Course overview
and
structure
Mobile Health
Dates: May 23-June 20, no class May 28
Times: 5:30-8:30pm ET + team meetings
What to do if missing all or part of class?
Meet in person: for class session, separately, or not at all?
Twitter and other social media
Social media survey
Online course feedback: you are not guinea pigs!
Questions:
l.gualtieri@tufts.edu, cell: 781-330-9456
dickie.wallace@tufts.edu, cell 413-335-3803
1
Healthy People 2020
• Health Communication and Health Information
Technology
• …many ways health communication and health IT can
have a positive impact on health, health care, and health
equity. They include…
– Providing personalized self-management tools and resources
– Building social support networks
– Delivering accurate, accessible, and actionable health
information that is targeted or tailored
– Increasing health literacy skills
– Providing sound principles in the design of programs and
interventions that result in healthier behaviors
– Increasing Internet and mobile access
• http://healthypeople.gov
2
Mobile is only part of digital landscape
3
Cell phone use in US
• 82% of adults in the US own a cell phone
• Unlike the internet, which has been associated
with a large digital divide, mobile phones are
being used by people in
– All geographic settings
– Across all age and racial/ethnic groups
– Pew Research Center 2011
4
Smartphone owners by age
• Smartphone
adoption
has grown
more than
54% in the
past year to
82.2
subscribers
(9/11/11)
• 36.1% of
Americans
13+ use
smartphone
5
Smartphone growth is across all ages
6
What exactly is an app – and what isn’t?
• Mobile development
– Mobile websites are similar to regular websites, typically
with browser pages built in HTML5, but are tailored for
the smaller display and touch-screen interface
– Native apps are downloadable programs on a
smartphone and dependent upon phone’s operating
system
– Hybrid apps are mobile sites wrapped in HTML5 and
presented as a native app
• Many issues with multi-platform development
• Many websites don’t accommodate mobile use well
7
Android Phones and iPhones
Dominating App Downloads in US
• 83% of app
downloaders
(in past 30
days) use
iPhone or
Android
smartphones
• Which is best
choice?
8
Popular
app
examples
9
Unintended consequences:
Words with Friends
Source: Words With Friends Apple iPhone app screen shots
10
Insurance: low frequency but mutually
advantageous
Having apps and using them
are not synonymous
• 26% who download health apps use them
only once
– Pamela Culver, Yahoo! News, 3/21/11
12
Mobile user experience
• What got me thinking about the entire
experience of learning about, downloading, and
using apps
• Dimensions of mobile design
13
Saugus, MA
14
15
16
Kowloon app
Everyone wants
to have or think
they need an
app – like web
17
Mobile design is the entire experience
•
•
•
•
•
•
•
•
•
•
•
Having a need and/or learning about an app
Deciding to download
Deciding to try - initial use
Sustained or ongoing use
Participatory or shared use
Not a continuum
May be dips
Can an app be successful with only initial or sporadic use?
Are incentives necessary and which work?
Is trust necessary and at which point(s)?
How is health different from commerce or entertainment?
18
How do people learn about apps?
• Pre-downloaded
• Signs on doors
• App stores
–
–
–
–
Search based on categories, cost, featured, etc.
Easier for iPhone because similar to iPod music?
Android Market to Google Play
Many of these provide ratings and reviews
• Participation is spotty
• Review sites
• Recommendations and word-of-mouth
• Ads, pop-ups, product packaging, TV, etc.
Why do people decide to try an app?
• Low barriers
• Hope to improve or simplify one’s life
– Entertainment
– Satisfy unmet need
– Satisfy unidentified need
• Commerce?
– Accomplish something otherwise not possible
– Accomplish something more easily than before
• Convenience
– Integrate disparate aspects of life
– Smart and/or innovative
Designing mobile user experience
• Smartphone capabilities
– Also limitations relative to desktop/laptop
• Smartphone layout and patterns
– De facto standards are emerging
• Apps are changing what people do
21
Smartphone in contrast to desktop/laptop
• Screen size and proportions
– Less screen real estate and more variety in screen proportions
• Direct interaction with screen
– No mouse so no roll-overs or tool-tips
– Only some have keyboard so users interact directly with the
screen
• Variable orientation
– Quick orientation switching
• Single-screen environment
– Hard to use multiple apps simultaneously even when possible
• Established device standards
– As market matures, consistent UI patterns are forming
• Limited resources
– Smartphones are limited by connection quality, battery life,
22
processing power, and onboard memory
Touchscreen inputs
• Touchscreen inputs include:
– Single tap: used in place of a standard mouse click
– Drag: scrolling or panning
– Flick: scroll of pan quickly
– Swipe: make selection, evoke a contextual menu, or
as part of a two step process like delete
– Pinch (open & close): zooming in/out
– Press and hold: make a selection or evoke a
contextual menu
23
Smartphone controls and capabilities
• Smartphone controls and capabilities for input/output
–
–
–
–
–
–
–
–
–
–
Visual: high resolution screen
Audible: speaker, headphone jack
Physical: vibration for alerts, haptic feedback
Dedicated keys: Volume control, Back, Search, Menu,
Power/Lock, Home
Physical keyboards: shortcuts, text input
Accelerometers: track motion and orientation
GPS
Backlight
Microphone: voice commands, ambient audio, music
Camera: photos and visual codes
24
Mobile design patterns:
de facto standards have emerged
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Activity Feeds
Check-in Screens
Comment Detail
Custom Tab Navigation
Dashboard Navigation
Edu Walk-Throughs
Empty Data Sets
Find Friends
Grouped Table Views
Lists
Maps
Notifications
Search
Settings
Sign Up Flows
Splash Screens
UI that I Heart
User Profiles
Venue Detail
25
Mobile design patterns for navigation
• Important because it is the most visible screen and therefore
needs to be appealing and usable
–
–
–
–
–
–
Springboard (Facebook)
Simple or expanding list menu (Blackboard)
Tab menu (Foursquare)
Gallery (Android gallery)
Dashboard
Metaphor
26
Design rules apply – even more so
• Make first experience positive
• Make subsequent experiences helpful and
compelling
• Consistency between screens
• Similar metaphors to other apps, as appropriate
• Well-written text
• Judicious use of imagery
• Name and branding
• Creative use of mobile capabilities!
27
Applying user experience design
to apps – and the app store!
• Appeal
– Immediate reaction
– Recommend to friend
– Rate or review
• Usability
– Easy to accomplish tasks
and know capabilities
• Effectiveness
– Accomplish goals
– Sustain use
28
4 dimensions of mobile design
Context
• Mobile users use their mobile device in any
location no matter what else they are doing
Immediacy
• Mobile users use their mobile device at a
moment’s notice including for urgent needs
Affinity
• Mobile users have an ongoing intimate and
personalized relationship with their digital
appendage and, through it, with others
Personalization
• “Big data” and predictive analytics offers
extensive personalization and tailoring (but
too invasive?)
Smartphone use for health
•
•
•
•
Opportunities through social networking
SMS/texting
Mobile browser
Apps
Social mobile health
• Managing health habits involves managing social
relationships, not just targeting a specific health
behavior for change - Bandura
• Mobile devices have increased the ways in which
individuals can access, receive, and provide social
support
• Is facilitation of social support through mobile
devices enough?
31
Mobile health interventions
• Mobile browser use
• Voice and text messaging interventions have been
shown to
– Increase quit rates among smokers
– Motivate healthy eating and physical fitness
– Facilitate self-management of asthma and diabetes
• Interventions to record/send personal health data to
a provider using mobile phone improved treatment
adherence for diabetes, asthma, and cancer patients
– Issue with where responsibility lies
• Research suggests that patient attitudes regarding
this type of intervention are relatively positive
32
Mobile access to health information
• 2/3 of mobile users used browsers instead of apps
to find health information
33
Who uses
health apps?
• Individuals with varying
–
–
–
–
–
–
–
–
Demographics
Health literacy skills
Health needs
Medical knowledge and
experience
Skills
Disabilities
Cultural and language
differences
Economic situations
34
Future growth
• More than 44 million mobile health apps will be
downloaded in 2012; more than 142 million by 2016
(Juniper Research)
• Market for mobile health technology, valued at $120
million in 2010, is expected to exceed $400 million by
2016 (ABI Research reported in eWeek 11/23/11)
• Growth triggers
– Health-related apps may offer proven techniques in the
future; FDA said it will begin requiring regulatory review and
software validation (Yahoo! News, 3/21/11)
– Development of more consumer-focused apps, with fitnessrelated apps dominating followed by home monitoring for
seniors
– Potential cost savings through remote patient monitoring
– More peripheral devices (weight scales, blood pressure
monitors, and glucose meters) that attach to mobile phones
35
Consumer Health Apps
36
Types of health apps
• 4+ categories
–
–
–
–
–
•
•
•
•
Educate
Connect
Track
Remind
“Detect”
Some apps do many of these
Gamification can encompass track and connect
Some apps learn from history and patterns of use
But how many incorporate context, immediacy, affinity,
and personalization?
– Location-based donut example
– Restaurant example
37
Research
• “No studies have assessed how well health-related
apps change behaviors primarily because academic
research tends to lag behind innovation in
technology”
– LiveScience/Fox News, 3/21/11
38
Limited research to date
• Evaluation of iPhone apps for smoking cessation
– App’s approach to cessation, its adherence to clinical
practice guidelines, and its frequency of downloads
– 11.3% of apps strongly followed a given guideline
– 4.3% of apps strongly followed the guideline to connect
a user with a Quitline
– 8.5% of apps made use of intra-treatment social support
• Apps that had the lowest adherence scores were
also the most downloaded
– Measuring downloads only measures downloads!
– Abroms
39
Analysis of diabetes apps compared to
evidence-based guidelines
• Research on both the design and the use of diabetes
mHealth applications is scarce
• 60 diabetes apps on iTunes for iPhone in July 2009; 260 in
February 2011
• Contrasted the prevalence of self-monitoring, education,
alerts and reminders, etc. with clinical guideline
recommendations for diabetes self-management
• “…obvious gaps between the evidence-based
recommendations and the functionality used in study
interventions or found in online markets. Current results
confirm personalized education as an underrepresented
feature in diabetes mobile applications”
– Taridzo Chomutare et al., Norwegian Centre for Integrated
Care and Telemedicine, University Hospital of North Norway,
40
Tromsø, Norway
Weight Loss Apps:
Obesity Trends Among US Adults 1985 and 2010

Definitions of Obesity
 Body Mass Index (BMI) of 30 or higher

BMI
 A measure of an adult’s weight in relation to his or
her height
 Specifically the adult’s weight in kilograms divided by
the square of his or her height in meters
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity and demographics
• Obesity affects some groups more than others
– Non-Hispanic blacks have the highest rates of obesity (44.1%)
compared with Mexican Americans (39.3%), all Hispanics (37.9%)
and non-Hispanic whites (32.6%).
• Obesity and socioeconomic status
– Among non-Hispanic black and Mexican-American men, those with
higher incomes are more likely to be obese than those with low
income.
– Higher income women are less likely to be obese than low-income
women.
– There is no significant relationship between obesity and education
among men. Among women, however, there is a trend—those with
college degrees are less likely to be obese compared with less
educated women.
– Between 1988–1994 and 2007–2008 the prevalence of obesity
increased in adults at all income and education levels
43
Healthy Weight Initiative (CDC)
• Recommendations designed for patients to
promote healthy weight management strategies
• Available at:
http://www.cdc.gov/healthyweight/index.html
• Guidelines that may inform mobile app
development
– 5 steps to weight loss or preventing weight gain:
http://www.cdc.gov/healthyweight/losing_weight/g
etting_started.html
44
5 Steps from Healthy Weight Initiative
1. Make commitment
– Write contract that includes goals for accountability
– Record important motivators
2. Define current health status and lifestyle
– Assess current weight
– Identify current eating and exercise habits
– Identify factors that help and hinder a healthy lifestyle
3. Set goals
– Set very specific short and long-term goals related to diet and
exercise
– Establish rewards to work toward
4. Access resources for education and support
– Identify resources to enable weight loss/healthy diet
5. Monitor progress
– Continuously monitor diet and weight & progress with respect to
established goals
– Record barriers/obstacles and rewrite goals to address these issues
45
Weight Management App
Reviews and Descriptions
• Were best-practices guidelines used?
– Not clear from app reviews or the descriptions of these apps
in app stores that the apps’ developers consulted bestpractices guidelines for weight management prior to app
design
– Few reviews of weight management apps (and other health
apps) and few app store descriptions mention evidence-base
at all; focus is on features
• How customizable?
– Some apps allow patients to create a customizable weight
management plan but mostly based on age, gender and
weight loss goals
– Few apps accommodate weight management needs of special
populations, such as dietary restrictions (vegan, gluten-free) or
health conditions that might influence how a weight
46
management program is planned and implemented
Research questions
• How do you define app success and learn from
experiences?
• Is facilitation of social support through mobile devices
enough in of itself?
• Do existing evidence-based guidelines apply to mobile
devices as is?
– If not, how can they be “adjusted” or reframed?
• Are new techniques needed to evaluate apps?
– Not successful for web yet – HONcode, URAC
• Are mobile literacy skills needed?
– Are mobile health literacy skills needed too?
• How can health and public health organizations get a
foothold with increasingly commercially-driven
approaches?
47
Mobile First
• Designing for mobile first instead of retrofitting
existing practices into mobile format
• Is what is best for people what is most successful
in the marketplace?
– Evaluation and market research only go so far
– My apps were mobile first
48
App challenges
49
My app design
• Business travelers
have increased rates
of poor health and
health risk factors,
including obesity
and high blood
pressure
• Many apps help
locate restaurants
based on cost,
location, and
ethnicity
50
Mobile Design Challenge
• Design app for Parents are the Key
– Mobile first
– Focus on scenario: inputs and outputs
– Incorporate mobile design principles of context,
immediacy, affinity, and personalization