Azam_Yang.pdf

8/10/2019 Azam_Yang.pdf

1/48

Mobile Health Services for Patients with

Chronic Diseases:

A Systematic Literature Review

Azam, Shadi

Yang, Yan


2/48

1

Laurea University of Applied Sciences

Otaniemi, Espoo

Mobile Health Services for Patients with Chronic Diseases:

A Systematic Literature Review


3/48

2

Laurea University of Applied Sciences Abstract

Laurea Otaniemi

Degree Programme in Nursing

Shadi Azam, Yan Yang

Mobile health services for patients with chronic diseases: a systematic literature review

Year 2013 Pages 47

Mobile health has been studied and applied for the management of chronic diseases. However, mHealth

has more potential applications in this field that has not been covered so far. For this reason, and for the

importance of chronic diseases management, this thesis was initiated to answer two questions: What

chronic diseases demand mobile health services? andHow have mobile health services been applied for

chronic diseases? The purpose of this study is to describe and discuss mobile health services for patientswith chronic diseases by conducting a systematic literature review. Through the research, mobile health as

a nursing intervention has been reviewed to explore the innovative approach of chronic patientsnursing

care.

A systematic literature search was conducted through electronic library NELLI. The primary search

collected 118 articles from the keywords mobile health, mHealth, and Telecare in conjunction

with Chronic disease. The literature filter was limited to only full text articles completely in English

which were published after 1st January 2004. Finally, a total of 6 studies were obtained. The extracted

data from the literature were analyzed in the aspects of studied chronic diseases, mobile health


4/48

3

CONTENTS

1. Introduction....................................................................................................... 4

2. Purpose statement and research questions.................................................................. 6

3. Systematic literature review................................................................................... 7

3.1. Literature Search............................................................................................ 8

3.2. Inclusion and exclusion criteria.......................................................................... 10

3.3. Data extraction............................................................................................. 12

3.4. Data analysis................................................................................................ 12

4. Findings ............................................................................................................. 15

4.1. Studied chronic diseases . ................................................................................. 15

4.2. mHealth interventions ...................................................................................... 16

4.3. Solutions of mHealth ........................................................................................ 18

4.4. Attitudes toward mHealth .................................................................................. 19

4.5. mHealth challenges in the future....................................................................... .20

5. Discussion ........................................................................................................... 21

5.1. Chronic diseases .............................................................................................. 21

5.2. Mobile health ................................................................................................. 24

5.3. mHealth as nursing interventions for chronic diseases ................................................ 27

6. Trustworthiness ................................................................................................... 31

7. Ethical considerations ............................................................................................ 34

8. Limitations and recommendations ............................................................................. 37

REFERENCES .............................................................................................................. 39


5/48

4

1.

Introduction

Chronic diseases are becoming the heaviest burden to healthcare systems worldwide (WHO, 2011). World

Health Organization (WHO, 2011) reported that, from 57 million global deaths in 2008, 63 percent were

due to chronic diseases mainly caused by pulmonary diseases, heart failure, cancer, and diabetes. In the

next several decades major chronic diseases will continue to increase the morbidity and mortality rate in

the entire world (Global status report on noncommunicable diseases, 2010). Obviously, traditional model

of episodic care in clinic and hospital-based settings is suboptimal for improving chronic disease outcomes

(Estrin & Sim, 2010). Indeed, in daily life, the prevention and treatment of chronic diseases take place

outside of traditional clinical settings. Therefore, more appropriate and higher quality nursing

interventions are required to support self-care, to reduce chronically ill hospitalization, and to eventually

ease the burden of chronic diseases.

Recently, healthcare professionals and researchers have introduced more and more technological solutions

into the healthcare system, particularly mobile Health (or mHealth). mHealth broadly encompasses

healthcare related utilization of a mobile telecommunication and multimedia technologies within health

service delivery and public health systems (Istepanian & Lacal, 2003). mHealthsinnovations in taking care

of chronic patients significantly improve the monitoring of long-term diseases, patients self-management,

and autonomy (Mair, Hiscock & Beaton, 2008). Often the determination and adjustment of chronic illness

treatment rely on patients reports of symptoms, side effects, and functional statuses. mHealth possesses

the feasibility to support data collection and transferring at any time, thereby promoting more rapidconvergence to optimal treatment (Estrin et al., 2010).

mHealth is an integration of mobile technologys advantages in healthcare system (WHO 2011) Mobile


6/48

5

using systematic literature review. The study aims to investigate how mHealth services have been applied

for chronic disease. Precisely by reviewing mHealth application for chronic ill patients, the research

explores the usability and acceptability of mHealth as innovative nursing interventions. Moreover, the

study is conducted through a systematic literature review because it is a practical research method in the

field of healthcare for searching targeted documents. This methodology assists researchers in synthesizing

previous findings in an unbiased way, thus objectively answering the research questions. Systematic

literature review also helps researchers to realize gaps and limitations in relation to the topic of research

(Hart, 1998, 13). This study is implementing a systematic review by searching recent and relevant researchin the electronic databases and filtering literature based on predefined criteria. In the chapter three, the

proceeding of a systematic literature review will be recorded and illustrated in detail.


7/48

6

2.

Purpose statement and research questions

The purpose of this thesis is to describe and discuss mobile health services for patients with chronic

diseases using systematic literature review.

Research Questions:

What chronic diseases demand mobile health services?

How have mobile health services been applied for chronic diseases?


8/48

7

3.

Systematic literature review

This research conducted through a systematic literature review to summarize previous mhealth studies in

relation to chronic illness care to resolve the research questions. The methodology implementation

included four steps: literature search from predefined databases; literature filter by criteria; data extract

on research questions; and data analysis in legible diagrams. As the main interest of this study was to

describe and discuss mHealth services for chronic patients, this thesis utilized qualitative approach in the

synthesis of findings. Statistical figures and trend were not sought for, but the eligible literature core

opinions were intended as the raw data.

The systematic literature review has been widely undertaken in healthcare related researches because it is

a practical research method in the field of medicine for searching targeted document (Hemingway &

Brereton, 2009). As far as the further application of the mHealth, health-related benefits of mHealth have

been covered by innumerable peer-reviewed journal articles, case studies, news articles, and reports

(WHO, 2008). However, it is extremely difficult for healthcare professionals and patients to allocate the

quality information among enormous publishing with limited time and expertise (Hemingway et al., 2009 &

Cochrane Handbook for Systematic Reviews of Interventions, 2012). Systematic review applies predesigned

methodologies to identify and access relevant literature, then summarizes conclusions from individual

studies to answer specific research question (Hemingway et al., 2009). The applying of the systematic

literature review method enables researchers to search information comprehensively. According to

Kitchenham (2004), reasons of undertaking systematic review include summarizing the benefits andlimitations of empirical evidence, identifying gaps in current research for further investigation, and

providing a framework to position new research activities.


9/48

8

defining a review protocol; 2. Systematic review prescribes a search strategy of detecting as much of the

relevant literature as possible; 3. Systematic review documents search strategy to prove its rigours andintegrity; 4. The primary study requires explicit inclusion and exclusion criteria; 5. Raw data should be

specified for evaluating the quality and trustworthiness; 6. A systematic literature review is a prerequisite

of quantitative meta-analysis.

A systematic search was conducted by predefining a review protocol to obtain appropriate studies.

Kitchenham (2004) stated that a pre-defined protocol is necessary to minimize possible researcher bias.

For instance, there are possibilities that literature selection or analysis may be driven by researchers

expectations if without a protocol (Kitchenham, 2004). The key elements of a protocol include research

purpose, research question, research strategy (search resources or databases), study selection criteria,

data extraction strategy, and synthesis of the extracted data (Kitchenham, 2004).

3.1. Literature Search

A systematic review requires a thorough, objective, and reproducible data search (Cocharane, 2012). The

aim of the preliminary search was to identify existing systematic reviews and assess the volume of

potentially relevant studies. Cocharane (2012) claimed that data search promotes the producing of reliable

effects and relieves preventable bias. Meanwhile, data search distinguishes systematic reviews from

traditional narrative reviews. Usually a designated number of databases are searched by using a

standardized or customized search filter. After that researchers identify as many relevant studies as

possible from the predefined data resources (Cocharane, 2012).

I hi d h d h d l d i l i i h h lib i i h h l


10/48

9

As Kitchenham (2004) stated that the data search of systematic review must be transparent and replicable.

Transparency and replicability enable readers to assess the thoroughness of the search with sufficientdetails. The primary search details are illustrated as below:

Table 1Overview of the databases and MeSH headings used in the computerized literature searches, and

the strategy and yield of the each search

EBSCO EBSCO Elsevier Science Ovid(CINAHL) (Academic Direct (MEDLINE)

Search Elite)

1. mobile Health & Chronic disease 5 12 19 13

2. mHealth & Chronic disease 1 2 1 0

3. Telecare & Chronic disease 10 7 14 34


11/48

10

3.2.

Inclusion and exclusion criteria

The literature selection criteria are intended to identify primary studies that provide specific evidence

about the research question (Kitchenham 2004). Cocharane (2012) emphasized that the method used for

this procedure must be transparent to minimize biases and human errors.

The screening of the primary studies should base on predefined criteria (Hemingway et al., 2009). In this

thesis, the criteria required full text articles completely in English which were published after 1st January

2004. Furthermore, in order to exactly address the research questions, qualified literature should be

focused on a specific chronic disease without too much emphasis on mHealth technology and a particular

population. These criteria had been set down on needs of the research. First of all, researchers need full

text article to completely analysis the studied phenomenon. Second, English is the only utilized language

of this study as well as written language. Third, the oldest official definition of mHealth was found in the

year of 2004 (WHO, 2008, 14). Fourth, the objective of researchers was mainly to study nursing

intervention, therefore it was not researchers intension to emphasis on mHealth technology development.

Finally, this study intended to study the research phenomena in general, which means the study results

will be applicable for the entire population.

The literature filter started by scanning titles, abstracts as well as the content of the articles. Included

literature could be human laboratory trials and epidemiological studies. Based on above preset criteria,

112 out of 118 articles were excluded as they did not meet inclusion criteria. As shown in Appendix 1

Selected Literature List (key items: literatures author, publishing year, title, methodology, purpose

statement & conclusions), 6 studies were found in the literature search (20042012) that examined the

outcomes of mHealth programs (See Figure 1)


12/48

11

Figure1.Flowchart shows the processes of literature selection

Potentially eligible articles identified

(n = 118)

Exclusion based on selection criteria (n = 90)

No English (n = 0)

Without Full text (n = 85) Published before 1stJanuary 2004 (n = 5)

28 articles for further evaluation

Excluded (n = 22)

Not focus on specific chronic diseases(n = 8)

Over lean to mHealth technology expatiations

(n = 6)

Selection of study population obviously biased

(n = 3)

Double publication (n = 5)


13/48

12

3.3.

Data extraction

The purpose of the data extraction is to extract findings in a consistent manner. It enables later data

synthesis and interpretation (Kitchenham, 2004). This stage is one of the most important and time-

consuming parts of a systematic literature review (Cocharane, 2012). A data extraction form is required

during the course of data extraction to accurately and unbiasedly record obtained information from

primary studies (Kitchenham, 2004). The data extraction form conveys what was reported by the original

investigators to what is ultimately reported by the review authors (Cocharane, 2012).

Meade, cited by Cocharane (2012), indicated that the data collection form includes four important

functions. First, it is a summary of selected studies. Second, it assesses the eligibility of the current study

because it directly links to the review questions and criteria. Third, it is a historical record throughout the

review process. Fourth, it is a resource of analysis. The design of the data collection form should firstly

consider the volume of the selected information (Cocharane, 2012). Obviously redundant information may

result in confusion and extra analysis effort. However, the review result can be even worse with too littleinformation or omission of key data.

In this thesis, data from each study were extracted independently by two researchers and recorded on the

predesigned data extraction form. The form was used to extract details i.e. chronic diseases, effective

interventions, user attitudes, mHealth solutions and future challenges (see Appendix 2 Data Extraction

Form). There were always discussions between two researchers about different views of data extraction

from the selected literature. All final selected data was agreed by two researchers.

3.4.

Data analysis


14/48

13

The analysis was inspired by principles of evidence-based review and adequate consideration. Two

meetings of data analysis were participated by two researchers and intended to produce validate results.The data were read through many times so that researchers were able to clearly grasp writers viewpoints.

There were two major sub-processes involved in data analysis: (1) data reduction and pattern

identification and (2) producing objective analytic conclusion (Wholey et al., 2004, 421). In the first sub-

process, primary data had been examined, categorized, tabulated, compared, contrasted, and combined.

All in all, the purpose of this process was to find themes and finally identify patterns (Wholey et al., 2004,

421). The second sub-process aimed to address the studys initial propositions, ruled out alternativeexplanations, and then presented the essence of what the data reveal (Wholey et al. 2004, 421).

During the analytical practices, researcher found that the essential task in qualitative analysis was not

data accumulating, but getting rid of most redundant data. Identifying, coding, clustering, and labeling

were utilized in the content analysis to facilitate the forming of primary themes. By categorizing, data was

broken down into discrete elements, such as events, relationships, or processes (Wholey et al., 2004, 421).

Finally data relationships had been categorized in five major themes and sixteen sub-categories. The main

themes emerging from the literature were studied chronic diseases, mHealth interventions, mHealth user

attitudes, mHealth solutions, and mHealth challenges in the future (See Figure 2).


15/48

14

Figure2. Flowchart shows the main themes and the sub-categories of data analysis

mHealth applied

in chronic diseases

Studied

chronic diseases

Diabetes

Obesity

Cancer

Chronic obstructive pulmonary

disease

mHeath

interventions

Monitoring

Adhering

Counseling

mHealth

solutions

Mobile phone

Short message

Application

M it


16/48

15

4.

Findings

In general, all selected studies investigating mHealth programs were found in mainly four categories of

chronic illnesses: diabetes (2studies), cancer (1 study), obese (1 study), and chronic obstructive pulmonary

disease (2 studies). All studies were relevant to action research. In this chapter, findings from six selected

articles will be deeply discussed from five aspects: studied chronic diseases, mHealth interventions,

mHealth attitudes, mHealth solutions, and mHealth future challenges. In addition, findings from 6 selected

articles will be discussed in a chronological order as presented in the follow chart of Figure 2.

4.1. Studied chronic diseases

Increasing number of patients with long-term conditions such as diabetes, heart failure, and chronic lung

disease have produced an obvious burden on healthcare systems worldwide. In order to provide more

efficient and higher quality nursing care, many researches are dedicated to the study of high-tech related

mobile health care. There were four chronic diseases which had been studied in the eligible researches:

diabetes, obesity, cancer, and chronic obstructive pulmonary disease.

Diabetes mellitus was a major theme in two studies. According to original investigators, diabetes had the

necessity and possibility to be studied in relation to mHealth concept. Firstly, millions of people around

the world were diabetes patients. Nowadays, this disease had progressed as one of the leading cause of

death globally. Moreover, traditional self-monitoring could not support patients self-care because there

was lack of health professional feedbackand guidance regarding self-monitoring results. Specifically, at

present self-management had been regarded as an effective way of improving diabetes health and

preventing the onset of complication The self-management mainly involved periodically blood glucose


17/48

16

efficiency. Therefore the Information and Telecommunication Technologies (ITT) had been applied for

obesity treatment. ITT improves patients adherence to prescribed treatment through extensivemonitoring and timely counseling. By using ITT the cost-effectiveness and time-efficiency would also be

improved, since the telecommunication technologies availability and popularity were marked as its

significant advantages.

One study analyzed the requirement of cancer patients in relation to mHealth. The study stated that

medical staff has difficulties to obtain up-to-date information from hospital discharged cancer patients.

For instance, there was lack of post-hospital records about patients symptoms like pain, anxiety,

depression and distress. The consequence of such missing data was inadequate illness evaluation and

inappropriate treatment. Thereby, there was a need of information sharing in between post-hospitalized

cancer patients and healthcare professionals. A Wireless Health Outcomes Monitoring System (WHOMS)

prototype was designed for addressing above difficulties. More specifically, the monitoring system allowed

patients to receive and self-report structured questionnaires via mobile phone; meanwhile it also allowed

physicians to examine reported data to detect patients suffering earlier, and to activate well-timed

interventions.

Two out of six reviewed articles mentioned the major theme of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) was a common disabling chronic disorder, affecting all age

groups particularly elder people. The long-term conditions had significant impact on patients life quality

because of the coupled disabling episode and the restricted mobility. New sophisticated technologies

including Telecare systems and stand-alone electronic devices were capable of supporting people at home.

The aims were to assist patients self-care and promote autonomy so that patients were able to remain

i d d tl t h t ll d i i d d h it li ti F ti f T l h d b


18/48

17

questionnaires via a mobile phone, therefore health care providers was able to track the trend of blood

glucose changes, receive real-time feedback from patients, and finally find medical concerns. Anotherprogram, named TEChnology for Obesity, enhanced by Telecare for the long-term treatment of obese

people with type 2 diabetes and aimed to seek intervention for weight loss. The program utilized a

multisensory armband to automatically monitor calories burned and physical activities. Moreover, one

study investigated the local Call Center which was used to address the maintenance of elder COPD patients

independently living at home. The Call Center collected patients daily monitoring results such as oxygen,

saturation, pulse, and respiratory, then delivered appropriate nursing intervention accordingly.

There were two researches which deeply studied the adhering intervention of mHealth. In one study,

targeted patients had diabetes II and meanwhile were physically obese. Objective of nursing intervention

was to find and conduct weight losing approaches and preventing the onset of complication. Clinical

practices showed significant difficulties in treatment adherence because weight management needed long

term compliance in diet. As one of the solution, researchers installed telecommunication software onto

the outpatients mobile phones. Via the mobile phone patients food consumption (frequency and portions)

was visually displayed to the health care givers. Therefore patients were restricted to obey the prescribed

diet prescriptions. Another case involved diabetes research, as an incentive to adhere patients to update

their blood glucose monitoring results in the cell phone system, patients who routinely entered glucose

readings into the WellDoc Diabetes Manager weekly received a $20 reduction on their cell phone bill each

month (Katz, Mesfin, & Barr, 2012). In this way diabetes patients were encouraged actively comply

periodical blood glucose measurement.

Finally, counseling was the major theme of two reviewed articles. The study of Telecare exploratory RCT

( d i d t ll d t i l) i d t th ff ti f t d di b t


19/48

18

4.3.

Solutions of mHealth

mHealth had potential to improve care processes, expand access to care, augment other home care

technologies, and reduce costs of care. mHealth is defined as the delivery of health-related services

through mobile technology platforms on cellular or wireless networks and can include tablets, mobile

phones, smartphones, mobile-enabled diagnostic devices, or devices with mobile alert systems.

Based on selected literature, most mHealth solutions needed a mobile phone as a platform of sending and

receiving information. The platform usually embodied an application in order to improve user ability and

simplify data manipulation. In several cases, the platform attached one or many measurement instruments

so that patientsphysical measurements could be transferred automatically.

In the Telecare study of chronic obstructive pulmonary disease, the Telecare solution consisted of a

videophone link and a series of attachments i.e. sphygmomanometer, thermometer, and portable oxygen

detector. Therefore patients physical status wasmonitored by both devices and medical professionals.

Another study utilized a questionnaire as a self-reported tool which was installed into the mobile phone,

and aimed to monitor cancer patients physical, psychological, and social domains of health . The reason of

using questionnaire was that patients up-to-date information was difficult to require when they were

discharged from hospital. However, it was hard to estimate patients functional status and intensity of

some physical symptoms like pain, anxiety, depression and distress because of the missing information. All

in all, such questionnaire provided the possibility to detect patients suffering earlier, thereby activating a

well-timed intervention.


20/48

19

4.4.

Attitudes toward mHealth

As all mobile services have their pros and cons, mHealth is not an exception. There are both positive and

negative views toward the application of mHealth in the reviewed literature. Often people easily accepted

to participate in the research regarding mHealth services and devices. Minority refused the invitation

mainly because of less familiarization with new communication technology, for instance, mobile phone

short message service, internet, email. However, supportive voices were stronger in general.

It was concluded by many selected researches that mHealth empowered healthcare services to be more

effective. For example in the project of George Washington University, by informing diabetes daily

monitoring figures via phone to health care professionals, eligible patients three measures (blood pressure,

foot exam, immunizations) were improved, and another three measures (HbA1c, lipids, and eye exams)

were reduced (Katz et al., 2012). As expected, the consequent result was the decreasing of hospitalization.

The positive user experiences also had been reported by the University of Surrey from United Kingdom.

The studied COPD patients highlighted benefits of Telecare as rapid access to care, increased sense ofpersonal safety and security, and continuity of care are perceived. In the TEChology for Obesity research,

the low compliance of traditional interventions had been compared by the active diet mobile monitoring

system. Diabetes patients who were offered motivational telephone support valued the telephone

conversation as support and encouragement.

Since mHealth was still a new concept especially for patients, problems in relation to equipments user-

friendliness, wireless availability and electronic system trouble-shooting had been frequently discussed in

the literature. In the Surrey Universitys Telecare study, some chronic obstructive pulmonary disease

patients complained that they could not cope with the device connection such as blood pressure cuff and


21/48

20

4.5.

mHealth challenges in the future

mHealth related chronic diseases management was facing challenges in mainly two aspects: devices and

involved participants.

From the report of Wireless Health Outcome Monitoring System, statistic results showed that 42 percent of

patients refused to participate in, mainly due to devices barriers(Bielli, Carminati, Capra, Lina, Brunelli,

& Tamburini, 2004). The report also explored that the most predictive factors included old age, lower

number of education years, and lack of familiarity with new communication technologies. Since the mean

age of the involved cancer patients were 52 years old, it was reasonable that they refused to use the new

devices during an imminent operation or physical pain (Bielli et al., 2004). Besides, there were system

design problems in the study, resulting in high amount of missing data (27 percent) (Bielli et al., 2004).

These design problems included the selection field being too close to, indistinguishable form, and wrong

setting of buttons. Another concern unveiled by the study of the Telecare for COPD patients. It stated that

healthcare professionals were lack of training in relation to mobile care devices. The study was initiated inthe circumstance of none of the healthcare professionals knew the Telecare equipment, and later on

involved professionals participated in only two training sections. Actually this phenomenon was not rare in

many mHealth or Telecare related researches. The challenge was that even professionals still had great

reservations about how confident they were able to coach their patients onto the new scheme. Finally, the

deficiency of Telecare devices user-friendliness had been discussed adequately in the findings of the same

report, for instance difficult to access reading; not match needs; patients had trouble in sending data; andthe temperature probe that took longer than expected.

Based on the research of George Washington University School of Medicine a successful mobile health


22/48

21

5.

Discussion

The rapid advances in mobile technologies promote a rise of opportunity for the integration of mHealth

concept into existing healthcare system. mHealth, known as the use of mobile and wireless technologies to

support healthcare objectives, has the potential to promote nursing services, particularly for chronic

illness patients who need long-term nursing intervention at home circumstances (WHO, 2011). According to

WHO (2011), mHealth has been widely applied in medical care at present such as appointment reminders,

treatment compliance, mobile patient records, information access, patient monitoring, health surveys, and

data collection.

What chronic diseases demand mobile health services? andHow mHealth serviceshave been applied for

chronic diseases? were the predefined research questions of this thesis. In order to answer this research

questions, a systematic literature review was conducted, and resulting in the generation of 6 qualified

articles. The qualitative synthesis approach was applied during the data analysis so that mHealth services

for chronic patients could be described and discussed comprehensively and deeply to achieve research

purpose. The findings were categorized in five domains: studied chronic diseases, mHealth interventions,

attitudes towards mHealth, mHealth solutions, and challenges in the future.

In the rest of this chapter, two main concepts (chronic disease & mHealth) in this research were further

studied in the purpose of understanding background of the phenomenon: chronic diseases management is

applying mHealth services. In the last section, discussion focused on mHealth as nursing interventions forchronic diseases to conclude the study.

5 1 Ch i di


23/48

22

are not genetics but mostly relegated to the diet and lifestyle which actually can be influenced by proper

nursing interventions (WHO, 2011). For example, nowadays peoples leisure time for therapeutic exercisehas significantly reduced because of the modern lifestyle. Indeed nursing intervened exercise reduces risks

of heart diseases, type 2 diabetes, colon, and breast cancer (Willett, Koplan, Nugent, Dusenbury, Puska, &

Gaziano, 2006).

Figure 3 Year 2008 Proportional mortality (Chronic diseases 63% of total deaths, all ages)

Communicable,

maternal,

perinatal and

nutritional

conditions

37 %

Cardiovascular

diseases30 %

Cancers

13 %

Chronic respiratory

diseases

8 %

Diabetes

2 %

Other Chronic

diseases

10 %


24/48

23

Diabetes mellitus

Diabetes is a group of metabolic diseases which are characterized as elevated levels of blood glucose

(hyperglycemia) caused by defects in insulin secretion, insulin action, or both (Maschak-Carey, 2003, 1150).

Clinical manifestations of all types of diabetes include polyuria, polydipsia, and polyphagia. The increased

appetite is caused by the catabolic state induced by insulin deficiency and the breakdown. Whereas the

increased urination and thirst are resulting from the excess loss of fluid associated with osmotic diuresis.

Complications of diabetes are severe such as retinopathy, nephropathy, and neuropathy. For this reason

main goal of diabetes care is to achieve normal blood glucose levels to reduce the development of

undesired complications, thus maintaining good quality of life. In order to achieve this goal diabetes

inventions have been categorized as nutritional management, exercise, monitoring, pharmacological

therapy and education (Maschak-Carey, 2003, 1155). More specifically, patients should receive periodical

insulin administration or oral antidiabetic drug as prescribed. A supervised exercise program could be

arranged for maintaining ideal blood glucose level. Then treat hypoglycemic reactions promptly by giving

carbohydrates in the form of fruit juice, hard candy, and honey or I.V. dextrose. The meticulous skin care

is needed particularly feet and legs. Care providers should also record accurately vital signs, weight, fluid

intake, urine output, and caloric intake. Moreover, the monitoring of diabetic effects should be insisted in

the aspects of cardiovascular, peripheral vascular, nervous, renal and ophthalmologic systems. Finally,

diabetic care also refers to teach patients and family members to monitor health status such as diet and

feet (Maschak-Carey, 2003, 1156).

Morbid obesity

Morbid obesity is the term applied to people who are more than twice of normal body mass index (> 30


25/48

24

Chronic obstructive pulmonary diseases

Chronic obstructive pulmonary disease is characterized by airflow limitation that is not fully reversible

(Brooks-Brunn, 2003, 571). COPD may include diseases such as emphysema, chronic bronchitis or a

combination of these disorders. COPD is generated by the abnormal inflammatory response of the lungs to

noxious particles or gases. Environmental exposures and host factors are risk factors of COPD, and the most

severe risk factor is cigarette smoking. There are three primary symptoms of COPD: cough, sputum

production, and dyspnea on exertion (Brooks-Brunn 2003, 572). Respiratory insufficiency and failure are

major life-threatening complications of COPD. The most effective intervention to prevent COPD or slow its

progression is smoking cessation. It is can be combine with pharmacology therapy, oxygen therapy and

surgical management. Nursing interventions are significant important relating to COPD rehabilitation,

particularly in teaching patients and facilitating daily care, for example, respiratory therapy education,

physical therapy for exercise and breathing retraining, occupational therapy for conserving energy during

activities of daily living, and nutritional counseling. Moreover monitoring is also important in nursing care

(Brooks-Brunn, 2003, 574). Nurses should periodically monitor pulse oximetry values to access patients

need for oxygen administers supplemental oxygen as prescribed. Furthermore, Reporting patients physical

and cognitive changes to physician is part of COPD nursing care to prevent various complications and acute

onset.

Cancer

Cancer can affect every age group, but mostly in people older than 65 years of age (Rokita, 2003, 315). It

is initiated from the genetic mutation that transforms cell into abnormal. Gradually the abnormal cell

starts to malignant growth and changes surrounding tissues. The metastasis occurs when cancerous cells


26/48

25

communication has broadly applied to diverse domains of healthcare system. This is attributed by the

rapid advances in mobile technologies, the continuous increasing coverage of mobile networks and theever-rising opportunity for integrating mobile concept with existing electronic health care services (WHO,

2011). Mobile technologies are featured as pervasiveness, portability, immediacy, and convenience which

make them as an ideal choice of new healthcare approach (Farhaan, Tony & Rosemary, 2008). In 2009,

WHO conducted a global survey, the investigation result showed that eighty three percent and twelve

member states reported their mHealth initiative in their own country. As Gough, Sarin & Atun (2006)

stated that mobile applications contribute efficiently and remarkably to health care communication.

mHealth broadly encompasses the use of mobile telecommunication technology within health care delivery

systems. In WHOs 2011 report, mHealth was defined as medical and public health practice supported by

mobile devices, including mobile phones, patient monitoring devices, personal digital assistants (PDAs),

and other wireless devices. Another definition was made by University of Cambridge in the report of Mobile

Communications for Medical Care (FREng et al., 2011) as such: a service or application that involves voice

or data communication for health purposes between a central point and remote locations. Generally, the

concept of m-health refers to mobile computing, medical sensor, and communications technologies for

health care (Istepanian Jovanov & Zhang, 2004).

mHealth is a sub-segment of eHealth (or electronic health). The eHealth as a new term can be traced back

to 1990s when internet started to proliferate and prevail in public. It was designed to build up efficient

communications among medical-related parties e.g. physician, nurse, and patient (Oh, Rizo, Enkin & Jadad,

2005). The most common cited definition of eHealth is from the WHO: use of information and

communication technology for health (2008). More precise, eHealth technologies include computers,

I t t t llit i bil h d P l Di it l A i t t (PDA) t Th f H lth


27/48

26

Figure 4 Categories of mHealth services

More precisely, the theme of primary care includes remote diagnosing and treatment provision which

support the access of medical care services, for example connecting the rural patient with the specialist in

the urban hospital (FREng et al. 2011). Secondly, the theme of emergency care mainly covers emergency

response systems such as one-touch calling, location-tracing, and fall-prevention (FREng et al., 2011).Thirdly, as the earliest application of Telecare, the management of long-term conditions supports the

provision of home care for patients who are undergoing chronic diseases particularly diabetes, asthma,

m ealth

Services


28/48

27

5.3.

mHealth as a nursing intervention for chronic diseases

At present mobile telecoms have been extensively exploited in health care domain, new technologies are

inducing hand in hand with the continuously changed expectations of care delivery. Precisely facing

dramatic increases in the numbers of chronically ill patients, almost every countrys health care system

has been challenged by the considerable shortage of health care providers in recent decade (WHO, 2010).

However as hardware capacity of mobile devices improved, a growing number of mHealth functionalities

have been designed specifically for health care field, making mhealth applications technically possess

feasibilities as innovative nursing interventions. While the purposes of this innovation for chronic diseases

are to promote patients health status andreduce hospitalization by improving patients self-management

capabilities (Fu, Patrick, Shen, Zhu, Yang & Mao, 2003). Indeed clinical practices have proved that chronic

diseases can be largely prevented or rehabilitated by approaches of effective nursing interventions. As

estimated, if the major risk factors for chronic diseases were eliminated, at around three-quarters of heart

disease, stroke, and type 2 diabetes would be prevented; and 40% of cancer would be prevented (WHO

2010). Nowadays successful mHealth experiments and implementations include high-resolution images for

remote diagnosing; large file exchange for the storage of medical records; data tracking for client locating;

interface with sensors for monitoring health index; healthcare apps for client information reading (FREng

et al., 2011). Furthermore, the affordability and popularity features of mobile devices support the

mHealth solution come into our daily life. For instance, in Finland the mobile network coverage is near-

ubiquitous and mobile handsets penetration rate is nearly 100% (Patrick et al., 2008). To sum up, the

potential of mHealth concept is thus to help provide more accessible, more efficient and more effective

health care.


29/48

28

altered diabetes care. It is known that self-monitoring supports the early detection and prevention of

hypoglycemia and hyperglycemia. Comparing with traditional paper records or logbook, the short messagesService tectonic is advanced at the function of interactive information communication, which enables

diabetic patientsautonomy and independency by timely professional suggestions via short message service.

Furthermore, the short message service is a simple form of data commuting between one and another but

sometimes also one and group if required. Although the internet or email may have the same functions,

but the availability and confidentiality of short message service is obviously more profitable (Rifat &

Soalen, 2006). Messages can be held until the recipients have time for reading, or it also can be stored at

the short message service Centre when the phone is switched off. The value of this function will avoid

unwished disturbing e.g. during driving and meeting. Furthermore, short message usually reaches

recipients within seconds, allowing for an immediate response, and a delivery receipt can be added to the

message to confirm that delivery has taken place. It is also possible to save text message on the phone and

access the content as often as liked. In routine healthcare activities, there are many short message service

applications such as reminding appointment, monitoring patients conditions, providing psychological

support to patients, communicating test results (Rifat & Soalen, 2006).

Camera

When camera was implanted into the mobile devices, innovations of patients monitoring system has

continuously progressed. The phone camera is an easily-approached feature that makes it as a useful tool

for collecting health-related data. It provides the possibility of remote diagnosis, protection, detection,

and prevention (Rifat & Soalen, 2006). Presently, there are three nursing interventions are supported by

mobile cameras: (1) evidencing health-related behaviors, such as asthma spray administering, (2) updating


30/48

29

Smartphone & Applications

Undoubtedly smartphone and its diverse applications have completely changed our life style. Those

applications utilized the mobile device functions e.g. dialog box, menus, calendar, cameras, contact list

and email to further promote communication. Regarding health related applications which have been

mainly categorized as such: (1) journaling application that assists users to record data such as diet,

exercise and blood glucose; (2) alarming application that detects emergency status for example

hypertension and heart failure; (3) collecting application that receives data from pedometers, blood

pressure monitors and other devices; (4) educating application that teaches users about health-related

skills (Predrag & Wanda, 2011).

Diabetes patients exercise isa good example of applying the mHealth application. Benefits of therapeutic

exercise are enormous and obvious for managing diabetes. It lowers the blood glucose level. During

exercise, not only circulation and muscle tone has been promoted, but also metabolic rate has been

obviously ameliorated (Maschak-Carey, 2003, 1156). But improper exercise, on the contrary, may lead to

hypoglycemia. Hypoglycemia occurs when relative to the exercise a person eats too little carbohydrate

(fruit, milk, starch), or takes too much medication, or had combined effect of food and medication

(Maschak-Carey, 2003, 1168). A smartphone based application can be utilized for planning and monitoring

patients exercise. Only in case of reasonable exercise, insulin can be ingested by body muscles to

achieving weight losing, stress easing and health feeling (Maschak-Carey 2003, 1198). Meanwhile exercise

also alters blood lipid level which is a critical risk factor of diabetes complication: cardiovascular disease.

All in all if exercise have been planned and conducted under the monitoring of a smartphone, exercise is

definitely a valuable aid to optimal health.


31/48

30

Automated sensing

Nearly all contemporary mobile phones were easily connected to other sensing devices, or designed as

containing build-in sensors (Predrag & Wanda 2011). In this way, mobile phones are enabled to gather

information from health monitoring devices such as blood pressure monitor, glucose meter, ECG or

pedometers. There is one example showed by iPones application- Runkeeper (http://runkeeper.com). The

movements route of user will be tracked by the phone, at the same time users burned calories are

calculated during and after these workouts.

It is known that the acute asthma episode is preventable by avoiding suspected provokers or causative

agents. Insisting on long-term pharmacologic therapy and monitoring are keys for asthma care which

require patients and health care professionals are perseverant (Brooks-Brunn, 2003, 589). Unfortunately,

there are always patients who are lack of encouragement to monitor their peak flow measurements with a

diary, who are lack of written, up-to-date educational materials (Brooks-Brunn, 2003, 592). The automated

sensing provides a simple and efficient approach to help asthma patients to remaindering and monitoring

their peak flow measurements. By attaching a peak flow meter, smartphone is able to collect

measurements and send results to healthcare center.

Internet access

Last but not least, Internet connection is one of the most important health interventions. One of the

examples is uploading critical measurement (e.g. glucose levels, peak flow) which enables track remote

customers health index(Predrag & Wanda 2011). These continuously updated data can be easily viewed,

cohered and analyzed, therefore promote early detection of emergency situation.


32/48

31

Internet based Healthcare system is not rare nowadays. In Cyprus, a homecare system, named Network for

Medical Collaboration, is aiming to support dynamic virtual collaborative HealthCare teams dealing withthe home-healthcare (Pitsillides, Pitsillides, Samaras, Dikaiakos, Christodoulou, Andreou, & Georgiadis,

2012). The research results showed that chronic care (e.g. cancer care) required specialized monitoring

and treatment by patient centered multi-professionals. Home environment is obviously comfortable for

chronic patients, but it is difficult to achieve the physical presence of all health care team members at all

demanded times. The Network for Medical Collaboration system had been produce particularly for

addressing the geographic communication difficulties among medical team. Medical team members are

able to share and discuss patients information via internet. Consequently patients will receive dedicated,

personalized and private services to home residing. And the most important thing is that patient sneeds

have been solved at home without the necessity to move to hospital (Pitsillides et al., 2012).

In this section, five applications of mHealth have been discussed i.e. short message services, camera,

applications, automated sensing, and internet access. At present, these applications have been broadly

used as a nursing intervention to support daily routines of chronic patients, for example monitoring

physical indexes, evidencing health related behaviors, updating health status, recoding the important

health data, educating the patients, and emergency alarming. The diversity of mHealth applications

represents enormous benefits in taking care of the patients with chronic diseases; also the burden of

healthcare system will be relieved consequently.

6.

Trustworthiness

In qualitative research, examination of trustworthiness is crucial (Golafshani, 2003). In order to produce a

d d bl d f i h h h i i i l h hi i ll diff


33/48

32

are growing dramatically in the healthcare system. However, the advancing of mobile technology provides

opportunities in nursing innovations for chronic disease care. As nursing degree students, it is one of ourmissions to study the future nursing interventions and promote the quality of nursing care.

Based on the systematic literature search and the pre-designed data processing procedures, the raw data

had been cautiously collected and comprehensively analyzed in order to answer the research questions:

What chronic diseases demand mobile health services? andHow have mHealth services been applied to

chronic diseases? Regarding the research method, the proceeding of the systematic literature review was

under a firmly theoretical study. On the basis of sufficiently theoretical instructions, the research process

had been conducted by being critical towards all selected articles as well as being systematic and unbiased

in the data collection and the data analysis process. Precisely, inclusion and exclusion criteria clarified

intelligibly which article was qualified as a target study. While, the data extraction form accurately and

unbiasedly recorded obtained information from primary studies. And all items of the extraction form had

been selected and discussed by two researchers so that they covered main themes within selected

literature as comprehensive as possible. In the data analysis process, two major sub-processes were

involved i.e. (1) data reduction and pattern identification and (2) producing objective analytic conclusion.

These processes supported researchers to systematically and logically interpret what the data revealed.

In this study, the researchers believed that providing sufficient amount of information for readers is an

important part of their personal commitments. Thereby, readers are able to evaluate the trustworthiness

of findings. Particularly, in the section of research method, researchers logically elaborated search

databases, search approach and keywords, literature selection criteria, data extraction tools, and data

analysis logics. In this manner, researchers achieved the pre-planned commitment to readers.


34/48

33

diseases care from the beginning to the end. In addition, mHealth and Telecare had been also included and

studied as main concept synonyms, abbreviations, and alternative spellings. Moreover, validity of thecollected data is related to how appropriate the research method has been designed by the researchers for

answering the research question (Carcary, 2009, 14). Reasons of conducting systematic review in this study

were; summarizing benefits and limitations of previous researches, identifying gaps in current researches

for further investigation, and providing a framework to position new research activities (Kitchenham, 2004).

These reasons consist of the basic instructions of answering the research question.

Reliability is defined as repeatability of in the qualitative research. Repeatability means the research

could be repeated and similar results could be reproduced (Kvale, 1996; Lee & Baskerville, 2003; Mason,

2002; Yin, 2003). According to Golafshani (2003, 201) the term reliability is used more in evaluating

quantitative research. Researchers realized that in qualitative research it is difficult to consider the

reliability, due to the fact that providing the precise conditions in which the data were collected is very

demanding (Strauss and Corbin, 1998). This study has tendency to be reproduced because all research

processes (literature search, data filtering, data extract, and data analysis) had been prescribed and

explained intelligible. However, the researched phenomena had been studied from contemporary

literature during a specific timeframe, thus it would be hard to achieve the same outcomes. Since the

researched phenomena (mHealth application within chronic diseases management) are always under

constant changes.

In systematic literature review, the credibility evaluation involves assessing the rigours of electronic

databases utilization, data collection, and interpretation of the data (Lodico, Spaulding, & Voegtle, 2010).

In this thesis, the literature search was conducted only from credible databases that were suggested on

L U i it f A li d S i Lib O li C t l b d th d t b EBSCO


35/48

34

Polit and Hungler (1991, 645) defined the term 'generalizability' as the extent to which findings from a

particular study may apply to different context or to the entire population. In this study, the literatureselection was conducted under the criterion of without too much emphasis on a particular population. As

a result, three articles had been excluded based on this criterion, for example, one of the excluded

articles was focused on mHealth application in a developing country. Therefore researchers had considered

the generalizability in proceeding the systematic literature review.

To sum up, trustworthiness had been considered in all aspects of this research. Producing valid findings

was one of the essential aims of researchers. For this reason, conducting the data search from credible

electronic databases, extracting and analyzing data by involving two researchers leaded the study to

generate valid and trustworthy findings. The researchers concluded that the collected data agreed with

the purpose of the study, i.e. describe and discuss mHealth services for patients with chronic diseases by

conducting systematic literature review and answered the research questions What chronic diseases

demand mobile health services? and How have mHealth services been applied to chronic diseases?

However, due to constant improvements in the field of health care and technology services, the

repeatability is limited in this study.

7.

Ethical considerations

Ethical issues are present in all types of researches including qualitative researches (Orb, Eisenhauer, &

Wynaden, 2000, 93). The term of ethicsis defined as doing good and preventing harm(Orb et al., 2000,

95). The main reason of including ethics in the research is to respect readers and participants, cause no


36/48

35

Throughout the study, the researchers were concerned about the ethical issues of using mhealth services.

According to Kotz (2011), the ethical issues of using mhealth services can be caused by data management,for instance, mhealth application provide an environment which allows broad range of data transmissions

among various users including: nurses, doctors, diet advisers, or lifestyle coaches. The complexity of the

privacy issues of using mhealth services arouse due to the fact that many aspects involved throughout the

entire course of data processing such as data storage, recording, and transmitting. In addition, Adesina,

Agbele, Februarie, Abidoy, & Nyongesa (2011, 30) suggested that exchanging the confidential information

is a serious issue in healthcare system, and it is one of the healthcare professionals responsibilities to

keep all patients information confidential and support the patients privacy. To prevent harm,

professionals were recommended to avoid the use of mHealth services when transmitting highly

confidential information, for instance, informing the patient concerning a particular tests resul t (Adesina

et al., 2011, 30).

One important step before conducting the study is to investigate the research question in relation to

previous studies on the same topic thus no repeating study will be conducted. For this reason, the search

was conducted from Theseus database (Electronic Library of the University of Applied Sciences) and the

results revealed that no similar studies had been done on the same topic. In the next step, the purpose

statement and the research questions were presented clearly to the supervisors at Laurea University of

Applied Sciences. Finally, permission of conducting the study and further recommendations on ethical

implications were obtained. The supervisors recommended using the keywords that are relevant to the

field of study, to promote the validity of the study. For this reason, mHealth, mobile health, andTelecare were searched as the keywords instead of telemedicine or telediagnose which are related to

the field of medicine.


37/48

36

concepts. Overall, the researchers concluded that the research questions were clear and valid thus the

researcher had been able to answer them within constrains time and available resources.

Transparency is important to ensure rigour of the qualitative studies (Yin, 2011, 19). Transparency of the

research refers to what extends the researcher has been described and documented the research process

clearly. In other words, other researchers and people should be able to understand and scrutinize the

research process by reviewing the study. In this thesis, the researchers explained clearly the research

method (systematic literature review), the main reason for conducting it, the process of data search, the

Inclusion, and exclusion criteria. Moreover, the researchers believed that the selected method was

appropriate and rigorous thus the findings corresponded to the purpose and answered the research

questions.

In qualitative studies, bias is considered as a potential treat to credibility and validity of the study (Klenke,

2008, 41). Bias is known as any conscious or unconscious influence of the researcher, in the way that the

outcomes support his/her personal opinions or beliefs (Bloor & Wood, 2006, 21). In this thesis, the

researchers controlled and avoided bias through different processes of the study. Systematic literature

review was conducted as the research method in this study. It is important to mention that, reducing the

influence of the researchers bias is one of the main characteristics of the systematic literature review as a

research method (Crowther, Lim, & Crowther, 2010). In addition, the researchers did not include their

personal opinions or their prior knowledge in performing the literature search, formulating inclusion and

exclusion criteria, data selection process, data analysis, presenting the findings, and writing the discussion

section. By conducting the objective methodology, the researchers ensured that the presented data in this

study are credible and they found four categories of chronic diseases diabetes (2studies), cancer (1 study),

b (1 t d ) d COPD (2 t di ) ithi th i l t d ti l


38/48

37

8.

Limitations and recommendations

This thesis has certain limitations that need to be taken into account when considering its contributions.

Limitation in research refers to the particular aspects that have adverse effects on the study results, while

the researcher has no control upon them (Sevilla, Ochave, Punsalan, Regala & Uriarte, 1992, 18). Although

this systematic literature review reached its aims, there were some unavoidable limitations concerning the

whole research process. Limitations regarding this systematic review were affiliated with the broadness of

the topic, language, keywords search, and demographic coverage.

Regarding the research topic, this study has focused on the general aspects of chronic diseases due to

restriction on accessing full free-text articles and time. Indeed, this research is suitable for readers who

intend to get information about mHealth application in the major chronic diseases particularly diabetes,

obesity, cancer and chronic obstructive pulmonary disease. The search for qualified research articles in

this literature review was conducted only in English language. Therefore, articles in other languages that

dealt with mhealth services and chronic diseases were excluded. At present, mobile health services havebeen applied to patients with chronic diseases globally to reduce communication barriers and improve the

quality of care (Bielli et al., 2004). In fact, the use of mHealth services for patients with chronic diseases

is internationally recognized as an innovation in healthcare. The limitation on language is known as an

impediment in assessing all the articles that have been studied internationally on this topic.

In this literature review, three keywords mHealth, mobile health, and Telecare had been searched in

conjunction with chronic disease in order to find the relevant and qualified articles. These keywords

were formulated in relation to the theme of our study, which is nursing. Therefore, other keywords, such

as telemedicine or telediagnose were excluded from the keywords search while they are also belong to


39/48

38

be focus on a particular topic relating to mHealth application in chronic diseases management, for

instance, a specific disease (diabetes, chronic obstructive pulmonary disease, cancer or obesity) or aspecific population. Especially mhealth services can be studied in relation to cardiovascular disease. In this

study, no articles related to cardiovascular disease were obtained from the databases search, but the

severity of this disease has significantly affected chronic diseases management. There is a necessity of

studying the interactions between cardiovascular disease and mobile health services. Moreover, in this

study, one of the selection criteria was not emphasis on a specific population thus the study was

conducted on the general aspects; however, nowadays most of the healthcare systems are built up on the

basis of their local society. Obviously, each of the healthcare system inevitably has its characters, such as

healthcare infrastructure, resident consumption level and cultural background. Thereby, specific study on

a targeted population is truly needed for the purpose of promoting mHealth services into the clinical

practices in chronic care domain. Secondly, this research was based on theoretical search. There are

valuable findings about mHealth user attitudes and future challenges. Obviously, these findings need to be

further validated and analyzed by the action research. By collecting the user s and healthcare

professionals experiences in this field, action research will promote the clinical practice of mHealth

services as a nursing intervention for patients with long-term conditions.


40/48

39

REFERENCES

Adesina, A. Agbele, K. Februarie, R. Abidoye, A. & Nyongesa, H. 2011. Ensuring the security and privacy of

information in mobile health-care communication systems. Department of Computer Science, University of

the Western Cape. South Africa.

Barr, V. J. Robinson. Marin-Link. Underhill. Dotts. Ravensdale & Salivaras 2003. An integration of conceptsand strategies from population health promotion and the chronic care model. Hospital quarterly vol. 7 no.1

Bielli, E. Carminati, F. Capra,S. Lina, M. Brunelli, C. & Tamburini, M. 2004. A Wireless Health OutcomesMonitoring System (WHOMS): development and field testing with cancer patients using mobile phones.Milan, Italy. doi:10.1186/1472-6947-4-7

Brooks-Brunn, J. A. 2003. Medical-Surgical Nursing. 10thedition. Chapter 24: Management of Patients WithChronic Obstructive Pulmonary Disorders. ISBN-10: 0781731933

Carcary, M. 2009. Enhancing Trustworthiness in Qualitative Inquiry. University of Limerick, Ireland.

Castelnuovo, C. Manzoni, G. Cuzziol, P. Cesa, G. Tuzzi, C. Villa, V. Liuzzi, A. Petroni, M. & Molinari, E.2010. TECNOB: study design of a randomized controlled trial of a multidisciplinary telecare interventionfor obese patients with type-2 diabetes. doi:10.1186/1471-2458-10-204.

Cochrane Handbook for Systematic Reviews of Interventions. Referred 5.05.2012

http://handbook.cochrane.org/

Consuelo, S. Ochave, J. Punsalan, T. Regala, B. & Uriarte, G. 1992. Research Methods. Revised Edition.Philippines.
http://handbook.cochrane.org/http://handbook.cochrane.org/http://handbook.cochrane.org/


41/48


42/48

41

Laurue, F. Colleau, S. M. Brasseur, L. & Cleeland, C. S. 1995. Multicentre study of cancer pain and itstreatment in France. BMJ VOLUME 310.

Lee, A.S. and Baskerville, R.L. (2003). Generalising generalisability in Information Systems research.Information Systems Research, 14, (3), 221-243.

Lodico,M. Spaulding,D. Voegtle,K. 2010. Methods in Educational Research. From Theory to Practice.Second edition. USA.

Loiselle,C. Profetto-McGrath,J. Polit,D. Beck, C. 2012. Canadian Essentials of Nursing Research. Thirdedition. Canada.

Mason, J. (2002). Qualitative researching, (2nd edn). Sage Publications, London.

May, C, R. Tracy L Finch, T, L. Cornford, J. Exley, C. Gately, C. Kirk, S. & Jenkings, K, N. 2011. Integratingtelecare for chronic disease management in the community: What needs to be done? BMC Health ServicesResearch 2011, 11:131

Mair, F. S. Hiscock, J.& Beaton, S. C. 2008. 'Understanding factors that inhibit or promote the utilization oftelecare in chronic lung disease', Chronic Illness 4(2): 110-117

Ministry of Social Affairs and Health. 2006. Health in Finland. Referred 16.03.2011http://www.ktl.fi/hif/hif.pdf

Maschak-Carey, B. J. 2003. Medicl-Surgical Nursing. 10thedition. Chapter 41: Assessment and Managementof Patients With Diabetes Mellitus. ISBN-10: 0781731933

Oh,H. Rizo, C. Enkin, M. & Jadad, A. 2005. What Is eHealth (3): A Systematic Review of PublishedDefinitions. Toronto ON, Canada.

Orb, A. Eisenhauer, L. Wynaden, D. 2000. Ethics in Qualitative Research. JOURNAL OF NURSINGSCHOLARSHIP, 2000; 33:1, 93-96.

Patrick K Griswold WG Raab F & Intille SS 2008 Health and the Mobile Phone American Journal of
http://www.ktl.fi/hif/hif.pdfhttp://www.ktl.fi/hif/hif.pdfhttp://www.ktl.fi/hif/hif.pdf


43/48

42

Roy, A. & Buranen, L. 1999. Perspectives on Plagiarism and Intellectual Property in a Postmodern World.State University of New York. United State of America. ISBN-13: 978-0791440803

Rubin, A. Babbie, E. 2010.Essential Research Methods for Social Work. Second Edition. United State ofAmerica.

Sim, J. & Wright, C.2000. Research in Health Care. Concepts, Designs and Methods. United Kingdom.

Smerltzer, S.C. et al. 2007. Textbook of Medical-Surgical Nursing. Eleventh edition. Lippincott Wiliams &Wilkins, New York

Statistics Finland. 2011. Referred 07.03.2012.http://www.stat.fi/til/ksyyt/2010/ksyyt_2010_2011-12-16_tie_001_en.html

Strauss, A. and Corbin, J. (1998). Basics of qualitative research techniques and procedures for developingGrounded Theory, (2nd edn). Sage Publications, London.

Weingarten, M. Paul, M. Leibovici, L. 2004. Assessing ethics of trials in systematic reviews. BMJ.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC404510/

Willett WC, Koplan JP, Nugent R, Dusenbury C, Puska P, Gaziano TA. 2006. Prevention of Chronic Diseaseby Means of Diet and Lifestyle Changes. 2nd edition. Washington (DC): World Bank; 2006. Chapter 44.

WHO. 2008. Towards the Development of an mHealth Strategy: A literature Review.

WHO. 2011. mHealth New horizons for health through mobile technoligies.

WHO. Chronic diseases. Referred 13.07.2012.http://www.who.int/topics/chronic_diseases/en/

Wholey, J, S. Hatry, H, P. & Newcomer, K, E. 2004. Handbook of Practical Program Evaluation. Secondedition. Jossey-Bass: San Francisco
http://www.stat.fi/til/ksyyt/2010/ksyyt_2010_2011-12-16_tie_001_en.htmlhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC404510/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC404510/http://www.who.int/topics/chronic_diseases/en/http://www.who.int/topics/chronic_diseases/en/http://www.who.int/topics/chronic_diseases/en/http://www.who.int/topics/chronic_diseases/en/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC404510/http://www.stat.fi/til/ksyyt/2010/ksyyt_2010_2011-12-16_tie_001_en.html


44/48

APPENDICES

Appendix 1 Selected Literature List

AUTHOR &PUBLISHINGYEAR

TITLE METHODOLOGY

PURPOSE STATMENT CONCLUSIONS

Katz, R.et al., 2012

Lessons From a Community-Based mHealth Diabetes Self-Management Program: It's NotJust About the Cell Phone

Actionresearch

The primary objective was to provide aneffective, sustainable self-care diseasemanagement real-world strategyconnecting patients using their own cellphones with a web-based diseasemanagement system, case managers, andprimary care providers.

A successful mHealth home managementhealth system requires attention to all ofthe links in the chain of chronic care.

Bielli,E. etal., 2004

A Wireless Health OutcomesMonitoring System (WHOMS):

development and field testingwith cancer patients usingmobile phones

Actionresearch

The aim of this study was to developa new system for transmitting patients'

self-reported outcomes using mobilephones or the internet, and to testwhether patients can and will use thesystem via a mobile phone.

More than half of the patients self-completed the questionnaire using the

mobile phone. Thisproportion may increase with the use ofmultichannel communications which can beincorporated into the system.

Horton,K.2008

The use of telecare for peoplewith chronic obstructivepulmonarydisease: implications formanagement

Actionresearch

To evaluate the telecare service offeredby Home Care teams to patients withchronic obstructive pulmonary disease(COPD).

The potential benefit of telecare as aneffective model of care promotingindependence, choice and capacitybuilding, and in supporting people withCOPD and their carers was not realised; thishad been hampered by limited knowledgeof the staff concerned.

Mair, F.S.

2008

Understanding factors that

inhibit or promote theutilization of telecare in chroniclung disease

Action

research

To perform a process evaluation of a

randomized controlled trial (RCT) ofhome telecare for the management ofacute exacerbations of chronicobstructive pulmonary disease (COPD),using the normalization process model(NPM) as an explanatory framework.

The telecare service seemed unlikely to

become normalized as part of routinehealthcare delivery, because the nursingteam lacked confidence that it was a safeway to provide healthcare in this contextand it was not perceived as improvingefficiency.


45/48

AUTHOR &PUBLISHING

YEARTITLE

METHODOLOGY

PURPOSE STATMENT CONCLUSION

Dale,J. et al.,2009

Telephone peer-deliveredintervention for diabetesmotivation and support: The

telecare exploratory RCT

Actionresearch

To test trial design issues related tomeasuring the effectiveness of a peertelephone

intervention to enhance self-efficacy intype 2 diabetes; evaluate the impact onself-efficacy and clinicaloutcome; and describe patient andpeer experience.

Further consideration needs to be given tothe targeting of the telecare peer support,its intensity, the training and ongoing

supervision of peer supporters, and theextent to which informationand advice should be incorporated.

Castelnuovo,Cet al .,2010

TECNOB: study design of arandomized controlledtrial of a multidisciplinarytelecare intervention forobese patients with type-2diabetes

Actionresearch

The aims of this study are to evaluatethe effectiveness of the TECNOBprogram in a sample of obese peoplewith type 2 diabetes seeking treatmentfor weight reduction and to find outwhat behavioral and psychologicalvariables are predictive of treatment

success.

Indeed, the mobile connectivity can extendthe treatment till the real-life environmentsof each patient, where traditionalinterventions typically fails because of thelow compliance many obese patients have incarrying on with diet programs withoutactive monitoring and support.


46/48

45

Appendix 2 Data Extraction Form

Reference Chronicdiseases

mHealthsolutions

mHealth interventions mHealth user attitudes Challenges in thefuture

Katz,R ., et al.2012Lessons From aCommunity-BasedmHealth DiabetesSelf-ManagementProgram: It's Not JustAbout the Cell Phone

Diabetes a cellphoneassisteddiabetesself-management system

Monitoring&adherence

project enrolled 32 patients

with Type 2 diabetes from acommunity clinic usingpatients cell phones connectedto the Well Doc DiabetesManager System withmonitoring by case managersand monthly reports to primarycare providers.

In the active patients group,three measures (bloodpressure, foot exam,immunizations) improved,and three measures (HbA1c,lipids, and eye exams) werereduced. All participantsfound the instant coachinghelpful.

Besides effectivemHealth solusion, asuccessful mHealthhome managementhealth system requiresattention to all of thelinks in the chain ofchronic care.

Bielli,E ., et al.2004A Wireless HealthOutcomes MonitoringSystem (WHOMS):development and fieldtesting with cancerpatients using mobilephones

Cancer mobilephonebasedWirelessHealthOutcomesMonitoringSystem

Monitoring Periodical sending ofquestionnaires to patients withmobile handsets. The physiciancan examine patient'ssymptoms according to theirquestionnaire answers. Thegraphical and chromaticrepresentation allows thedoctor a quick and clear visionof how the patient's symptomsare evolving.

The present studydemonstrated the majorityof patients agreed to use amobile phone-based wirelesshealth outcomes monitoringsystem.

The reasons forrefusal were usuallyrelated to thepatient's unfamiliaritywith this form ofcommunicationtechnology.Preoccupation due toan imminent operationand physical painwere also given asexplanations forrefusal.

Horton,K.2008The use of telecarefor people withchronic obstructivepulmonarydisease: implicationsfor management

COPD Telecaredevices(telephone,bloodpressurecuff andthetemperatureprobe)

Monitoring (1) daily monitoring of thepatients condition via the localCall Centre with an integratedcommunity response service;(2) in parallel, a more intensivemonitoring was instigated todetermine any physiologicalchanges, and (3) an escalationprocedure was set up inorder that the Call Centreoperator would know whatintervention would beappropriate.

Case studies highlight thatthe rapid access to care, anincreased sense of personalsafety and security, and thecontinuity of care areperceived as benefits.the equipment wasperceived as not userfriendly and bulky.

The equipment wasperceived as not userfriendly and bulky.


47/48

Reference Chronicdiseases

mHealthsolutions

mHealth interventions mHealth user attitudes Challenges in thefuture

Mair, F.S.2008Understanding factorsthat inhibit or

promote theutilization of telecarein chronic lung disease

COPD videophone Monitoring The telecare service consistedof a videophone link andattachments thatpermitted remote physiological

monitoring of blood pressure,pulse, temperature and pulseoximetry.

The telecare service did notprovide an interactionaladvantage for the nursesproviding this service and

did not fit with the nursesviews of the mostappropriate or preferred useof their skills.

The telecare serviceseemed unlikely tobecome normalized aspart of routine

healthcare delivery,because the nursingteam lackedconfidence that it wasa safe way to providehealthcare in thiscontext and it was notperceived asimproving efficiency.

Dale,J ., et al.2009Telephone peer-

delivered interventionfor diabetesmotivation andsupport: The telecareexploratory RCT

Diabetes telephone Adherence&Consulting

Telecare support was intendedto supplement routine care bymotivating adherence to the

advice provided by the generalpractitioner or practice nurseat the time of a change(medication and/or lifestyle) inthe patients diabetes care.

Most participants valuedhaving someone they couldtalk to about diabetes who

could offer them supportand encouragement.

Further considerationneeds to be given tothe targeting of the

telecare peer support,its intensity, thetraining and ongoingsupervision of peersupporters, and theextent to whichinformation andadvice should beincorporated.

Castelnuovo,G ., et al.2010STtuEdCy

pNrotOocoBl : studydesign of arandomized controlledtrial of amultidisciplinarytelecare interventionforobese patients withtype-2 diabetes

Diabetes

Obesity

telecarethrough aweb-

platformandmobilephones

Monitoring&Adherence

&Consulting

They receive a multisensoryarmband(SenseWear Pro2 Armband),

an electronic tool that enablesautomated monitoring of totalenergy expenditure(calories burned), active energyexpenditure, physical activityduration and levels (METs) andsleep/wake states duration.

the software previouslyinstalled into the outpatients'

the mobile connectivity canextend the treatment tillthe real-life environments of

each patient, wheretraditional interventionstypically fails because of thelow compliance many obesepatients have in carrying onwith diet programs withoutactive monitoring andsupport.


48/48

47

mobile phones, uses in order tovisually display the food choices(frequency and portions)outpatients have to adhereaccording to diet prescriptions.

Outpatients are instructed touse the videoconference tool.Thanks to this medium, theyreceive nutritional andcognitive-behavioral tele-counseling with the dietitianand the clinical sychologist

Azam_Yang.pdf

Documents

Transcript of Azam_Yang.pdf