Peter J. Schulz

Mapping mHealth research: a decade of evolution.

Background For the last decade, mHealth has constantly expanded as a part of eHealth. Mobile applications for health have the potential to target heterogeneous audiences and address specific needs in different situations, with diverse outcomes, and to complement highly developed health care technologies. The market is rapidly evolving, making countless new mobile technologies potentially available to the health care system; however, systematic research on the impact of these technologies on health outcomes remains scarce. Objective To provide a comprehensive view of the field of mHealth research to date and to understand whether and how the new generation of smartphones has triggered research, since their introduction 5 years ago. Specifically, we focused on studies aiming to evaluate the impact of mobile phones on health, and we sought to identify the main areas of health care delivery where mobile technologies can have an impact. Methods A systematic literature review was conducted on the impact of mobile phones and smartphones in health care. Abstracts and articles were categorized using typologies that were partly adapted from existing literature and partly created inductively from publications included in the review. Results The final sample consisted of 117 articles published between 2002 and 2012. The majority of them were published in the second half of our observation period, with a clear upsurge between 2007 and 2008, when the number of articles almost doubled. The articles were published in 77 different journals, mostly from the field of medicine or technology and medicine. Although the range of health conditions addressed was very wide, a clear focus on chronic conditions was noted. The research methodology of these studies was mostly clinical trials and pilot studies, but new designs were introduced in the second half of our observation period. The size of the samples drawn to test mobile health applications also increased over time. The majority of the studies tested basic mobile phone features (eg, text messaging), while only a few assessed the impact of smartphone apps. Regarding the investigated outcomes, we observed a shift from assessment of the technology itself to assessment of its impact. The outcome measures used in the studies were mostly clinical, including both self-reported and objective measures. Conclusions Research interest in mHealth is growing, together with an increasing complexity in research designs and aim specifications, as well as a diversification of the impact areas. However, new opportunities offered by new mobile technologies do not seem to have been explored thus far. Mapping the evolution of the field allows a better understanding of its strengths and weaknesses and can inform future developments.

Health literacy and patient empowerment in health communication: The importance of separating conjoined twins

OBJECTIVE Patient empowerment and health literacy have both been studied empirically, but they have hardly ever been explicitly linked. METHODS Pertinent literature from the development of both concepts was studied, drawing not only on health care literature, but also on management research. RESULTS This article argues that it is important to recognize that the concepts are distinct, both conceptually and empirically. At the same time, the impacts of health literacy and patient empowerment are deeply intertwined. High literacy does not necessarily entail empowerment and vice versa, and mismatches of the two can have deleterious consequences. High levels of health literacy without a corresponding high degree of patient empowerment creates an unnecessary dependence of patients on health professionals, while a high degree of empowerment without a corresponding degree of health literacy poses the risk of dangerous health choices. CONCLUSION We discuss the importance of carefully conceptualizing both approaches, the implications for their measurement and the design of health interventions. PRACTICE IMPLICATIONS Communication programs must include the empowerment that motivates consumers to engage and the literacy that enables them to make informed and reasoned choices.

Defining and measuring health literacy: how can we profit from other literacy domains?

When the antecedents of health-promoting behavior are explored, the concept of health literacy is deemed a factor of major influence. Originally defined as reading, writing and numeracy skills in the health domain, health literacy is now considered a multidimensional concept. The ongoing discussion on health literacy reveals that no agreement exists about which dimensions to include in the concept. To contribute to the development of a consistent and parsimonious concept of health literacy, we conducted a critical review of concepts in other literacy domains. Our review was guided by two research questions: (i) Which dimensions are included in the concepts of other literacy domains? (ii) How can health literacy research profit from other literacy domains? Based on articles collected from PubMed, PsycINFO, Communication & Mass Media Complete, CINAHL, SAGE Full-Text Collection, Cochrane Library and Google Scholar as well as selected monographs and editions, we identified seven distinct dimensions. Some of the dimensions recur across all reviewed literacy domains and first attempts have been made to operationalize the dimensions. Expanding upon these dimensions, the paper discusses how they can prove useful for elaborating a consistent and parsimonious concept of health literacy and foster the development of a more holistic measure.

Online Health Information Seeking in the Context of the Medical Consultation in Switzerland

A growing number of patients search for medical information on the Internet. Understanding how they use the Internet is important, as this might impact their health, patient—practitioner roles, and general health care provision. In this article, we illustrate the motives of online health information seeking in the context of the doctor—patient relationship in Switzerland. We conducted semistructured interviews with patients who searched for health information online before or after a medical consultation. Findings suggest that patients searched for health information online to achieve the goals of preparing for the consultation, complementing it, validating it, and/or challenging its outcome. The initial motivations for online health information seeking are identified in the needs for acknowledgment, reduction of uncertainty, and perspective. Searching health information online was also encouraged by personal and contextual factors, that is, a person’s sense of self-responsibility and the opportunity to use the Internet. Based on these results, we argue that online health information seeking is less concerned with what happens during the consultation than with what happens before or after it, in the sociocultural context.

The Effect of Information Communication Technology Interventions on Reducing Social Isolation in the Elderly: A Systematic Review

Background The aging of the population is an inexorable change that challenges governments and societies in every developed country. Based on clinical and empirical data, social isolation is found to be prevalent among elderly people, and it has negative consequences on the elderly’s psychological and physical health. Targeting social isolation has become a focus area for policy and practice. Evidence indicates that contemporary information and communication technologies (ICT) have the potential to prevent or reduce the social isolation of elderly people via various mechanisms. Objective This systematic review explored the effects of ICT interventions on reducing social isolation of the elderly. Methods Relevant electronic databases (PsycINFO, PubMed, MEDLINE, EBSCO, SSCI, Communication Studies: a SAGE Full-Text Collection, Communication & Mass Media Complete, Association for Computing Machinery (ACM) Digital Library, and IEEE Xplore) were systematically searched using a unified strategy to identify quantitative and qualitative studies on the effectiveness of ICT-mediated social isolation interventions for elderly people published in English between 2002 and 2015. Narrative synthesis was performed to interpret the results of the identified studies, and their quality was also appraised. Results Twenty-five publications were included in the review. Four of them were evaluated as rigorous research. Most studies measured the effectiveness of ICT by measuring specific dimensions rather than social isolation in general. ICT use was consistently found to affect social support, social connectedness, and social isolation in general positively. The results for loneliness were inconclusive. Even though most were positive, some studies found a nonsignificant or negative impact. More importantly, the positive effect of ICT use on social connectedness and social support seemed to be short-term and did not last for more than six months after the intervention. The results for self-esteem and control over one’s life were consistent but generally nonsignificant. ICT was found to alleviate the elderly’s social isolation through four mechanisms: connecting to the outside world, gaining social support, engaging in activities of interests, and boosting self-confidence. Conclusions More well-designed studies that contain a minimum risk of research bias are needed to draw conclusions on the effectiveness of ICT interventions for elderly people in reducing their perceived social isolation as a multidimensional concept. The results of this review suggest that ICT could be an effective tool to tackle social isolation among the elderly. However, it is not suitable for every senior alike. Future research should identify who among elderly people can most benefit from ICT use in reducing social isolation. Research on other types of ICT (eg, mobile phone–based instant messaging apps) should be conducted to promote understanding and practice of ICT-based social-isolation interventions for elderly people.

The Effect of Social Support Features and Gamification on a Web-Based Intervention for Rheumatoid Arthritis Patients: Randomized Controlled Trial

Background Rheumatoid arthritis (RA) is chronic systematic disease that affects people during the most productive period of their lives. Web-based health interventions have been effective in many studies; however, there is little evidence and few studies showing the effectiveness of online social support and especially gamification on patients’ behavioral and health outcomes. Objective The aim of this study was to look into the effects of a Web-based intervention that included online social support features and gamification on physical activity, health care utilization, medication overuse, empowerment, and RA knowledge of RA patients. The effect of gamification on website use was also investigated. Methods We conducted a 5-arm parallel randomized controlled trial for RA patients in Ticino (Italian-speaking part of Switzerland). A total of 157 patients were recruited through brochures left with physicians and were randomly allocated to 1 of 4 experimental conditions with different types of access to online social support and gamification features and a control group that had no access to the website. Data were collected at 3 time points through questionnaires at baseline, posttest 2 months later, and at follow-up after another 2 months. Primary outcomes were physical activity, health care utilization, and medication overuse; secondary outcomes included empowerment and RA knowledge. All outcomes were self-reported. Intention-to-treat analysis was followed and multilevel linear mixed models were used to study the change of outcomes over time. Results The best-fit multilevel models (growth curve models) that described the change in the primary outcomes over the course of the intervention included time and empowerment as time-variant predictors. The growth curve analyses of experimental conditions were compared to the control group. Physical activity increased over time for patients having access to social support sections plus gaming (unstandardized beta coefficient [B]=3.39, P=.02). Health care utilization showed a significant decrease for patients accessing social support features (B=–0.41, P=.01) and patients accessing both social support features and gaming (B=–0.33, P=.03). Patients who had access to either social support sections or the gaming experience of the website gained more empowerment (B=2.59, P=.03; B=2.29, P=.05; respectively). Patients who were offered a gamified experience used the website more often than the ones without gaming (t 91=–2.41, P=.02; U=812, P=.02). Conclusions The Web-based intervention had a positive impact (more desirable outcomes) on intervention groups compared to the control group. Social support sections on the website decreased health care utilization and medication overuse and increased empowerment. Gamification alone or with social support increased physical activity and empowerment and decreased health care utilization. This study provides evidence demonstrating the potential positive effect of gamification and online social support on health and behavioral outcomes. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 57366516; http://www.controlled-trials. com/ISRCTN57366516 (Archived by webcite at http://www.webcitation.org/6PBvvAvvV).

Health literacy beyond knowledge and behaviour: letting the patient be a patient.

Health literacy is widely regarded as critical for managing personal health (Nutbeam and Kickbusch 2000; Schloman 2004; Andrus and Roth 2002) and is an important sociopolitical issue in that limited health literacy can result in enormous burdens to healthcare systems (Dubow 2004; DeBuono 2004). Lack of specific skills and knowledge associated with health literacy has been shown to negatively affect people’s understanding and use of information provided by health professionals. Much descriptive research has sought to elucidate the concept of health literacy, its measurement, and the problem of low health literacy. The term ‘‘health literacy’’ was first used by Simonds in the context of school health education. Simonds argued for the importance of students becoming as ‘‘literate’’ in health as they were in other disciplines (Ratzan 2001). This view crystallized an understanding of health literacy as ‘‘functional literacy’’, as exemplified by the American Medical Association report where health literacy is conceived as ‘‘the ability to read and comprehend prescription bottles, appointment slips, and the other essential health-related materials’’ (Ad hoc committee on health literacy for the counsel of scientific affairs. American Medical Association 1999). This functional approach to health literacy assumes epistemic objectivity; that is, reading skill and comprehension are objectively measurable. Certainly, deficiencies in reading and numeracy skills represent a major barrier to health education and management (Brown et al. 2003; Schloman 2004; Williams et al. 1995; Parker et al. 2003), and this has given rise to a large body of research on proposing tests for assessing literacy levels and strategies for improving the accessibility of materials such as patient education leaflets and informed-consent documents (Maag 2005). In recent years, however, an expanded view of health literacy has been motivated by evidence of an at best weak link between the ability to read and understand health communication and patients’ actual performance. This gap between functional skills and patient practice created the need to extend the definition of health literacy to include factors that can influence health decisions (Ratzan 2001; Kickbusch and Ratzan 2001; Cutilli 2005; Parker 2000; Nutbeam 2000; McCray 2005) as reflected in the WHO definition of health literacy as ‘‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’’ (World Health Organization 1998). Some recent definitions of health literacy have expanded the concept to the point where literacy becomes the ability to make sound decisions in all domains; from home and the workplace to the political arena (Kickbusch et al. 2005). However, with these skill-based enrichments of the concept (especially in health promotion-oriented visions), health literacy has grown broader in extension but impoverished in its intension. Factors that extend the limited definition of functional literacy have been incorporated but, at the same time, have lost focus on the central link between the person’s goals and actions, reducing health literacy to a set of skills and taking for granted motivation and the meaning of ‘‘good health’’. S. Rubinelli (&) P. J. Schulz Institute of Communication and Health, University of Lugano, Via Buffi 13, 6904 Lugano (CH), Switzerland e-mail: sara.rubinelli@lu.unisi.ch

An internet-based approach to enhance self-management of chronic low back pain in the Italian-speaking population of Switzerland: results from a pilot study

SummaryObjective:To illustrate the development and pilot evaluation of a website designed to enhance self-management of chronic low back pain for the Italian-speaking population of Switzerland.Methods:20 patients affected by chronic low back pain used a website – specifically created for the project – for a period of five months, under the monitoring of a team of health professionals. Evaluation was carried out by means of a telephone questionnaire administered at baseline and at the end of the intervention, and intermediate online user-testing performed in the fourth month of the intervention. A control group of 15 patients was created to assist the evaluation.Results:Compared to the control group, results from the pilot evaluation suggest a decrease in the intensity of back pain in people with access to the website; an increase in physical activity; a reduction in both medical consultation and the use of painkillers, and a gain in declarative and procedural knowledge. This coincides with a general positive assessment of the website.Conclusion:The study supports the need to test the proposed approach on a wider scale.

Distorted food pyramid in kids programmes: A content analysis of television advertising watched in Switzerland

BACKGROUND In the light of increasing childhood obesity, the role of food advertisements relayed on television (TV) is of high interest. There is evidence of food commercials having an impact on childrens food preferences, choices, consumption and obesity. We describe the product categories advertised during kids programmes, the type of food promoted and the characteristics of food commercials targeting children. METHODS A content analysis of the commercials aired during the kids programmes of six Swiss, one German and one Italian stations was conducted. The commercials were collected over a 6-month period in 2006. RESULTS Overall, 1365 h of kids programme were recorded and 11 613 advertisements were found: 3061 commercials (26.4%) for food, 2696 (23.3%) promoting toys, followed by those of media, cleaning products and cosmetics. Regarding the broadcast food advertisements, 55% were for fast food restaurants or candies. CONCLUSION The results of the content analysis suggest that food advertising contributes to the obesity problem: every fourth advertisement is for food, half of them for products high in sugar and fat and hardly any for fruit or vegetables. Long-term exposure to this distortion of the pyramid of recommended food should be considered in the discussion of legal restrictions for food advertising targeting children.

Cyberdrugs: a cross-sectional study of online pharmacies characteristics

As e-commerce and online pharmacies (OPs) arose, the potential impact of the Internet on the world of health shifted from merely the spread of information to a real opportunity to acquire health services directly. Aim of the study was to investigate the offer of prescription drugs in OPs, analysing their characteristics, using the content analysis method. The research performed using the Google search engine led to an analysis of 118 online pharmacies. Only 51 (43.2%) of them stated their precise location. Ninety-six (81.4%) online pharmacies did not require a medical prescription from the customers physician. Online pharmacies rise complex issues in terms of patient-doctor relationship, consumer empowerment, drug quality, regulation and public health implications.