Modification and Validation of an mHealth App Quality Assessment Methodology for International Use: Cross-sectional and eDelphi Studies.

BACKGROUND: Over 325,000 mobile health (mHealth) apps are available to download across various app stores. However, quality assurance in this field of medicine remains relatively undefined. Globally, around 84% of the population have access to mobile broadband networks. Given the potential for mHealth app use in health promotion and disease prevention, their role in patient care worldwide is ever apparent. Quality assurance regulations both nationally and internationally will take time to develop. Frameworks such as the Mobile App Rating Scale and Enlight Suite have demonstrated potential for use in the interim. However, these frameworks require adaptation to be suitable for international use. OBJECTIVE: This study aims to modify the Enlight Suite, a comprehensive app quality assessment methodology, to improve its applicability internationally and to assess the preliminary validity and reliability of this modified tool in practice. METHODS: A two-round Delphi study involving 7 international mHealth experts with varied backgrounds in health, technology, and clinical psychology was conducted to modify the Enlight Suite for international use and to improve its content validity. The Modified Enlight Suite (MES) was then used by 800 health care professionals and health care students in Ireland to assess a COVID-19 tracker app in an online survey. The reliability of the MES was assessed using Cronbach alpha, while the construct validity was evaluated using confirmatory factor analysis. RESULTS: The final version of the MES has 7 sections with 32 evaluating items. Of these items, 5 were novel and based on consensus for inclusion by Delphi panel members. The MES has satisfactory reliability with a Cronbach alpha score of .925. The subscales also demonstrated acceptable internal consistency. Similarly, the confirmatory factor analysis demonstrated a positive and significant factor loading for all 32 items in the MES with a modestly acceptable model fit, thus indicating the construct validity of the MES. CONCLUSIONS: The Enlight Suite was modified to improve its international relevance to app quality assessment by introducing new items relating to cultural appropriateness, accessibility, and readability of mHealth app content. This study indicates both the reliability and validity of the MES for assessing the quality of mHealth apps in a high-income country, with further studies being planned to extrapolate these findings to low- and middle-income countries.

Identification and Evaluation of Methodologies to Assess the Quality of Mobile Health Apps in High-, Low-, and Middle-Income Countries: Rapid Review.

BACKGROUND: In recent years, there has been rapid growth in the availability and use of mobile health (mHealth) apps around the world. A consensus regarding an accepted standard to assess the quality of such apps has yet to be reached. A factor that exacerbates the challenge of mHealth app quality assessment is variations in the interpretation of quality and its subdimensions. Consequently, it has become increasingly difficult for health care professionals worldwide to distinguish apps of high quality from those of lower quality. This exposes both patients and health care professionals to unnecessary risks. Despite progress, limited understanding of the contributions of researchers in low- and middle-income countries (LMICs) exists on this topic. Furthermore, the applicability of quality assessment methodologies in LMIC settings remains relatively unexplored. OBJECTIVE: This rapid review aims to identify current methodologies in the literature to assess the quality of mHealth apps, understand what aspects of quality these methodologies address, determine what input has been made by authors from LMICs, and examine the applicability of such methodologies in LMICs. METHODS: This review was registered with PROSPERO (International Prospective Register of Systematic Reviews). A search of PubMed, EMBASE, Web of Science, and Scopus was performed for papers related to mHealth app quality assessment methodologies, which were published in English between 2005 and 2020. By taking a rapid review approach, a thematic and descriptive analysis of the papers was performed. RESULTS: Electronic database searches identified 841 papers. After the screening process, 52 papers remained for inclusion. Of the 52 papers, 5 (10%) proposed novel methodologies that could be used to evaluate mHealth apps of diverse medical areas of interest, 8 (15%) proposed methodologies that could be used to assess apps concerned with a specific medical focus, and 39 (75%) used methodologies developed by other published authors to evaluate the quality of various groups of mHealth apps. The authors in 6% (3/52) of papers were solely affiliated to institutes in LMICs. A further 15% (8/52) of papers had at least one coauthor affiliated to an institute in an 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 across LMICs; however, limited consideration of current generic methodologies for application in LMIC settings has been identified. TRIAL REGISTRATION: PROSPERO CRD42020205149; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=205149.

Implementing Innovative Approaches to Healthcare in a Lower-Middle Income Country: Perspectives from Malawi.

INTRODUCTION: Safe, reliable, and effective healthcare systems are essential for all nations to ensure the health and wellbeing of their citizens. However, this is not always achievable with clinical therapies constantly evolving, resulting in a domino effect of structural, policy and training changes. For low- and middle-income countries (LMICs), implementing change is restricted. It is essential that innovative and realistic solutions are developed, so that effective change can be realised in LMICs. MATERIALS AND METHODS: In this report of a global health conference held in July 2019, six perspectives are presented which aim to generate long-term positive change in Malawi. Perspective 1: Pneumonia - the BIOTOPE study (BIOmarkers TO diagnose PnEumonia) sought to determine the aetiology of pneumonia in children presenting in primary care. It assessed blood-based markers of bacterial infection as part of a rapid diagnostic approach to better utilise existing resources in Malawi. Perspective 2: Cardiovascular - the CARDIA project (CARdiac Dysfunction in Africa) was established to assess clinical and biochemical phenotypes of diabetic patients in Malawi. Perspective 3: Asthma - an observational study was conducted to implement a health system strengthening initiative for asthma. The use of locally adapted formularies and protocols with ongoing online mentoring through expert partnerships provided an opportunity to sustainably build capacity. Perspective 4: Sustainable Partnerships - establishing the Malawi electronic Health (eHealth) Research Centre, an international hub to develop education, research and innovation for long-term collaboration. Perspective 5: Part-Time PhD Studies - undertaking a part-time PhD within a LMIC provides logistic challenges, but also a number of opportunities for observational research. Perspective 6: Medical electives - an undergraduate elective allows real exposure to global health and facilitates life-long collaborations at an early stage in a medical career. CONCLUSION: Malawi is an under-doctored and resource-poor country. North-South partnerships in Malawi should be strengthened with particular emphasis on healthcare innovations, such as eHealth, which allow healthcare problems to be highlighted early while preventative measures are still possible.

Anaesthesia in austere environments: literature review and considerations for future space exploration missions.

Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.

Training effect of using Touch Surgery for intramedullary femoral nailing.

BACKGROUND: Simulation in orthopaedic training is becoming increasingly popular and has been widely used in formal curricula. However, these resources are expensive and not easily accessible to every trainee. Other means of disseminating surgical education through virtual reality (VR) multimedia can act as useful adjunct to traditional methods of teaching. One validated VR platform is Touch Surgery, a cognitive task simulation and rehearsal app. OBJECTIVES: The primary objective of this study was to identify the training effect of Touch Surgery intramedullary femoral nailing (IFN) modules using objective performance metrics over six consecutive attempts. Secondary objectives consisted of validated multiple choice questions (MCQ) testing before the first (pre) and after the sixth (post) attempts. METHODS: 27 medical undergraduates were recruited to complete the decision-making process six consecutive times for four modules on the procedural steps of IFN. The modules consisted of (i) preparing the patient and equipment, (ii) femoral canal preparation, (iii) nail insertion and proximal locking, and (iv) distal locking and closure. Real-time objective performance metrics were obtained, stored electronically and analysed using the median and Bonett-Price 95% confidence intervals from the participants' attempts to assess training effect. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value <0.05. RESULTS: Median performance scores per attempt for all four modules demonstrated a significant improvement ranging from 58 to 115%. Scoring variability and distribution was reduced and more predictable per attempt. Logarithmic learning curves elicited strong positive correlations between the number of attempts and scoring. Mean scores for pre and post-study MCQs tests significantly improved from 83 to 94% in all modules. CONCLUSION: IFN modules on Touch Surgery app demonstrated a significant training effect with practice. Novices demonstrated cognitive competencies to ensure patient safety prior to operating. The app is an effective adjunct to traditional learning methods and has the potential for curricular implementation.

Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing.

BACKGROUND: The role of simulation in orthopaedic surgical training is becoming increasingly evident, as simulation allows repeated sustained practice in an environment that does not harm the patient. Previous studies have shown that the cognitive aspects of surgery are of equal if not greater importance in developing decision making than the practical aspects. AIM: To observe construct, content and face validity of four IFN modules on a cognitive simulator, Touch Surgery™. METHODS: 39 novices and 10 experts were recruited to complete four simulation modules on surgical decision-making that represented the procedural steps of preparing the patient and equipment, inserting and locking an intramedullary femoral nail. Real-time objective performance metrics were obtained, stored electronically and analysed using median and Bonett-Price 95% confidence intervals from the participant's primary attempt to assess for construct validity. The median score of a post-study questionnaire using 5-point Likert scales assessed face and content validity. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value<0.05. RESULTS: Experts significantly outperformed novices in all four modules to demonstrate construct validity (p<0.001). Specifically, experts scored 32.5% higher for patient positioning and preparation (p<0.0001), 31.5% higher for femoral canal preparation (p<0.0001), 22.5% higher for proximal locking (p<0.0001) and 17% higher scores for distal locking and closure (p<0.001). Both cohorts either agreed or strongly agreed that the graphics, simulated environment and procedural steps were realistic. Also, both cohorts agreed that the app was useful for surgical training and rehearsal, should be implemented within the curriculum and would want to use it to learn other surgical procedures. CONCLUSION: IFN on the Touch Surgery app demonstrated construct, face and content validity. Users can demonstrate cognitive competencies prior to performing surgical procedures in the operating room. The application is an effective adjunct to traditional learning methods and has potential for curricular implementation.