Effectiveness of mHealth apps and their prescribability in general practice

Student thesis: Doctoral Thesis


The last decade witnessed the unprecedented popularity of smartphones in all aspects of our lives. Two categories of smartphone applications – Medical, and Health and Fitness - which are collectively called ‘mobile health apps’ or mHealth apps also became universal. Their availability and accessibility to patients make them a potentially prescribable non-drug intervention to enhance self-management of many conditions. However, their effectiveness and usability are not well scrutinized. It is challenging for doctors to navigate 350 000 mHealth apps to find the right ones to recommend. Moreover, mHealth app use by Australian general practitioners (GPs) and the barriers and facilitators they encounter when integrating mHealth apps in their clinical practice have not been studied comprehensively. Potential solutions to overcome the barriers to prescribing effective mHealth apps in practice needs to be explored.

The overall aim of this thesis is to explore the possibility of better mHealth app prescription in Australian general practice. To achieve this aim, the three main research areas examined were: (1) the evidence of effectiveness of mHealth apps; (2) the barriers and facilitators to prescribing mHealth apps in Australian general practice; and (3) the feasibility of an intervention to increase app prescription by GPs.

The aims were addressed by four interrelated studies. First, an overview of systematic reviews of randomized controlled trials (RCTs) of stand-alone mHealth apps evaluated the evidence-base behind “prescribable” apps. Prescribable apps were defined as: currently available, proven effective and preferably stand-alone. The overview identified 6 systematic reviews including 23 RCTs evaluating 22 available apps that mostly addressed diabetes, mental health, and obesity. Most trials were pilots with small sample size and of short duration. Risk of bias of the included reviews and trials was high. Eleven of the 23 trials showed a meaningful effect on health or surrogate outcomes attributable to apps, thus qualifying the tested apps to be prescribable.

Second, semi-structured interviews with GPs and patients were conducted to explore their perspectives on barriers and facilitators to mHealth app prescription in general practice. A total of 20 GPs and 15 adult patients (18-75 years old) were interviewed. From the GPs’ perspectives, the main barriers to prescribing apps were: a generational difference in the digital propensity for both the GPs and patients; lack of knowledge of prescribable apps and lack of reliable source to access them; time commitments required of the GPs and patients; and privacy, safety and trustworthiness of health apps. From the patients’ perspectives, the biggest barriers were the patients’ age and the usability of apps. Surprisingly, patients were not concerned about privacy and data safety issues. The facilitators of app prescription were similar for patients and GPs: (1) ubiquity of smartphones and apps and younger generation; and (2) trustworthy source of prescribable apps – for patients it was their doctors, but the doctors needed a reliable professionally vetted source to access effective apps. Evidence of effectiveness was identified as an independent theme by both GPs’ and patients.

Third, a survey of Australian GPs aimed to assess how the barriers identified in the previous study were perceived in a national sample of GPs. Based on the findings of the second study, we developed specific questions to the mHealth section of the 2017 Royal Australian College of General Practitioners (RACGP) Annual Technology survey. The survey gathered a total of 1014 responses, of which 621 completed the mHealth section. The participants’ median years practised was 20.7 years. Two-thirds of the GPs use apps professionally as medical calculators and point-of-care references. A little over half of the GPs recommended apps for patients daily, weekly or monthly (13%, 26%, and 13% respectively). Mindfulness and mental health apps were recommended most often (n=337; 33%), followed by diet and nutrition (n=144; 14%), exercise and fitness (n=132; 13%), and women’s health (n=104; 10%) related apps. Knowledge and usage of evidence-based apps from the Handbook of Non-Drug Interventions (HANDI) were low. The prevailing barriers to app prescription were lack of knowledge of effective apps (n=372; 60%) and lack of trustworthy source to access them (n=96; 15%). GPs expressed their need for a list of safe and effective apps from a trustworthy source such as the RACGP. They prefer online video training material or webinar to learn more about mHealth apps.

Lastly, a single group before-and-after study was conducted to evaluate the feasibility of app prescription in Australian general practice and to measure the effectiveness of an intervention to increase app prescription uptake. A two-part intervention was developed: a 6 app prescription pad and short introductory videos for each app. Of the 40 GPs recruited from all around Australia, 36 completed the study. Over 4 months in total, 1324 app prescriptions were dispensed. The median number of apps prescribed per GP was 30 [range 6-111]. The median number of apps prescribed per GP per fortnight increased from the pre-study level of 1.7 to 4.1. Confidence about prescribing apps doubled from a mean of 2 (not so confident) to 4 (very confident). App videos did not affect subsequent prescription rates substantially. Post-study interviews revealed that the intervention was highly acceptable.

The findings of these studies highlight the less than robust evidence-base for mHealth apps including major gaps in the quantity and the quality of the testing. We also identified that mHealth app prescription to be feasible in general practice both from the GPs’ and patients’ perspectives. Most GPs are using apps professionally and already recommend apps to patients, albeit sparingly. But their main challenges are lack of knowledge of effective apps and lack of trustworthy source to access them. A curated compilation of effective mHealth apps provided by a trustworthy professional organization would address both barriers. Our final study proved the feasibility of such solution in increasing app prescription. Besides creation and maintenance, the future of greater uptake of mHealth app prescription depends on the scalability and sustainability of a reliable app repository.
Date of Award3 Feb 2021
Original languageEnglish
SupervisorPaul Glasziou (Supervisor), Tammy Hoffmann (Supervisor) & Elaine Beller (Supervisor)

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