Development and evaluation of an educational game to support pharmacy students.

INTRODUCTION: United Kingdom pharmacy students need to efficiently navigate the British National Formulary (BNF), a standard medicines reference source. "Pharmacy Challenge" is a web-based prototype game based on the BNF. This research aimed to evaluate the game in terms of design, content, and impact on students' performance and confidence. METHODS: Evaluation was comprised of three phases: implementation, perception, and impact. Game design and evaluation methods were modelled using adapted elements of the Relevance Embedding Translation Adaption Immersion and Naturalisation framework. Qualitative and quantitative questionnaires were utilised to assess students' perceptions of the game and its role in their education and to evaluate changes in confidence and performance after playing the game. Quizzes were developed to determine changes in performance. RESULTS: The questionnaire evaluation (n = 152) found students' confidence increased significantly (p < .05) in speed of using, knowledge of BNF sections, extracting information, and knowing where to look for the answer. Most students (88%) felt they had learnt something new and 86% felt that it reinforced their learning. A significant (p < .05) increase in pre- and post- BNF quiz marks was observed. CONCLUSIONS: Statistically significant improvement in students' perceived confidence was noted. The study identified design elements such as the need for a simple interface to encourage engagement. The prototype has undergone a design transformation based on the feedback provided and is now released under the name "DOSE" with a bank of 300 questions, improved graphics, a leadership board, and medals.

A systematic review of reviews to identify key research opportunities within the field of eHealth implementation.

INTRODUCTION: This paper is a systematic review of the relevant literature surrounding the implementation and utilisation of eHealth to identify key challenges and opportunities to future eHealth applications. METHODS: NHS Evidence, PubMed, IEEE Explorer, Cochrane Library and JMIR Publications were all searched for reviews published between 1 January 2010 and 30 June 2017. RESULTS: A total of 47 papers met the final inclusion criterion. The published literature focused on a wide array of challenges categorised into five areas, facing the implementation and utilisation of eHealth; from this, four areas of opportunity to advance eHealth were identified. DISCUSSION: The five challenge areas are (C1) stakeholders and system users, (C2) technology and interoperability, (C3) cost-effectiveness and start-up costs, (C4) legal clarity and legal framework and (C5) local context and regional differences. The four opportunity areas are (O1) participation and contribution, (O2) foundation and sustainability, (O3) improvement and productivity and (O4) identification and application. CONCLUSION: The literature analysed in this systematic review identifies design and implementation priorities that can guide the development and utilisation of future eHealth initiatives.

Evaluation of the effectiveness of mobile diabetes management system with social networking and cognitive behavioural therapy (CBT) for T2D.

BACKGROUND: In the Saudi Arabia region there are no previous studies related to the use of social networks combined with the management of mobile diabetes. In this sense, the aim of this feasibility investigation is to evaluate the application and utility of the SANAD system (Saudi Arabia Networking for Aiding Diabetes) to support Saudi type 2 diabetes adult patients. METHODS: Twenty patients from a clinic in Saudi Arabia-Dammam were recruited to use the SANAD system. The study design was a randomized controlled trial (RCT) with two groups: an intervention group using SANAD system and a control group using conventional diabetes treatment. Glycated hemoglobin (HbA1c), diabetes knowledge test (DKT) and Self-efficacy Scale (SES) were documented. RESULTS: Nineteen patients completed the study. Mean baseline HbA1c (%) was 8.14 (SD 1.20) and decreased to 7.54 (SD 0.96) after the SANAD intervention process [mean (SEM) decrease 0.600 (0.102)]. A paired-samples t-test showed this change to be significant (P=0.000). Linear regression analyzed each study group separately, and revealed that age significantly predicted change in HbA1c (%) in the intervention group, with older age (i.e., 41-50 years) associated with higher HbA1c (%) at 6 months, as compared with baseline values (ß=0.865, t=3.67, P<0.05). The mean diabetes knowledge score prior to the intervention (baseline) was 12.11 (SD 2.09), which rose to 14.56 (SD 1.59) afterward. This increase [mean (SEM), 2.44 (0.530)] was shown to be significant using the paired-samples t-test (P=0.002). Linear regression demonstrated that age, gender, and educational level were not related to increased diabetes knowledge in each study group. The mean self-efficacy score prior to the intervention (baseline) was 5.17 (SD 0.45), which rose to 6.17 (SD 0.39) afterward. This increase [mean (SEM), 0.944 (0.192)] was shown to be significant using the paired-samples t-test (P=0.001). Linear regression demonstrated that age, gender, and educational level were not related to increased self-efficacy in each study group. CONCLUSIONS: This study demonstrates that using of SANAD system is acceptable, and feasible in supporting diabetes care in Saudi Arabia. This study is the first in Saudi Arabia to demonstrate similar benefits of using this technology on social diabetes and management. A national clinical trial is needed to assess precise benefits of self-care and knowledge.

Feasibility and acceptability of text messaging to support antenatal healthcare in Iraqi pregnant women: a pilot study.

OBJECTIVE: To determine the feasibility and acceptability of mobile health technology and its potential to improve antenatal care (ANC) services in Iraq. METHODS: This was a controlled experimental study conducted at primary health care centers. One hundred pregnant women who attended those centres for ANC were exposed to weekly text messages varying in content, depending on the week of gestation, while 150 women were recruited for the unexposed group. The number of ANC visits in the intervention and control groups, was the main outcome measure. The Mann-Whitney test and the Poisson regression model were the two main statistical tests used. RESULTS: More than 85% of recipients were in agreement with the following statements: "the client recommends this program for other pregnant women", "personal rating for the message as a whole" and "obtained benefit from the messages". There was a statistically significant increase in the median number of antenatal clinic visits from two to four per pregnancy, in addition to being relatively of low cost, and could be provided for a larger population with not much difference in the efforts. CONCLUSIONS: Text messaging is feasible, low cost and reasonably acceptable to Iraqi pregnant women, and encourages their ANC visits.

Features of a Mobile Support App for Patients With Chronic Obstructive Pulmonary Disease: Literature Review and Current Applications.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a serious long-term lung disease in which the airflow from the lungs is progressively reduced. By 2030, COPD will become the third cause of mortality and seventh cause of morbidity worldwide. With advances in technology and mobile communications, significant progress in the mobile health (mHealth) sector has been recently observed. Mobile phones with app capabilities (smartphones) are now considered as potential media for the self-management of certain types of diseases such as asthma, cancer, COPD, or cardiovascular diseases. While many mobile apps for patients with COPD are currently found on the market, there is little published material on the effectiveness of most of them, their features, and their adoption in health care settings. OBJECTIVES: The aim of this study was to search the literature for current systems related to COPD and identify any missing links and studies that were carried out to evaluate the effectiveness of COPD mobile apps. In addition, we reviewed existing mHealth apps from different stores in order to identify features that can be considered in the initial design of a COPD support tool to improve health care services and patient outcomes. METHODS: In total, 206 articles related to COPD management systems were identified from different databases. Irrelevant materials and duplicates were excluded. Of those, 38 articles were reviewed to extract important features. We identified 214 apps from online stores. Following exclusion of irrelevant apps, 48 were selected and 20 of them were downloaded to review some of their common features. RESULTS: Our review found that out of the 20 apps downloaded, 13 (65%, 13/20) had an education section, 5 (25%, 5/20) consisted of medication and guidelines, 6 (30%, 6/20) included a calendar or diary and other features such as reminders or symptom tracking. There was little published material on the effectiveness of the identified COPD apps. Features such as (1) a social networking tool; (2) personalized education; (3) feedback; (4) e-coaching; and (5) psychological motivation to enhance behavioral change were found to be missing in many of the downloaded apps. CONCLUSIONS: This paper summarizes the features of a COPD patient-support mobile app that can be taken into consideration for the initial design of an integrated care system to encourage the self-management of their condition at home.

COPD care delivery pathways in five European Union countries: mapping and health care professionals' perceptions.

BACKGROUND: COPD is among the leading causes of chronic morbidity and mortality in the European Union with an estimated annual economic burden of €25.1 billion. Various care pathways for COPD exist across Europe leading to different responses to similar problems. Determining these differences and the similarities may improve health and the functioning of health services. OBJECTIVE: The aim of this study was to compare COPD patients' care pathway in five European Union countries including England, Ireland, the Netherlands, Greece, and Germany and to explore health care professionals' (HCPs) perceptions about the current pathways. METHODS: HCPs were interviewed in two stages using a qualitative, semistructured email interview and a face-to-face semistructured interview. RESULTS: Lack of communication among different health care providers managing COPD and comorbidities was a common feature of the studied care pathways. General practitioners/family doctors are responsible for liaising between different teams/services, except in Greece where this is done through pulmonologists. Ireland and the UK are the only countries with services for patients at home to shorten unnecessary hospital stay. HCPs emphasized lack of communication, limited resources, and poor patient engagement as issues in the current pathways. Furthermore, no specified role exists for pharmacists and informal carers. CONCLUSION: Service and professional integration between care settings using a unified system targeting COPD and comorbidities is a priority. Better communication between health care providers, establishing a clear role for informal carers, and enhancing patients' engagement could optimize current care pathways resulting in a better integrated system.

Design and Usability Evaluation of Social Mobile Diabetes Management System in the Gulf Region.

BACKGROUND: The prevalence of diabetes in the Gulf States is one of the highest globally. It is estimated that 20% of the population in the region has been diagnosed with diabetes and according to the International Diabetes Federation (IDF), five of the IDF's "top 10" countries for diabetes prevalence in 2011 and projected for 2030 are in this region. In recent years, there have been an increasing number of clinical studies advocating the use of mobile phone technology for diabetes self-management with improved clinical outcomes. However, there are few studies to date addressing the application of mobile diabetes management in the Gulf region, particularly in the Kingdom of Saudi Arabia (KSA), where there is exponential increase in mobile phone usage and access to social networking. OBJECTIVE: The objective of this paper is to present the design and development of a new mobile health system for social behavioral change and management tailored for Saudi patients with diabetes called Saudi Arabia Networking for Aiding Diabetes (SANAD). A usability study for the SANAD system is presented to validate the acceptability of using mobile technologies among patients with diabetes in the KSA and the Gulf region. METHODS: The SANAD system was developed using mobile phone technology with diabetes management and social networking modules. For the usability study the Questionnaire for User Interaction Satisfaction was used to evaluate the usability aspect of the SANAD system. A total of 33 users with type 2 diabetes participated in the study. RESULTS: The key modules of the SANAD system consist of (1) a mobile diabetes management module; (2) a social networking module; and (3) a cognitive behavioral therapy module for behavioral change issues. The preliminary results of the usability study indicated general acceptance of the patients in using the system with higher usability rating in patients with type 2 diabetes. CONCLUSIONS: We found that the acceptability of the system was high among Saudi patients with diabetes, and ongoing work in this research area is underway to conduct a clinical pilot study in the KSA for patients with type 2 diabetes. The wide deployment of such a system is timely and required in the Gulf region due to the wide use of mobile phones and social networking mediums.

Qualitative investigation into a wearable system for chronic obstructive pulmonary disease: the stakeholders' perspective.

OBJECTIVES: To ascertain the stakeholders' views and devise recommendations for further stages of the Wearable Sensing and Smart Cloud Computing for Integrated Care to Chronic Obstructive Pulmonary Disease (COPD) Patients with Co-morbidities (WELCOME) system development. This system aims to create a wearable vest to monitor physiological signals for patients concerned incorporating an inhaler adherence monitoring, weight, temperature, blood pressure and glucose metres, and a mobile health application for communication with healthcare professionals (HCPs). DESIGN: A study of qualitative data derived from focus groups and semistructured interviews. SETTING: 4 participating clinical sites in Greece, the UK, Ireland and the Netherlands. PARTICIPANTS: Purposive sampling was used to recruit 32 patients with COPD with heart failure, diabetes, anxiety or depression, 27 informal carers and 23 HCPs from 4 European Union (EU) countries for focus groups and interviews. RESULTS: Most patients and HCPs described the WELCOME system as 'brilliant and creative' and felt it gave a sense of safety. Both users and HCPs agreed that the duration and frequency of vest wear should be individualised as should the mobile application functions. The parameters and frequency of monitoring should be personalised using a multidisciplinary approach. A 'traffic light' alert system was proposed by HCPs for abnormal results. Patients were happy to take actions in response. CONCLUSIONS: WELCOME stakeholders provided valuable views on the development of the system, which should take into account patient's individual comorbidities, circumstances and concerns. This will enable the development of the individualised system in each member state concerned.

A mobile diabetes management and educational system for type-2 diabetics in Saudi Arabia (SAED).

BACKGROUND: Diabetes is a chronic disease, with high prevalence across many nations, which is characterized by elevated level of blood glucose and risk of acute and chronic complication. The Kingdom of Saudi Arabia (KSA) has one of the highest levels of diabetes prevalence globally. It is well-known that the treatment of diabetes is complex process and requires both lifestyle change and clear pharmacologic treatment plan. To avoid the complication from diabetes, the effective behavioural change and extensive education and self-management is one of the key approaches to alleviate such complications. However, this process is lengthy and expensive. The recent studies on the user of smart phone technologies for diabetes self-management have proven to be an effective tool in controlling hemoglobin (HbA1c) levels especially in type-2 diabetic (T2D) patients. However, to date no reported study addressed the effectiveness of this approach in the in Saudi patients. This study investigates the impact of using mobile health technologies for the self-management of diabetes in Saudi Arabia. METHODS: In this study, an intelligent mobile diabetes management system (SAED), tailored for T2D patients in KSA was developed. A pilot study of the SAED system was conducted in Saudi Arabia with 20 diabetic patients for 6 months duration. The patients were randomly categorized into a control group who did not use the SAED system and an intervention group whom used the SAED system for their diabetes management during this period. At the end of the follow-up period, the HbA1c levels in the patients in both groups were measure together with a diabetes knowledge test was also conducted to test the diabetes awareness of the patients. RESULTS: The results of SAED pilot study showed that the patients in the intervention group were able to significantly decrease their HbA1c levels compared to the control group. The SAED system also enhanced the diabetes awareness amongst the patients in the intervention group during the trial period. These outcomes confirm the global studies on the effectiveness of smart phone technologies in diabetes management. The significance of the study is that this was one of the first such studies conducted on Saudi patients and of their acceptance for such technology in their diabetes self-management treatment plans. CONCLUSIONS: The pilot study of the SAED system showed that a mobile health technology can significantly improve the HbA1C levels among Saudi diabetic and improve their disease management plans. The SAED system can also be an effective and low-cost solution in improving the quality of life of diabetic patients in the Kingdom considering the high level of prevalence and the increasing economic burden of this disease.

Evaluation of a Telehealth Service for COPD and HF patients: Clinical outcome and patients' perceptions.

NHS Croydon Health Services and NHS Croydon Clinical Commissioning Group have been providing telehealth services for the past 36 months. The aim of this study was to measure the impact of telehealth when implemented as a service within a standard patient care pathway. To measure the clinical outcomes, the number of A&E visits and hospital admissions, recorded on the NHS Secondary Uses Service database, were compared before and after the implementation of the telehealth service. The number of all events despite its cause and the number of events related to the patients' diagnosed condition were collected. To elicit patients' perceptions about the telehealth service, a cross sectional survey of patients registered on the triage manager database was used to explore their perceptions, concerns and general satisfaction with the telehealth service via a 4 point likert scale questionnaire. The data of 48 patients were collected and telehealth reduced the number of both A&E and hospital admission due to all causes by 13% (P = 0.42) and 22% (P = 0.048), respectively. When only the events directly related to the patient's diagnosed condition were considered, a reduction by 36% (P = 0.03) and 28% (P = 0.02) was recorded for A&E visits and hospital admission respectively. 27 patients consented to participate in the survey. Overall, patients were very satisfied with telehealth services. Patients agreed that telehealth had improved their health, it was a convenient form of health care delivery for them and they were more involved in the decisions about their care or treatment. In addition, since being on telehealth, patients' confidence in managing their health increased from somewhat confident to confident. Telehealth, when provided as a service within a standard care pathway, seems to decrease hospital admissions and A&E visits. Good patient satisfaction suggests that the current service is accepted and it could be further expanded to include a larger number of patients.

Optimizing cancer care through mobile health.

The survival rates for patients living with cancer are increasing, due to recent advances in detection, prevention and treatment. It has been estimated that there were 28 million cancer survivors around the world in 2012. In the UK, for patients diagnosed in 2007, it is predicted that more than half of them will survive their cancer for 5 years or more. A large majority of cancer survivors report unmet supportive care needs and distressing symptoms and adverse long-term consequences related to their cancer. Cancer management could be optimized to better meet patients demand through technology, including mobile health (m-Health). m-Health is defined as the use of mobile communications and network technologies for health care. m-Health can help both patients and health-care professionals and play an important part in managing and delivering cancer care including managing side effects, supporting drug adherence, providing cancer information, planning and follow up and detecting and diagnosing cancer. Health authorities have already published guidelines regulating m-Health to insure patient safety and improve the accountability of its applications.

Implementing a telehealth service: nurses' perceptions and experiences.

BACKGROUND: Telehealth is defined as the remote surveillance of a patient's health to aid early diagnosis and timely intervention. Understanding how the stakeholders perceive telehealth can influence its acceptability and diffusion. INTRODUCTION: A primary care trust (PCT) in south London has been providing telehealth services for chronic obstructive pulmonary disease (COPD) and heart-failure patients for the past 22 months. The aim of this study was to elicit practice nurses' perceptions of the telehealth service provided by this PCT. MATERIALS AND METHODS: A descriptive qualitative design was chosen to elicit practice nurses' perceptions. A semi-structured email interview was used to investigate their experiences of the service to date and their views about the future of the service. RESULTS: Seven nurses, working on telehealth for an average of 15 months and providing the service to 34 patients, were interviewed. Overall, the nurses described their experience with telehealth to be positive. Lack of resources, organisational support, patient selection criteria and technical support were identified as barriers to effective implementation of telehealth. Additional team members, more input and training, and expanded patient selection criteria were suggested by the nurses to enhance and ensure the success of telehealth. DISCUSSION AND CONCLUSIONS: The challenges and barriers to the implementation of telehealth identified by the practice nurses need to be addressed by health services to ensure its continuity and success.

A feasibility study of mobile phone text messaging to support education and management of type 2 diabetes in Iraq.

BACKGROUND: We undertook a feasibility study to evaluate feasibility and utility of short message services (SMSs) to support Iraqi adults with newly diagnosed type 2 diabetes. SUBJECTS AND METHODS: Fifty patients from a teaching hospital clinic in Basrah in the first year after diagnosis were recruited to receive weekly SMSs relating to diabetes self-management over 29 weeks. Numbers of messages received, acceptability, cost, effect on glycated hemoglobin (HbA1c), and diabetes knowledge were documented. RESULTS: Forty-two patients completed the study, receiving an average 22 of 28 messages. Mean knowledge score rose from 8.6 (SD 1.5) at baseline to 9.9 (SD 1.4) 6 months after receipt of SMSs (P=0.002). Baseline and 6-month knowledge scores correlated (r=0.297, P=0.049). Mean baseline HbA1c was 79 mmol/mol (SD 14 mmol/mol) (9.3% [SD 1.3%]) and decreased to 70 mmol/mol (SD 13 mmol/mol) (8.6% [SD 1.2%]) (P=0.001) 6 months after the SMS intervention. Baseline and 6-month values were correlated (r=0.898, P=0.001). Age, gender, and educational level showed no association with changes in HbA1c or knowledge score. Changes in knowledge score were correlated with postintervention HbA1c (r=-0.341, P=0.027). All patients were satisfied with text messages and wished the service to be continued after the study. The cost of SMSs was €0.065 per message. CONCLUSIONS: This study demonstrates SMSs are acceptable, cost-effective, and feasible in supporting diabetes care in the challenging, resource-poor environment of modern-day Iraq. This study is the first in Iraq to demonstrate similar benefits of this technology on diabetes education and management to those seen from its use in better-resourced parts of the world. A randomized controlled trial is needed to assess precise benefits on self-care and knowledge.

WELCOME ­ innovative integrated care platform using wearable sensing and smart cloud computing for COPD patients with comorbidities.

We propose WELCOME, an innovative integrated care platform using wearable sensors and smart cloud computing for Chronic Obstructive Pulmonary Disease (COPD) patients with co-morbidities. WELCOME aims to bring about a change in the reactive nature of the management of chronic diseases and its comorbidities, in particular through the development of a patient centred and proactive approach to COPD management. The aim of WELCOME is to support healthcare services to give early detection of complications (potentially reducing hospitalisations) and the prevention and mitigation of comorbidities (Heart Failure, Diabetes, Anxiety and Depression). The system incorporates patient hub, where it interacts with the patient via a light vest including a large number of non-invasive chest sensors for monitoring various relevant parameters. In addition, interactive applications to monitor and manage diabetes, anxiety and lifestyle issues will be provided to the patient. Informal carers will also be supported in dealing with their patients. On the other hand, welcome smart cloud platform is the heart of the proposed system where all the medical records and the monitoring data are managed and processed via the decision support system. Healthcare professionals will be able to securely access the WELCOME applications to monitor and manage the patient's conditions and respond to alerts on personalized level.

Cross layer design for optimised region of interest of ultrasound video data over mobile WiMAX.

The application of advanced error concealment techniques applied as a post-process to conceal lost video information in error-prone channels, such as the wireless channel, demand additional processing at the receiver. This increases the delivery delay and needs more computational power. However, in general, only a small region within medical video is of interest to the physician and thus if only this area is considered, the number of computations can be curtailed. In this paper we present a technique whereby the Region of Interest (ROI) specified by the physician is used to delimit the area where the more complex concealment techniques are applied. A cross layer design approach in mobile WiMAX wireless communication environment is adopted in this paper to provide an optimized Quality of Experience (QoE) in the region that matters most to the mobile physician while relaxing the requirements in the background, ensuring real-time delivery. Results show that a diagnostically acceptable Peak Signal-to-Noise-Ratio (PSNR) of about 36 dB can still be achieved within reasonable decoding time.

Cross-layer ultrasound video streaming over mobile WiMAX and HSUPA networks.

It is well known that the evolution of 4G-based mobile multimedia network systems will contribute significantly to future mobile healthcare (m-health) applications that require high bandwidth and fast data rates. Central to the success of such emerging applications is the compatibility of broadband networks, such as mobile Worldwide Interoperability For Microwave Access (WiMAX) and High-Speed Uplink Packet Access (HSUPA), and especially their rate adaption issues combined with the acceptable real-time medical quality of service requirements. In this paper, we address the relevant challenges of cross-layer design requirements for real-time rate adaptation of ultrasound video streaming in mobile WiMAX and HSUPA networks. A comparative performance analysis of such approach is validated in two experimental m-health test bed systems for both mobile WiMAX and HSUPA networks. The experimental results have shown an improved performance of mobile WiMAX compared to the HSUPA using the same cross-layer optimization approach.

Provisioning of medical quality of services for HSDPA and mobile WiMAX in healthcare applications.

Mobile healthcare, or m-health, is an evolutionary concept that provides both mobility and an 'always connected' healthcare functionality. The development of this concept depends on how best the available bandwidth in (HSDPA/HSUPA) and emerging (Mobile WiMAX) networks can be correlated with the relevant medical quality of services issues. In this paper we address and discuss some of these issues and challenges. We also provide an example of a bandwidth demanding application to verify such provision mechanisms.

A cross-layer approach for wireless medical video streaming in robotic teleultrasonography.

M-health is an emerging area of research integrating emerging wireless technologies with healthcare systems. One of the key challenges in future research in this area, especially from the communications perspective, is medical video streaming over 3G and 4G systems. In this paper, video streaming in a robotic teleultrasonography system through a cross-layer approach based on tailor made controller structures is presented. Simulation results of the proposed system demonstrate the successful performance of the proposed controller structures in this advanced mobile telemedical environment.

Fragility issues of medical video streaming over 802.11e-WLAN m-health environments.

This paper presents some of the fragility issues of a medical video streaming over 802.11e-WLAN in m-health applications. In particular, we present a medical channel-adaptive fair allocation (MCAFA) scheme for enhanced QoS support for IEEE 802.11 (WLAN), as a modification for the standard 802.11e enhanced distributed coordination function (EDCF) is proposed for enhanced medical data performance. The medical channel-adaptive fair allocation (MCAFA) proposed extends the EDCF, by halving the contention window (CW) after zeta consecutive successful transmissions to reduce the collision probability when channel is busy. Simulation results show that MCAFA outperforms EDCF in-terms of overall performance relevant to the requirements of high throughput of medical data and video streaming traffic in 3G/WLAN wireless environments.