by Eun-Shim Nahm, PhD, RN, FAAN
University of Maryland School of Nursing
655 W. Lombard St, Suite 455 C
Baltimore, MD 21201
Tel: (W) 410-706-4913
Nahm, E. (2013). Guest Editorial. Mobile Technologies for Health Education: What Do We Need to Consider? Online Journal of Nursing Informatics (OJNI), 17 (2), Available at http://ojni.org/issues/?p=2655
In the past several years, there has been a significant national emphasis on the use of health information technology (HIT) to make health care safer and more efficient. Healthy People 2020 also highlights the importance of using Internet and mobile devices to promote public health (U.S. Department of Health and Human Services, 2012). In fact, the Internet has already become an excellent dissemination medium for health information, and the public now has access to an unprecedented amount of online health information. In 2012, 81% of American adults were online users (Pew Internet, 2012), and 59% of them used the Internet to find health information (Fox & Duggan, 2013). Many major hospitals use patient health portals, allowing patients to review their health records and communicate with their health care providers.
Recently, mobile technologies, such as mobile phones and tablets, are one of the fastest growing online access platforms (Rainie & Fox, 2012). In 2012, 87% of American adults owned a mobile phone, and 45% of them had a smartphone. Since the introduction of iPads in 2010, there has been a rapid growth in the use of tablets. Now, 31% of American adults own a tablet computer (Pew Internet, 2013), and many clinicians are using them in clinical settings (e.g., for information retrieval). Some clinicians have found iPads helpful when explaining certain procedures and disease processes to their patients at the bedside (e.g., as a visual aid) (Blaz, Kapsandoy, & Staggers, 2011; Feldman, Nathanson, Halamka, & Meyers, 2011; Valentine, Dundas, & Fitz, 2011; Zhang et al., 2011). Many laypersons also use iPads to access health information as well. With their mobility, easy user interfaces (i.e., touch screens), and convenient connectivity, mobile programs offer health care providers an excellent opportunity to reach out and connect many different segments of populations to existing eHealth resources. This column will discuss the use of mobile technologies for health education specifically focusing on design issues.
Mobile phone-based health interventions (voice-based and/or text-based messages) are already in active use, and many studies showed their effectiveness on health outcomes. For example, a systematic review of 18 studies found some positive impact of cell phone-based health information interventions on health outcomes, including provider-patient communication and patients’ satisfaction with care (Krishna & Boren, 2008). The majority of the interventions used in the published studies have focused on the use of short message service (SMS) based interventions or health apps. In an RCT (N = 5,800) that used a text message support program for smoking cessation (“TXT2STOP”), the intervention group showed significantly higher cessation rates(Free, et al., 2011). In another RCT (Patrick et al., 2009), overweight adults (N=75; mean age, 44.9) who were exposed to a 16-week text message-based program showed significantly greater weight loss (mean weight loss, 2.88 kg). Other studies have also reported the effectiveness of text messages on adherence rates for clinic visits (Taylor, Bottrell, Lawler, & Benjamin, 2012; Vawdrey et al., 2011).
Now, let’s think about developing mobile health education interventions for specific groups or target populations. The content can be delivered in various ways, including SMS, learning modules, or video lectures, as well as any combination of these programs. In a traditional online learning environment, the content is often delivered using the online learning module format. Those learning modules consist of text, audio, and/or video materials. Mobile platform settings, however, can pose some specific design challenges, such as limited screen space, device-specific operation systems, unique navigation methods, and certain program compatibilities (e.g., Flash program and iPads). The magnitude of the screen size limitations is less in tablets than smart phones. In light of using mobile platforms for health education, usability (“user friendliness”) of the mobile programs is vital for interaction and to achieve desired health outcomes. Although there has been extensive research regarding usability of online health programs, few studies have been conducted on mobile health programs. In fact, most health websites are accessible via mobile devices. To date, however, many of those online programs are not optimized for access via mobile devices, resulting in reading and navigation difficulties. Furthermore, screen optimization differs depending on the mobile device (e.g., tablets vs. smartphones). Compared to the rapid growth in using mobile technologies for personal health, the research focused on effective design methodologies for mobile health programs has been slow. The design issues have become prominent, particularly when health programs target middle-aged or older adults, who have the most interest in health topics. These older adults did not grow up using mobile technologies and may not be as proficient as younger generations. Similar phenomena occurred with the previous emergence of the Internet.
The care providers or researchers who plan to develop mobile health programs, must have sound understanding of the target populations’ competency levels in using mobile devices and the device platforms they use. Although technical experts perform the actual coding of the program, the clinicians or researchers need to determine the amount of information for the entire program, each screen, and navigation methods. The developers must make careful decisions regarding the amount of content and the number of pages to make the site both effective, efficienct and appealing. This can be a difficult balancing act because from a health educators’ standpoint, provision of sufficient information is vital in making the content clear to the majority of the target group. From the “look and feel” perspective, mobile health programs need to be optimized for smartphones, tablets, and computer access. Each type of device requires unique design heuristics (guidelines). The Word Wide Web Consortium (W3C) recommends design guidelines for mobile developers (W3C®, 2008). For example, limited use of pictures and external sources are recommended for websites that are accessed via smartphones. In contrast, most tablets (e.g., iPads) use many icons to accommodate users’ touchscreen inputs.
In a pilot study, our research team developed a prototype mobile health web program which focused on healthy eating and exercise for underserved populations (Nahm et al., 2013). We found that the navigation approaches used by smartphones were quite different than those of iPads or regular web browsers, and required a completely different structure of the content. In addition, the design optimized for iPads looked different than regular web pages that are often found on public health websites (e.g., font sizes and alignment of the content). In particular, the differences are more prominent when specific features (e.g. footers) are set based on the size of the tablet screen. Thus, the development of well designed, device agnostic mobile health learning programs seems to take much more effort and resources compared to online programs accessed via traditional computers. In addition, usability testing of these programs also takes much longer and requires more resources as the testing must be performed for each device.
Mobile health technologies fit well with the current emphasis on personalized health initiatives and hold great promise. Although there has been rapid growth in the use of these technologies in health care (e.g., various health apps), little research has been conducted on usability of those health programs and design heuristics. Many more studies are needed in this area using various devices, programs, and populations. Clinical nurses and informatics nurse specialists are well positioned to lead this endeavor as they have a great deal of experience in patient and family education and many opportunities to communicate with patients to assess their competencies in using these technologies.
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Feldman, H., Nathanson, L., Halamka, J., & Meyers, J. (2011, October). Tablets in healthcare: Not just for pills anymore. Paper presented at the American Medical Informatics Association, Washington, D.C.
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Krishna, S., & Boren, S. A. (2008). Diabetes self-management care via cell phone: A systematic review. Journal of Diabetes Science and Technology, 2(3), 509-517.
Nahm, E.-S., Antol, S., Carter-Pokras, O., Zhang, D., Kapustin, J., Plummer, L., . . . Rietschel, M. (2013, March). Development and testing of a mobile health website for mobile clinic patients. Paper presented at the Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine, San Francisco, CA.
Patrick, K., Raab, F., Adams, M. A., Dillon, L., Zabinski, M., Rock, C. L., . . . Norman, G. N.(2009). A text message-based intervention for weight loss: Randomized controlled trial. Journal of Medical Internet Research, 11(1), e1. doi: 10.2196/jmir.1100
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Taylor, N. F., Bottrell, J., Lawler, K., & Benjamin, D. (2012). Mobile telephone short message service reminders can reduce nonattendance in physical therapy outpatient clinics: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 93(1), 21-26. doi: 10.1016/j.apmr.2011.08.007
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Valentine, S., Dundas, J. A., & Fitz, K. (2011). Evidence for the use of a new patient-centered fitting tool. Hearing Review, 18(4), 28-34.
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Zhang, P., Recio, A., Wills, G., Smitham, P., Gilbert, L., Santer, M., . . . Grange, S.(2011, March). Catch before a fall–an iPad application for osteoporosis risk assessment. Paper presented at the International Association for Development of the Information Society (IADIS) International Conference on e-Society, Avila, Spain.