quality on 7 domains. Interrater reliability was tested using intraclass correlations. Results: One paid and 3 free DASH apps were evaluated. Interrater reliability (n = 5) was good for 3 apps and fair for 1 app. Only the paid app scored high (>8 of 10) on most AQEL quality domains. Conclusions and implications: Based on lower quality found among the included free apps, further development of free apps is warranted. Whereas the paid app may be useful in supporting DASH education, future research should determine whether improvements in clinical outcomes are found and whether this app should be improved to address AQEL domains better.
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The usability and acceptability of patient-centered mobile health tracking apps among most clinical populations are unknown. This mixed-methods feasibility study evaluated the usability and acceptability of the Health Storylines app among 32 adult radiation oncology patients in a 2-week trial. Data were collected via pre- and post-app use surveys and digital analytics. Participants accessed the app platform a total of 711 times. The overall usability of the Heath Storylines app was rated favorably, and 81% of participants reported the app easy to use. This study provides beginning evidence of the usability and acceptability of this type of mobile health tracking app in adult oncology patients.
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Young adults are the poorest consumers of vegetables. Social media and smartphones are frequently used by this demographic and could serve as an engaging medium for nutrition promotion. Five focus groups were conducted to capture participants' perceptions of a theory-based gamified self-monitoring app for improving vegetable intake of young adults. Ranking activities were used to gather feedback on preferences for social media posts. Data arising from group discussion were analysed using NVivo software using a deductive approach to group common ideas into themes. Thirty two participants (14 males) attended (mean age 23.1 (SD 2.7) years). Qualitative analyses of open discussion revealed two major themes regarding preferred features for a smartphone app; (1) the use of visual guides for estimating quantities of vegetables and tracking progress, and (2) a simple interface. Gamification strategies such as earning badges were viewed more positively than the use of a self-reward framework. Social media posts which presented food pictures and recipes were ranked most motivating, while awareness-raising posts received lower scores. Participants indicated a preference for viewing but reluctance to post information onto social media. "Just in time" situational cues were ranked highly and the use of an "authoritative" tone was preferred and associated with credibility. Young adults also ranked messages containing "Gen Y" language highly, with a preference for those which were personally relevant. The proposed use of social media and mobile-gaming was seen as an acceptable approach for improving vegetable intake. Materials should be visually appealing, simply designed, credible, and personally relevant to appeal to this population. This feedback may inform future mobile-phone based interventions targeting improved nutrition in young adults.
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Background Mobile apps for mobile phones and tablet devices are widely used by children and young people aged 0-18 years with long-term health conditions, such as chronic kidney disease (CKD), and their healthy peers for social networking or gaming. They are also poised to become a major source of health guidance. However, app development processes that are coproduced, rigorously developed, and evaluated to provide tailored, condition-specific, practical advice on day-to-day care management are seldom systematic or sufficiently described to enable replication. Furthermore, attempts to extrapolate to the real world are hampered by a poor understanding of the effects of key elements of app components. Therefore, effective and cost-effective novel, digital apps that will effectively and safely support care management are critical and timely. To inform development of such an app for children with CKD, a user requirements-gathering exercise was first needed. Objective To explore the views of children with CKD, their parents, and health care professionals to inform future development of a child-focused, care-management app. Methods Using age- and developmentally appropriate methods, we interviewed 36 participants: 5-10-year-olds (n=6), 11-14-year-olds (n=6), 15-18-year-olds (n=5), mothers (n=10), fathers (n=2), and health care professionals (n=7). Data were analyzed using Framework Analysis and behavior change theories. Results Of the 27 interviews, 19 (70%) interviews were individual and 8 (30%) were joint—5 out of 8 (63%) joint interviews were with a child or young person and their parent, 1 out of 8 (13%) were with a child and both parents, and 2 out of 8 (25%) were with 2 professionals. Three key themes emerged to inform development of a software requirement specification for a future home-based, digital care-management app intervention: (1) Gaps in current online information and support, (2) Difficulties experienced by children with a long-term condition, and (3) Suggestions for a digital care-management app. Reported gaps included the fact that current online information is not usually appropriate for children as it is “dry” and “boring,” could be “scary,” and was either hard to understand or not relevant to individuals’ circumstances. For children, searching online was much less accessible than using a professional-endorsed mobile app. Children also reported difficulty explaining their condition to others, maintaining treatment adherence, coping with feeling isolated, and with trying to live a “normal” life. There was recognition that a developmentally appropriate, CKD-specific app could support the process of explaining the condition to healthy peers, reducing isolation, adhering to care-management plans, and living a “normal” life. Participants recommended a range of media and content to include in a tailored, interactive, age- and developmentally appropriate app. For example, the user would be able to enter their age and diagnosis so that only age-appropriate and condition-specific content is displayed. Conclusions Future development of a digital app that meets the identified information and support needs and preferences of children with CKD will maximize its utility, thereby augmenting CKD caregiving and optimizing outcomes.
Article
Background Type 1 diabetes (T1D) afflicts approximately 154,000 people under 20 years of age. Three-quarters of adolescents are not achieving glycosylated hemoglobin (HbA1c) targets, which leads to negative health outcomes. Mobile health (mHealth), the use of technology in health, has been used successfully to improve health in many chronic conditions, including diabetes. Objective The purpose of this study was to use patient-centered research methods to inform and improve the design and functionality of our T1D app, MyT1DHero, and to provide insight for others who are designing a health app for adolescents and parents. Methods This study included data from focus groups with participants recruited from the Juvenile Diabetes Research Foundation (JDRF) southeast Michigan’s family network. All data collected during the sessions were audio-recorded, transcribed, and coded. Results Four key themes were identified: (1) diabetes is unpredictable, (2) negative and frustrated communication, (3) motivations to use an app, and (4) feedback specific to our app. Conclusions A patient-centered approach was used to assist in the development of an app for adolescents with T1D. Participants were satisfied with overall app design; customization, interactivity, and tangible rewards were identified as being necessary for continued use. Participants believed the app would help improve the communication between parents and adolescents. Many apps developed in the health context have not used a patient-centered design method or have seen vast improvements in health. This paper offers suggestions to others seeking to develop apps for adolescents and their parents.
Article
Purpose: A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable). Method: Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified. Results: Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue. Conclusion: The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.
Article
Background Self-regulation theory suggests people learn to influence their own behavior through self-monitoring, goal-setting, feedback, self-reward, and self-instruction, all of which smartphones are now capable of facilitating. Several mobile apps exist to manage asthma; however, little evidence exists about whether these apps employ user-centered design processes that adhere to government usability guidelines for mobile apps. Objective Building upon a previous study that documented adolescent preferences for an asthma self-management app, we employed a user-centered approach to assess the usability of a high-fidelity wireframe for an asthma self-management app intended for use by adolescents with persistent asthma. Methods Individual interviews were conducted with adolescents (ages 11-18 years) with persistent asthma who owned a smartphone (N=8). Adolescents were asked to evaluate a PDF app wireframe consisting of 76 screen shots displaying app features, including log in and home screen, profile setup, settings and info, self-management features, and graphical displays for charting asthma control and medication. Preferences, comments, and suggestions for each set of screen shots were assessed using the audio-recorded interviews. Two coders reached consensus on adolescent evaluations of the following aspects of app features: (1) usability, (2) behavioral intentions to use, (3) confusing aspects, and (4) suggestions for improvement. Results The app wireframe was generally well received, and several suggestions for improvement were recorded. Suggestions included increased customization of charts and notifications, reminders, and alerts. Participants preferred longitudinal data about asthma control and medication use to be displayed using line graphs. All participants reported that they would find an asthma management app like the one depicted in the wireframe useful for managing their asthma. Conclusions Early stage usability tests guided by government usability guidelines (usability.gov) revealed areas for improvement for an asthma self-management app for adolescents. Addressing these areas will be critical to developing an engaging and effective asthma self-management app that is capable of improving adolescent asthma outcomes.
Article
Background Cancer survivors are at an elevated risk for several negative health outcomes, but physical activity (PA) can decrease those risks. Unfortunately, adherence to PA recommendations among survivors is low. Fitness mobile apps have been shown to facilitate the adoption of PA in the general population, but there are limited apps specifically designed for cancer survivors. This population has unique needs and barriers to PA, and most existing PA apps do not address these issues. Moreover, incorporating user preferences has been identified as an important priority for technology-based PA interventions, but at present there is limited literature that serves to establish these preferences in cancer survivors. This is especially problematic given the high cost of app development and because the majority of downloaded apps fail to engage users over the long term. Objective The aim of this study was to take a qualitative approach to provide practical insight regarding this population’s preferences for the features and messages of an app to increase PA. Methods A total of 35 cancer survivors each attended 2 focus groups; a moderator presented slide shows on potential app features and messages and asked open-ended questions to elicit participant preferences. All sessions were audio recorded and transcribed verbatim. Three reviewers independently conducted thematic content analysis on all transcripts, then organized and consolidated findings to identify salient themes. Results Participants (mean age 63.7, SD 10.8, years) were mostly female (24/35, 69%) and mostly white (25/35, 71%). Participants generally had access to technology and were receptive to engaging with an app to increase PA. Themes identified included preferences for (1) a casual, concise, and positive tone, (2) tools for personal goal attainment, (3) a prescription for PA, and (4) an experience that is tailored to the user. Participants reported wanting extensive background data collection with low data entry burden and to have a trustworthy source translate their personal data into individualized PA recommendations. They expressed a desire for app functions that could facilitate goal achievement and articulated a preference for a more private social experience. Finally, results indicated that PA goals might be best established in the context of personally held priorities and values. Conclusions Many of the desired features identified are compatible with both empirically supported methods of behavior change and the relative strengths of an app as a delivery vehicle for behavioral intervention. Participating cancer survivors’ preferences contrasted with many current standard practices for mobile app development, including value-based rather than numeric goals, private socialization in small groups rather than sharing with broader social networks, and interpretation of PA data rather than merely providing numerical data. Taken together, these insights may help increase the acceptability of theory-based mHealth PA interventions in cancer survivors.
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Asthma apps often lack strong theoretical underpinnings. We describe how specific features of asthma apps influenced adolescents' self-observation, self-judgment, and self-reactions, which are key constructs of Self-Regulation Theory (SRT). Adolescents (ages 12-16) with persistent asthma (n = 20) used two asthma self-management apps over a 1-week period. During semi-structured interviews, participants identified their asthma goals and the app features that best promoted self-observation, self-judgment, and fostered positive self-reactions. Interviews were digitally recorded, transcribed verbatim, and analyzed thematically using MAXQDA. Adolescents' goals were to reduce the impact of asthma on their lives. Adolescents reported that self-check quizzes, reminders, and charting features increased their ability to self-observe and self-judge their asthma, which, in turn, helped them feel more confident they could manage their asthma independently and keep their asthma well-controlled. Asthma apps can positively influence adolescents' self-management behaviors via increased self-observation, self-judgment, and increased self-efficacy.
Article
Objectives: This study examines: 1) adolescent preferences for using asthma self-management mobile applications (apps) to interact with their friends, caregivers, medical providers, and other adolescents with asthma and 2) how caregivers and friends would use mobile apps to communicate with the adolescent and serve as sources of support for asthma management. Methods: We recruited 20 adolescents aged 12-16 years with persistent asthma, their caregivers (n = 20), and friends (n = 3) from two suburban pediatric practices in North Carolina. We gave participants iPods with two preloaded asthma apps and asked them to use the apps for 1-week. Adolescents and caregivers provided app feedback during a semi-structured interview at a regularly-scheduled clinic appointment and during a telephone interview one week later. Friends completed one telephone interview. Interviews were audio-recorded and transcribed verbatim. An inductive, theory-driven analysis was used to identify themes and preferences. Results: Adolescents preferred to use apps for instrumental support from caregivers, informational support from friends, and belonging and informational support from others with asthma. The majority of adolescents believed apps could enhance communication with their caregivers and medical providers, and the theme of self-reliance emerged in which caregivers and adolescents believed apps could enable adolescents to better self-manage their asthma. Friends preferred to use apps to provide instrumental and informational support. Conclusions: Given preferences expressed in this study, apps may help adolescents obtain social support to better self-manage their asthma. Future app-based interventions should include features enabling adolescents with asthma to communicate and interact with their caregivers, medical providers, and friends.
Article
This article addresses criticisms of qualitative research for spawning studies that lack analytic development and theoretical import. It focuses on teaching initial grounded theory tools while interviewing, coding, and writing memos for the purpose of scaling up the analytic level of students' research and advancing theory construction. Adopting these tools can improve teaching qualitative methods at all levels although doctoral education is emphasized here. What teachers cover in qualitative methods courses matters. The pedagogy presented here requires a supportive environment and relies on demonstration, collective participation, measured tasks, progressive analytic complexity, and accountability. Lessons learned from using initial grounded theory tools are exemplified in a doctoral student's coding and memo-writing excerpts that demonstrate progressive analytic development. The conclusion calls for increasing the number and depth of qualitative methods courses and for creating a cadre of expert qualitative methodologists.
Article
Applying principles of user-centered design, we iteratively developed and tested the prototype of TPP, an mHealth application to promote medication adherence and enhance communication about medication management between adolescents and primary caregivers. A purposive sample of seven adolescent solid organ transplant recipients who were ≥one yr post-transplant and their primary caregivers participated. Participants completed up to three face-to-face laboratory usability sessions, a 6-week field test, and a debriefing session. Primary caregivers participated in an additional usability telephone session. Participants completed usability and satisfaction measures. Sample included liver (n = 4), heart (n = 2), and lung (n = 1) recipients aged 11-18 yr (57% were female, 86% were Caucasian), and nine primary caregivers aged 42-61 yr (88.9% were parents, 88% were female, 88% were Caucasian). Ninety percent of the adolescents endorsed the graphs or logs of missed/late medication dosing as useful and 100% endorsed the remaining features (e.g., medication list, dose time reminders/warnings) as useful. All adolescents expressed interest in using TPP for monitoring medications and satisfaction with the automatic messaging between adolescent and caregiver versions of the application. Adolescents unanimously found TPP easy to use. TPP shows promise as an mHealth adherence tool. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Article
Despite the growing market of e-health disease self-management tools, few studies have reported the presence of teen patients in all phases of product design. While rates of American teens using mobile Internet grow, an opportunity to deliver disease self-management targeted for teen patients exists. Building on findings from previous investigations with teens with asthma, we explored teens' insights on the development of a patient-centered asthma management application (app). Two existing asthma apps were used by 16 teen asthmatics for 7-10 days. At the end of the trial period, in-depth interviews were conducted with each participant to gather insights about the user experience. Participants requested more asthma-related content that educates them about their condition. Suggested improvements to currently available apps included a longer list of selectable symptoms to track, medication tracking, and more compelling interface features. Participants showed interest in using apps for managing their asthma, yet recommended improvements on current design. Whereas national figures point to a more ubiquitous mobile device environment, implementation efforts must respond to participants' recommendations while minding lingering digital divides. Currently available apps lack appealing components that teens seek or desire. Subsequent development should include teens' participation in component design insights.
Article
In Germany, about 1 800 new cases of childhood cancer are diagnosed every year. The chances of survival have increased significantly over the last 40 years due to the continuous improvement of treatment strategies. The number of childhood cancer survivors in Germany thus ranges around 30 000 nowadays. But their treatment with surgery, chemotherapy, and radiation has certain side-effects. In addition to the acute effects during the treatment phase, the disease- and treatment-related late effects can occur even decades after the end of therapy. These late effects draw attention as the survival rate constantly increases. Two-thirds of the former patients retain long-term consequences, nearly a fifth with a resulting diminished quality of life. Early detection of these late effects can help to reduce or even to prevent serious health damage. Therefore, the study group LESS supplies long-term follow-up recommendations for former patients. The project described in this paper was to design and implement a mobile application to increase the compliance for this aftercare program. This application provides information about the patient's individual aftercare plan and supports appointment management as well as a reminding functionality. A prototype for former osteosarcoma patients was tested and evaluated in two university hospitals. First results show the application's very high potential for patient empowerment. © Georg Thieme Verlag KG Stuttgart · New York.
Article
Traditional challenges of creating a medical app include hearing the voices of various stakeholders as a collective rather than in a consultative process that is sequential. This report describes the development of a mobile (smartphone) app for adolescents with lupus as well as the process that was used to overcome the challenge described above. The development of the smartphone app addressed optimal ways to incorporate information about 1) lupus, including the effects of both the disease and the medications used to treat it; 2) how life choices can affect lupus patients' condition; and 3) ways to increase self-management and communication. The collaborative concept-generating and requirements-gathering methodology was used during a two-day workshop with a range of stakeholders (ages 16 - 59 years) that focused on leveraging user-centered design methods to generate guidance to mobile app developers. The app development process conducted during the workshop included the following steps: 1) recruiting a goal-focused collaborative group, 2) defining app objectives, 3) evaluating potential needs of users, 4) brainstorming app features and use-case modeling, 5) reviewing existing app features and prototypes, 6) refining functionalities, 7) writing user narratives, 8) visualizing navigation and feature design, and 9) identifying content. The use of creative devices such as drawing interfaces fostered fun, engagement, and sustained energy, and the use of a brainstorming technique leveraged methods that ensured an inclusive process so that even participants who were shy, quiet, or easily intimidated by "professionals" felt confident to contribute. In addition to a name change for the app, project outcomes included the selection of the following app features: symptom tracking; appointment and medication reminders; a social media component; a medical summary; easy navigation; informational content; gamification; and personalization (options for customization).
Article
Self-management of asthma can now leverage new media technologies. To optimize implementation they must employ a consumer-oriented developmental approach. This study explored benefits of and barriers to improved asthma self-management and identified key elements for the development of a digital media tool to enhance asthma control. Between August 2010 and January 2011, 18 teens with asthma and 18 parent-caregivers participated in semistructured in-depth interviews to identify mechanisms for improving asthma self-management and propose characteristics for developing a digital media tool to aid such efforts. Teens and caregivers enumerated physician-recommended strategies for asthma management as well as currently employed strategies. Both groups thought of a potential digital media solution as positive, but indicated specific design requirements for such a solution to have utility. Whereas most participants perceived mobile platforms to be viable modes to improve asthma self-management, interest in having social networking capabilities was mixed. A digital media product capable of tracking conditions, triggers, and related asthma activities can be a core element of improved asthma control for youth. Improved asthma control will help decrease school absenteeism.
Article
To identify and critique literature on the adolescent lived experience of chronic illness; describe the lived experience; and to make recommendations for clinical practice. Young people with chronic illness have the same developmental issues as those who are healthy. However, development can be disrupted by treatment and repeated hospitalisation. While the physical consequences of chronic illness on development have been established, the subjective personal experience is less known. Literature review. Electronic databases and hand searches were made of the literature published between January 1990-September 2007. Literature was eligible for inclusion if it involved adolescents between 10-19 years, and published in English and used qualitative methods of data collection. Methodological quality was assessed using the criteria described by Cesario et al. [Journal of Obstetrics, Gynaecology and Neonatal Nursing 31 (2002) 31]. Twenty studies were identified involving young people with a wide variety of chronic illnesses. The study quality was variable, however, generally the majority was assessed as being good or fair. Seven common themes were found between the identified studies: developing and maintaining friendships; being normal/getting on with life; the importance of family; attitude to treatment; experiences of school; relationship with the healthcare professionals; and the future. As there was commonality in themes between studies strategies to lessen the burden of chronic illness during adolescence do not necessarily need to be disease specific. Nurses need to focus on treating the young person rather than their illness.
Maternal & Child Health Bureau. The National Survey of Children With Special Health Care Needs
Health Resources & Services Administration, Maternal & Child Health Bureau. The National Survey of Children With Special Health Care Needs. Chartbook 2009-2010, p. 9. https://mchb.hrsa.gov/cshcn0910/. Accessed August 3, 2017.
Teen, social media and technology overview
  • A Lenhart
Lenhart A. Teen, social media and technology overview. Pew Research Center. 2015; http://www.pewinternet. org/2015/04/09/a-majority-of-american-teens-reportaccess-to-a-computer-game-console-smartphone-anda-tablet/. Accessed January 24, 2018.
Proposal: a Mixed Methods Approaisal Tool for Systematic Mixed Studies Reviews
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Pluye P, Robert E, Cargo M, et al. Proposal: a Mixed Methods Approaisal Tool for Systematic Mixed Studies Reviews. 2011; http://mixedmethodsappraisaltoolpublic. pbworks.com. Accessed November, 2017.