Public mobile chronic obstructive pulmonary disease applications for self-management: Patients and healthcare professionals’ perspectives

Abstract

Poorly controlled chronic obstructive pulmonary disease (COPD) can negatively impact quality of life but mobile applications (apps) are popular digital tools that may mitigate these support needs. However, it is unclear if public mobile COPD apps are acceptable to healthcare professionals and patients, people living with COPD. Objectives: The primary objective is to determine people with COPD and healthcare professionals' perspectives on the appropriateness of public mobile COPD apps for supporting individuals’ needs. The secondary objectives were to identify the ideal features and styles of mobile COPD apps for COPD self-management; and to identify the facilitators, barriers and needs for future COPD app research and development. Methods: Public mobile COPD apps were rated by questionnaires administered before and after focus group meetings. Ratings were reported as medians with interquartile ranges and median scores were categorized into three levels of appropriateness: 1-3 for inappropriate; 4-6 for uncertain; and 7-9 for appropriate. Results: A total of 6 people with COPD (mean age 68.2 ± 4.8years) and 22 healthcare professionals (mean age 45 ± 8.3years) completed this study. People with COPD identified one and healthcare professionals identified three public mobile COPD apps to be appropriate. They had different preferences for features and engagement styles but similar preferences for facilitators and barriers to use. Stakeholders mutually rated one public mobile COPD app as appropriate for self-management and emphasized the need for apps to be supplementary and customizable, rather than replacements for clinical management.

Keywords

chronic obstructive pulmonary disease digital health mobile technology respiratory care respiratory health

Introduction

The prevalence of chronic obstructive pulmonary disease (COPD) in Canadians steadily increases with age, from an estimated 0.8% in 35 to 40 year old to 8.3% in those over 65 years old, totalling to about 2 million people.^1,2 COPD care is a significant burden to the healthcare system, with an estimated cost of approximately $1.5 billion Canadian dollars (CAD) in 2017,³ and will likely increase to cost $101.4 billion CAD by 2035.⁴ Many people with COPD experience physical and mental health burdens to their lives, especially when their pulmonary and extra-pulmonary symptoms are left uncontrolled.^5–7 Therefore, to minimize the personal and economic burden of COPD, it is necessary to strengthen the efficacy and uptake of current and novel approaches for disease management.^4,6,8

COPD self-management has been shown to improve symptoms,⁹ health related quality of life,^9,10 and reduce hospitalizations.^11,12 Self-management should be carefully tailored to meet patients’ needs, incorporating elements of disease knowledge, behavioural changes and emotional support to optimize self-efficacy.^8,13 Use of technologies such as mobile applications (apps) have potential as useful tools to improve access to resources and to facilitate self-management.^14,15 There are several studies evaluating the effectiveness of mobile COPD apps in patient outcomes, including decreased symptom severity,^16,17 hospital readmissions,^18,19 smoking behaviours,²⁰ and increased physical activity.^{12,15,17,20–22} Although mobile apps are often easy to use, there is still limited information regarding their overall effectiveness.^14,16,23

In 2018, Statistics Canada reported 88% of Canadians owned a smartphone,²⁴ and the Canadian Agency for Drugs and Technology in Health (CADTH) suggested smartphone availability enforced people’s interest in using readily available health apps for their chronic diseases.²⁵ In combination with the recent pandemic, interest for using apps for health self-management has grown, demonstrating the need for awareness between people with COPD and healthcare professionals. Using mobile apps may have benefits,^14,23 but common barriers to their uptake include financial limitations and privacy and confidentiality concerns.^26–29 Past studies have evaluated apps created by research teams,³⁰ but these are inaccessible to the public. Therefore, greater attention towards public mobile COPD apps is necessary since they are easily accessible to people and can be used without supervision.^31,32 There are many free COPD self-management apps in the current marketplace, although their credibility is unclear. This lack of regulation and monitoring of health information generates concerns for their safe use, prompting researchers at Harvard Medical School, Division of Digital Psychiatry, to create and implement the mHealth Index and Navigation Database (MIND) evaluation framework and website (https://mindapps.org/).^33,34 The MIND website was created with the primary goal of displaying the assessments of public mental health apps, using the MIND evaluation framework which has over 100 objective questions, across five domains. Currently, MIND website serves as a repository of app assessments for publicly accessible mental health apps to ensure healthcare professionals and their patient users have the necessary information to make informed choices on their use. Previously, we used the MIND evaluation framework to evaluate free COPD self-management apps in the public marketplace and found they were mostly created by for-profit organizations, with variable features, questionable credibility, and no evidence to support clinical use.³¹ Given their poor designs and credibility concerns based on standardized checklists, it is important to further understand how these apps are perceived by their targeted stakeholders and users.

There are a few studies that have reported on the ideal features and characteristics of mobile COPD apps, especially from those living with COPD.^28,35–38 Generally, people with COPD believed that easy-to-use mobile COPD apps can guide them with their care,²² providing them with adequate information to support their daily lives and during exacerbations.³⁷ However, more research is needed to identify which specific mobile app features and qualities are desirable to people with COPD and healthcare professionals, in combination with their facilitators and barriers. By elaborating on known facilitators and barriers, these may facilitate mobile COPD app research, design and integration. Therefore, the objectives of this study were to explore: (1) the appropriateness of public mobile COPD self-management apps available in the marketplace; (2) the ideal app qualities (features, input and output data) for COPD self-management; and (3) the facilitators, barriers and needs for app use, from the perspectives of healthcare professionals and patients, people living with COPD.

Materials and methods

Study design

Healthcare professionals and people with COPD were invited to participate in a prospective, virtual RAND/UCLA Appropriateness Method (RAM) study to share their perspectives and feedback on the appropriateness of public mobile COPD self-management apps and their ideal characteristics.³¹ The RAM is a mixed-method technique, utilizing focus groups and surveys to determine expert consensus on a specific topic. This study was approved by the Hamilton Integrated Research Ethics Board (#15484) at McMaster University. Participants had the opportunity to review the consent form before providing their written consent to enrol into this study.

RAND/UCLA Appropriateness Method (RAM)

The RAM is described as a variant of the Delphi consensus technique, and the RAND Corporation published a detailed procedure manual in 2001.³⁹ This method utilizes current scientific literature, complemented with collective feedback from experts using both survey questionnaires and focus group meetings to form a consensus opinion about a particular topic.^40,41 Currently, there is no consensus on the number of expert panelists required for the RAM, with the RAND Corporation recommending a minimum of seven to nine,³⁹ and past studies ranged from 10 to 50.^40,41 However, it is important that the RAM recruits experts from multiple disciplines to ensure all perspectives are considered for the discussed topic.³⁹

The research team identifies individuals qualified to be experts in a RAM study, typically individuals with adequate knowledge and experience in the topic of interest.³⁹ The overall purpose of the RAM is to discuss the appropriateness of the ideas presented, not to generate new ideas.^39,40 The experts provide their feedback across two rounds using two questionnaires and one focus group meeting in between.^39,41 Round 1 consists of experts completing a questionnaire anonymously and asynchronously. Round 1 data is aggregated and provided to the experts to review prior to round 2, which includes the focus group meeting and the final questionnaire. See Figure 1 for an overview of the process in this study.

Figure 1.

Timeline and flow diagram of the RAND/UCLA method used for this study. *Contents of the survey were informed by research team’s previous work³¹ and list of possible features, and engagement styles outlined in the MIND evaluation framework^33,34; ^†Focus group meetings were approximately 60 to 90 min in length. See Supplemental Materials for survey and moderator guide.

Participants and recruitment

The stakeholders for this study were: (1) people living with COPD (patient stakeholder); and (2) healthcare professionals with experience caring for people with COPD. People were eligible to be part of the patient stakeholder if they were diagnosed with COPD. Healthcare professionals were eligible to enrol if they had experience treating and caring for patients with COPD, and were from a regulated healthcare discipline, including, but not limited to physiotherapists, occupational therapists, respiratory therapists, respirologists, and nurses. All participants were required to have interest in the use and potential of mobile technology in healthcare. They were also required to be proficient in English to provide informed consent and feedback.

Healthcare professionals were identified by public websites (i.e., university profiles, clinic staff directory) and by the snowball sampling technique. For people with COPD, we used a registry of individuals who had agreed to be contacted for participation in future clinical research studies. All potential participants were invited by email, with reminder emails sent 2 weeks after the initial email if a response was not received. After this timeframe, no further emails were sent.

Questionnaire development

For this study, a questionnaire was developed to understand the stakeholders’ perspectives on the appropriateness of the current state of COPD apps and the ideal characteristics in apps. The questionnaire consisted of two separate components: (1) Appropriateness of current public mobile COPD apps; and (2) Ideal Engagement features, input and output styles. For the first part, the list of public mobile COPD apps available in the marketplace was generated and informed from our previous evaluation report.³¹ These apps were COPD specific, patient-facing, free from the Apple and Google Play Store, but only 10 of the 13 public mobile COPD apps from our previous report were available to be included in this questionnaire. Participants were not expected to download the apps or use them before providing their feedback. The research team created an infographic handout outlining each app’s characteristics, features and other qualities for participants to review before rating apps’ appropriateness. The infographic handout is available in Supplemental Material.

For the second part regarding ideal app qualities, three subsections under the “Engagement style” domain of the MIND evaluation framework were included: features, input and output.³⁴ An extensive list of all the possible app characteristics and qualities identified in these three subsections were included. This questionnaire was specifically seeking participants’ feedback and perceived appropriateness on features and qualities related to app user experience, inviting participants to share their personal experiences with apps. This study was not a test trial of any specific apps.³⁴ See Supplemental Material for the questionnaire.

Study process

Participants were electronically invited to provide their opinion on the appropriateness for each item on the survey using a 9-point Likert scale, where 1 to 3 for inappropriate, 3 to 6 for uncertain, and 7 to 9 for appropriate (Table 1). Research Data Capture (REDCap)⁴² was used to distribute and manage data collection for the questionnaires in round 1 and 2.

Table 1.

Classification of the level of appropriateness and agreement based on each item’s aggregated median and rankings. Information adapted from RAND/UCLA Appropriateness User Manual.³⁹

Median	≥75% participants	Classification
1 – 3	No	Inappropriate without agreement
1 – 3	Yes	Inappropriate with agreement
4 – 6	No	Uncertain without agreement
4 – 6	Yes	Uncertain with agreement
7 – 9	No	Appropriate without agreement
7 – 9	Yes	Appropriate with agreement

After round 1, the responses were summarized and analyzed to provide participants with a summary of the median and individual rating for each questionnaire item. This handout was provided to participants prior to their focus group meeting (the handout template is available in Supplemental Material).

Next, the focus group meetings were conducted and recorded on Zoom (license provided by McMaster University), scheduled for approximately 60 min, facilitated by SQ using an ethics approved moderator guide. The moderator guide was created to guide the discussion on the topics outlined in the MIND evaluation framework and to review participants’ ratings in round 1. People with COPD and healthcare professionals were scheduled into separate peer focus group meetings to reduce influence or discomfort individuals may experience when sharing their personal thoughts.⁴³ Reporting of the focus group discussions were guided by the Consolidated criteria for reporting qualitative research (COREQ).⁴⁴

Data analysis

Demographic information and responses to the questionnaires were aggregated to report the means, medians, dispersion ranges (standard deviations, interquartile ranges), frequencies and percentages, where appropriate. The median for each questionnaire item was used to classify the level of appropriateness, categorized by 3-point tertile: 1 to 3 for inappropriate; 4 to 6 for uncertain; and 7 to 9 for appropriate.^39,40 Participants reached an agreement for the appropriateness of the item if at least 75% of the participants’ responses were in the same appropriateness category, see Table 1.³⁹

Audio files were transcribed verbatim and stripped of identifiers by a third party transcriber. Transcription analysis was completed using Microsoft Excel by two independent authors (SQ, AB) using inductive and deductive analyses.⁴⁵ An initial code manual was developed by using the questionnaire categories as general categories (i.e., public mobile COPD apps, engagement features, inputs, outputs) and those identified in previously reported mixed methods studies by Alwashmi et al (e.g., barriers, facilitators).^28,35 Additionally, new categories were derived after subsequent review of the transcripts for common key concepts.⁴⁵ The reliability of the codes were tested on one transcript before the reviewers compared results and mutually agreed on the modifications to the predetermined code manual. The qualitative data were organized by categories; participants’ quotes were used to illustrate and supplement the questionnaire results and the discussion of apps in clinical care.

Results

Participants’ characteristics

Email invitations were sent to six people with COPD across Ontario and Manitoba and 43 healthcare professionals across seven provinces in Canada, leading to expressed interest from all six (100%) people with COPD and 25 (58%) healthcare professionals. A total of 28 participants participated, six (21%) people with COPD and 22 (79%) healthcare professionals.

The mean age (±standard deviation [SD]) of people with COPD was 68.2 (4.8) years with four females (67%). These individuals were diagnosed with COPD over 5 years ago and have experienced acute exacerbations of COPD within the last year. Regarding their interest in mobile apps for self-care, three (50%) felt that apps have the potential to facilitate their self-management needs, while one (17%) said no, and two (33%) were unsure. Full characteristic details of the patient stakeholder is outlined in Table 2.

Table 2.

Demographic characteristics of people living with COPD (n=6).

Measure	Item	Count (%)
Sex	Female	4 (67)
Age	Average (SD)	68.17 (4.83)
Age	Median (Q1, Q3)	67 (65, 69)
City of residence	Semi-urban centre (1000-5000 habitants)	2 (33)
City of residence	Urban centre (>5000 habitants)	4 (67)
Time of COPD diagnosis	6-10 years ago	2 (33)
	11-15 years ago	2 (33)
	Over 15 years ago	2 (33)
Last COPD exacerbation	3-6 months	1 (17)
	7-9 months	3 (50)
	9-12 months	2 (33)
Last hospitalization for COPD exacerbation within the past year	None	3 (50)
	1 time	2 (33)
	2 times	1 (17)
mMRC dyspnea scale	0	0
	1	1 (17)
	2	4 (67)
	3	1 (17)
	4	0
Requires help	Yes	2 (33)^a
Interest in apps in self- care
Do you think mobile applications have potential to help you with your self-management?	Yes	3 (50)
	No	1 (17)
	Unsure	2 (33)

^aPatients require help with housework and transportation.

Abbreviations. mMRC = Modified Medical Research Council

The mean age (SD) of healthcare professionals was 45 (8.19) years with 15 (62%) female participants. Healthcare professionals included were from multiple professions, including physicians (5, 23%), physiotherapists (5, 23%), nurses (5, 23%), respiratory therapists (5, 23%), a pharmacist (1, 5%) and an occupational therapist (1, 5%). They had at least 1 year of experience treating patients with COPD, with four (18%) having over 20 years of experience. All healthcare professionals worked in an urban areas, with the majority practicing at rehabilitation centers (12, 55%), acute care hospitals (4, 18%), primary care clinics (5, 23%), speciality clinics (2, 9%), and post-secondary institutions (2, 9%). Regarding their interest in mobile apps to support their patients’ self-management, 19 (86%) felt that mobile apps could be integrated into patient-care plans and 20 (91%) would recommend them if they were credible and validated. All healthcare professionals believed that mobile apps had the potential to support people with their COPD self-management. Full characteristic details of the healthcare professionals are outlined in Table 3.

Table 3.

Demographic characteristics of healthcare professionals (n=22).

Measure	Item	Count (%)
Sex	Male	8 (36)
Sex	Female	14 (64)
Age	Average (SD)	45 (8.27)
Age	Median (Q1, Q3)	46 (41, 51)
Healthcare discipline	Respirologist	4 (18)
	Family physician	1 (5)
	Physiotherapist	5 (23)
	Registered nurse	4 (18)
	Nurse practitioner	1 (5)
	Respiratory therapist	5 (23)
	Pharmacist	1 (5)
	Occupational therapist	1 (5)
Years spent providing care for people with COPD	1-5 years	3 (14)
	5-10 years	6 (27)
	10-20 years	9 (41)
	20 or more years	4 (18)
Work setting^†	Acute care hospital	4 (18)
	Primary care	5 (23)
	Specialty clinic	2 (9)
	Rehabilitation center	12 (55)
	Post-secondary institution	2 (9)
Interest in apps to support patients
Do you think mobile applications can be integrated into patients’ care plans?	Yes	19 (86)
	Unsure	3 (14)
Do you think mobile applications have potential to help patients with their self-management?	Yes	24 (100)
Would you recommend mobile applications (if validated, and credible) for your patients?	Yes	20 (91)
	Unsure	2 (9)

^†several participants worked in more than one clinical setting.

Questionnaire responses – public mobile COPD apps

Of the 10 public mobile COPD apps, the patient stakeholder was uncertain about all the apps’ appropriateness for COPD self-management in round 1. After the focus group meeting, one app was ranked appropriate (the COPD Pocket Consultant Guide created by the COPD Foundation). In contrast, healthcare professionals ranked three apps as appropriate in the questionnaire before and after the focus group meeting (COPD Support, COPD Pocket Consultant Guide, NHS Wales: COPDHub) (Tables 4 and 5). The remaining apps were rated as uncertain. After the focus group meetings, the same three apps identified from round 1 were re-rated as appropriate, one app rated as inappropriate and the remainder as uncertain. Across both questionnaires, healthcare professionals rated the COPD Pocket Consultant Guide as appropriate, with agreement. See Tables 4 and 5 for details on the ratings for each public mobile COPD apps surveyed.

Table 4.

Cumulative ratings of public mobile COPD apps by people living with COPD, before and after focus group meeting.

Public mobile apps	Pre-meeting (T1)			Post-meeting survey (T2)
Public mobile apps	Inappropriate	Uncertain	Appropriate	Inappropriate	Uncertain	Appropriate
COPD support		✓			✓
Home remedies for COPD		✓			✓
COPD		✓			✓
Chronic obstructive pulmonary disease assessment		✓			✓
Book of COPD		✓			✓
NIH: COPD		✓			✓*
Chronic lung disease treatment		✓			✓
COPD pocket consultant guide		✓				✓
NHS wales: COPDhub		✓			✓
Pulmonary scan		✓			✓

* = Agreed when ≥75% of participants’ ranks fell within a category, i.e., inappropriate (1-3), uncertain (4-6), appropriate (7-9).

Table 5.

Cumulative ratings of public mobile COPD apps by healthcare professionals, before and after focus group meeting.

Public mobile apps	Pre-meeting (T1)			Post-meeting survey (T2)
Public mobile apps	Inappropriate	Uncertain	Appropriate	Inappropriate	Uncertain	Appropriate
COPD support			✓			✓
Home remedies for COPD		✓		✓
COPD		✓			✓
Chronic obstructive pulmonary disease assessment		✓			✓
Book of COPD		✓			✓
NIH: COPD		✓			✓*
Chronic lung disease treatment		✓			✓
COPD pocket consultant guide			✓*			✓*
NHS wales: COPDhub			✓			✓
Pulmonary scan		✓			✓

* = Agreed when ≥75% of participants’ ranks fell within a category, i.e., inappropriate (1-3), uncertain (4-6), appropriate (7-9).

Questionnaire responses – features and engagement style

The patient stakeholder rated 11 of 18 (61%) app features as appropriate with 3 (17%) meeting the 75% threshold for agreement in round 1, but after the discussion, they only rated six (33%) to be appropriate. The six features that rated appropriate for before and after the meeting were: (1) medication tracking; (2) physical exercise tracking; (3) deep breathing exercises; (4) peer support; (5) connection to therapist/ coach; and (6) physical health exercises. The patient stakeholder rated inputting contacts, step counts and external devices (3, 33%) to be appropriate app engagement styles in round 1, but were collectively uncertain after the focus group meeting. As for output styles, the patient stakeholder regarded both reminders and connections to formal care as appropriate (2, 33%) but their final ratings only identified connections to formal care to be appropriate. The rating details for each of the features and engagement styles by people with COPD are outlined in Table 6.

Table 6.

Cumulative ratings of potential features, output, and input engagement styles to consider in COPD self-management apps by people living with COPD.

	Pre-meeting (T1)			Post-meeting (T2)
	Inappropriate	Uncertain	Appropriate	Inappropriate	Uncertain	Appropriate
Features
Mood tracking			✓		✓
Medication tracking			✓			✓
Sleep tracking		✓		✓
Physical exercise tracking			✓			✓
Psychoeducation			✓		✓
Journaling		✓			✓
Picture gallery/ Hope board		✓			✓
Mindfulness exercises			✓*		✓
Deep breathing			✓*			✓
Sleep therapy/ Interventional cognitive therapy			✓		✓
Psychotherapiesa		✓			✓
Peer support			✓			✓
Connect with coach/ therapist			✓			✓
Biodata			✓*		✓*
Goal setting/Habits		✓			✓
Physical health exercises			✓			✓
Bbotb		✓			✓
Biofeedback		✓			✓
Engagement style
Input
Surveys		✓			✓
Diary		✓			✓
Geolocation		✓			✓
Contact list			✓		✓
Camera in the app		✓			✓
Microphone in the app		✓			✓
Step count			✓		✓
External devices			✓*		✓
Connect social media		✓			✓
Output
Notifications		✓			✓
Social network		✓			✓
Reminders			✓		✓
Data graphs		✓			✓
Data summary		✓			✓
Links to formal care/Coaching			✓			✓

* = Agreed when ≥75% of participants’ ranks fell within a category, i.e., inappropriate (1-3), uncertain (4-6), appropriate (7-9).

^aBehavioural therapy that includes cognitive, acceptance and commitment, and dialectical behavioural therapy.

^binteractive virtual character, i.e., users can interact with virtual robot.

Healthcare professionals rated many features to be appropriate before and after their focus group meetings. Pre-focus group meeting, 16 (89%) appropriate with 10 (56%) reaching the 75% threshold of agreement. However, after discussion, 13 (72%) were rated as appropriate, with only 4 (22%) reaching consensus agreement. The four features rated as appropriate with agreement were: (1) medication tracking; (2) physical exercise tracking; (3) mindfulness exercises; and (4) peer support. Other features that were rated appropriate at both time points but failed to achieve agreement were: (1) mood tracking; (2) sleep tracking; (3) psychoeducation; (4) deep breathing; (5) sleep therapy; (6) connection with therapist/ coach; (7) biodata; (8) goal setting; and (8) physical health exercises. For input styles, healthcare professionals rated four (44%) data inputs as appropriate in round 1 but this changed to only three (33%) after the meeting, specifically: (1) surveys; (2) step counts; and (3) external devices. Only input for step counts was rated appropriate and reached the threshold for agreement. For output styles, healthcare professionals rated five (83%) data outputs as appropriate at both timepoints: (1) notifications; (2) reminders; (3) data graphs; (4) data summaries; and (5) connections to formal care. Only notifications and reminders were rated as appropriate with at least 75% agreement at both timepoints. The rating details for each of the features and engagement styles by healthcare professionals are outlined in Table 7.

Table 7.

Cumulative ratings of potential features, output, and input engagement styles to consider in COPD self-management apps by healthcare professionals.

	Pre-meeting (T1)			Post-meeting (T2)
	Inappropriate	Uncertain	Appropriate	Inappropriate	Uncertain	Appropriate
Features
Mood tracking			✓			✓
Medication tracking			✓*			✓*
Sleep tracking			✓*			✓
Physical exercise tracking			✓*			✓*
Psychoeducation			✓*			✓
Journaling			✓		✓
Picture gallery/ Hope board		✓			✓
Mindfulness exercises			✓*			✓*
Deep breathing			✓*			✓
Sleep therapy			✓			✓
Psychotherapies^a			✓		✓
Peer support			✓*			✓*
Connect with a coach/ therapist			✓*			✓
Biodata			✓			✓
Goal setting/Habits			✓*			✓
Physical health exercises			✓*			✓
Bbot^b		✓			✓
Biofeedback			✓		✓
Engagement style
Input
Surveys			✓*			✓
Diary			✓		✓
Geolocation		✓			✓
Contact list		✓			✓
Camera in the app		✓			✓
Microphone in the app		✓			✓
Step count			✓*			✓*
External devices			✓*			✓
Connect social media		✓			✓
Output
Notifications			✓*			✓*
Social network		✓			✓
Reminders			✓*			✓*
Data graphs			✓*			✓
Data summary			✓			✓*
Links to formal care/Coaching			✓*			✓

^* = Agreed when ≥75% of participants’ ranks fell within a category, i.e., inappropriate (1-3), uncertain (4-6), appropriate (7-9).

^aBehavioural therapy that includes cognitive, acceptance and commitment, and dialectical behavioural therapy.

^binteractive virtual character, i.e., users can interact with virtual robot.

Focus groups

Between the two rounds of questionnaires, participants were invited to engage in peer discussions about the public mobile COPD apps, app features and qualities outlined in the questionnaire, at the scheduled meetings held from March to May 2023. All participants of the patient stakeholder attended their focus group meeting on May 2, 2023 (duration 97:36). For healthcare professionals, a total of four focus group meetings were assembled to maximize participation and disciplines were distributed across each meeting to ensure diversity of the participants (duration range 40:38-65:15). A total of 21 (95%) healthcare professionals attended their assigned focus group meeting. See Figure 1 for the timeline.

Stakeholder transcripts were analyzed separately. Five overarching categories were noticed across the transcripts: (1) appropriateness of public mobile COPD apps; (2) ideal features and qualities; (3) facilitators to app use; (4) barriers to app use; and (5) needs for apps for self-management. Since the focus groups were guided by the contents in our questionnaire, categories 1 to 4 reflect the questionnaire’s sections and subsections. Category 5 was identified from recurring phrases and feedback across the stakeholders. These categories and subcategories are outlined in Tables 8 and 9 (Table 8 for people with COPD, Table 9 for healthcare professionals).

Table 8.

Identified themes and subthemes in the patient stakeholder's focus group meeting (May 2, 2023) and corresponding quotes.

	Quotes
Public mobile COPD apps
Appropriate: COPD foundation	“I did find one that I liked. COPD Foundation. It was a very comprehensive app and had lots of links.”
Inappropriate-Difficult to comprehend-Lack of support	“I want to be able to read treatments and diagnoses and so on and not answer all these questionnaires and not get anything back. A lot of the questionnaires were really complicated, and it would be very hard for a lay person to answer.”
Ideal features
Education	“I found education was the cornerstone of my recovery. The exercise was a great thing but hearing little tidbits of this, that, and the other thing that you can apply to your everyday life.”
Peer support
Connection to healthcare team	“The key is to have everyone connected. Your family doctor, your respirologist, your pharmacist. Everybody must be connected.”
Facilitators
Credibility	“I don’t think any of the apps were very comprehensive or written by or in consultation with a person with COPD.”
Team support	“The key is to have everyone connected. Your family doctor, your respirologist, your pharmacist. Everybody has to be connected.”
Customization	“You cannot paint COPD with the same brush. Everyone has a different story and is coming from a different direction.”
Barriers
Privacy concerns	“I found that they were asking for a lot of information, and I did not want to give out that information.”
Overwhelmingness	“They wanted you to keep track of your daily scores, tracking symptoms so on and so forth and just all the questionnaires right off the bat, it turned me right off.”
Needs
Team support	“I would want it coming from doctors, respirologists and physiotherapists and people who play a big part in COPD. That would draw me in.”
Consultation with patient stakeholder	“I don’t think any of these apps were designed by a person with COPD.”

Table 9.

Identified themes and subthemes below were consistently mentioned in all meetings, and sample quotes are provided. Focus group meetings for healthcare professionals occurred across four meetings dates.

	Quotes
Public mobile COPD apps
Appropriate: COPD foundation	“When you compare all the apps and look at what the COPD Foundation app offered, the other ones fail in comparison…”
Appropriate: COPD foundation	“I think the COPD Foundation are reputable and that would seem like the best fit.”
Inappropriate-Non-interactive-Questionable credibility-Home remedies for COPD	“I cannot imagine people going back to that app to look up information when they can go to a website. It seemed like a single use kind of thing as opposed to an app.”
Ideal features
Interactive components	“I liked the app about how you are feeling on the daily, tracking emotions that would explain why you are having a higher breathing day. I liked the more detailed ones or the goal setting apps.”
Motivational components	“If they had something to motivate them to keep going in that regard and P2 mentioned having awards or prizes and making it competitive or at least rewarding, because a lot of patients that I am seeing, once the exercise is done, that’s it and as they would say, go back and sit on their butts and do nothing.”
Peer support	“I find also that peer support is really important. I know personally that is one of the ways that I keep myself motivated or to do things like that.”
Facilitators
Credibility	“I like the idea that the apps are funded or founded by institutions that appear legitimate and as an evidence-based practitioner and as P2 was saying, I had not put these into use and thoroughly evaluated them.”
Interactive	“Anything that really involved the patient in terms of their experience and how they were feeling, their moods and those types of things. Those intangible things that we do not think about really sticks out.”
Ease of use	“Not overwhelming the patient with a lot of information which for them would not engage them in their care.”
Integrated use	“Maybe that needs to be our focus, on how best to integrate them but not how to use them as a stand alone… “
Health benefits	“We don’t have enough time to educate the patients about the disease and the medications and maybe the apps can add this part.”
Barriers
Privacy concerns	“You never know what is going to happen with that data. If you could have a closed loop where your phone or your app is connecting to your healthcare provider, your clinic or day hospital no problem but if it is a third party type of a Peloton thing then I do not like that idea.”
Safety concerns	“A lot of the resources seemed really questionable and just going through these apps and really wondering the basis and the references for these.”
Limited uptake by elderly	“Our patient population, a lot of them are older as well and they are not as familiar with using apps and it might not be the most friendly thing for them.”
Needs
Customization	“The thing that matter to me as a clinician are not the same things that matter to patients.”
Customization	“So build their own app from a menu of options and tailor it towards what they want to have.”
Mental health needs	“I am finding that 99.9% of them are dealing with anxiety and it’s almost out of control. So, I guess I would like to see a little bit focus on the mental health.”
Liability	“If such apps are to be implemented, it should be through a health team where there is some liability for both sides.”
Liability	“There has to be professional oversight to a lot of this and that is the important thing.”
App growth and research	“…sometimes we do not give enough credit to our older folks and what they are willing to figure out in order to stay connected with the world as it is.”
App growth and research	“In the next 10-20 years, everyone who is going to potentially have COPD will be very tech savvy … It seems like this would be an appropriate thing to consider and very meaningful to me as a healthcare provider.”

Appropriateness of public mobile COPD apps

Generally, both stakeholders noted most public mobile COPD apps to be questionable and inappropriate. However, both stakeholders expressed the COPD Pocket Consultant Guide app by the COPD Foundation was the most appropriate for use based on its comprehensiveness and credibility.

Ideal features

Education and connection with peers experiencing the same disease were regarded as important features by people with COPD. Additionally, features to connect everyone on their healthcare team together was viewed as optimal. In contrast, healthcare professionals strongly emphasized ideal features to be more than informational, requiring features to be interactive and motivational to engage with their users and to be clinically meaningful.

Facilitators to app use

Regarding the use of apps for their COPD self-management, the patient stakeholder noted that apps need to be vetted by their healthcare team and must be customizable to address individuals’ differing needs. Healthcare professionals discussed and identified many potential facilitators that could support patients’ use of apps such as app credibility, interactive features, and overall ease of use. Furthermore, healthcare professionals discussed the potential of apps as adjunct support tools to their own practices. All of these were listed as important considerations to facilitate app use in people with COPD, but also to facilitate healthcare professionals’ willingness to adopt apps in their clinical practice.

Barriers to app use

Within the patient stakeholder, privacy concerns and feelings of being overwhelmed prevented them from using apps. Particularly, people with COPD described apps with features seeking information through questionnaires with constant reminders caused them to feel stressed and burdened, leading to an unwillingness to use apps. Similarly, healthcare professionals expressed privacy and safety concerns to be barriers in app use. Safety concerns included the possibility of apps providing unverified advice, the developers’ level of credibility and the need for evidence to support their use.

Needs in future mobile apps

A gap identified by the patient stakeholder was the lack of consultation with people living with COPD in the design of these public mobile COPD apps. The patient stakeholder also emphasized the need for future apps to integrate app features facilitating communication between the members of their health team and ensuring they are informed of their action plans.

Meanwhile, the needs identified by healthcare professionals included focus on mental health and wellbeing, customization to address personalized needs and the liability associated with app use. If apps were to be adopted and integrated into care plans, professional liability and oversight are required to ensure their safe use. Healthcare professionals stressed the need for frequent and ongoing evaluations of emerging COPD self-management apps to understand their potential in clinical practice. The healthcare professionals acknowledged that their needs and desires in apps likely diverged from people with COPD.

Discussion

In this study, we used questionnaires and focus groups to ascertain the opinions of people with COPD and healthcare professionals on the appropriateness of public mobile COPD apps in supporting self-management. This includes ideal features required to support people living with COPD, the facilitators and barriers for use and the ongoing needs for future COPD app development. The COPD Pocket Consultant (COPD Foundation) was considered by both stakeholders to be the most appropriate app. The remaining public mobile COPD apps were ranked with uncertainty and inconsistent endorsement between the two stakeholders. Ideal features differed among the stakeholders but there were shared endorsements of their value for peer support, medication tracking and physical exercises.

COPD Pocket Consultant by the COPD Foundation was consistently rated as appropriate by both stakeholders, which may be attributed to what the app offers to people with COPD. Similarly, our previous report found this app to be one of the more comprehensive apps available, as rated using the MIND evaluation framework.³¹ The patient’s app version provides users and their caregivers with multiple features to support COPD self-management, incorporating elements of symptom tracking, medication tracking, physical exercises education and tracking, COPD action plan, COPD360Social (peer support network), journaling and appointment reminders. The included features in the COPD Pocket Consultant app align with past studies that have emphasized the necessity of incorporating features that will help patients monitor and engage with their disease plans.^29,35,36,46 The combination of these features with the app’s origin may be contributors to the high appropriateness rankings observed in the stakeholders of this study. Ideal app features identified in past studies include education, action plans, tracking and networking, which can be leveraged to elicit behavioural changes for improved patient outcomes, if done collaboratively.^21,47–49 Additionally, the app’s developer is COPD Foundation, a reputable non-profit organization, partnered with healthcare professionals, in North America (https://www.copdfoundation.org/), providing assurance to stakeholders on the app’s overall quality and credibility. These are all notable app traits that can facilitate use, emphasizing the importance of partnerships between developers to ensure credibility and safety.^28,35,50 Furthermore, these findings strongly advocates for the inclusion of app features and qualities that are relevant for users' needs,^46–49,51 with the potential of improving their outcomes.^19,21,52

NHSWales: COPDHub was ranked as appropriate by healthcare professionals, likely because it was developed by the Welsh National Health Service as part of digital solutions to support clinicians to improve patient care (https://www.nhs.wales/). Although COPDHub has elements of personalized COPD plans, education and clinical data tracking, the patient stakeholder rated this app with uncertainty. This could be explained by its lack of social and peer support features. Past research has identified the necessity of social and peer networking features in apps, as people with COPD perceived these features to be fundamental and useful, possibly improving patient-outcomes.^47,49,53,54 This is confirmed by our patient stakeholder as they described enjoyment in connecting with their peers who understand their condition, and can offer “tips and tricks” and experienced wisdom. Therefore, apps that merge users' need for peer support with digitally convenient features could be beneficial in facilitating their communication and awareness for community resources.^54,55

Currently, COPD Foundation’s COPD Pocket Consultant and NHSWales: COPDHub are available publicly. Both mobile apps are from credible sources and contain ideal features and qualities, as reported in our previous evaluation report by Quach et al³¹ (Further details are available on the MIND website: https://mindapps.org/). Previous trials reported on the effectiveness of mobile COPD apps that were created by their respective research teams^19,21,22,52; however, many are unavailable for public use. Regardless, publicly available mobile apps also need to be reviewed and deemed appropriate by the relevant stakeholders. Thus, our study provides a new perspective on public mobile COPD apps and their potential. It is important to note that although stakeholders rated these public mobile COPD apps to be appropriate, they need to be used in clinical trials to understand their effectiveness and benefits.

Many of the identified facilitators and barriers to app use in COPD self-management differed between healthcare professionals and people with COPD, and were previously reported.^27,28,38,56 Facilitators for people with COPD were related to the app interface, familiarity,⁵⁷ credibility and clinician endorsement,^27,28,56 with stronger interest in apps with interactive features.^36,50,55,58 It is strongly believed that mobile apps have the potential to address users’ needs, if mobile apps are credible and straightforward in their use,^28,37 as mentioned in our current findings too. While barriers were related to safety, confidentiality, privacy and lack of interest, which were previously reported.^27,56 Healthcare professionals felt similarly, and emphasized the growing concern regarding misinformation and the potential for associated liability.^50,59 Stakeholders emphasized that apps should balance promoting motivation without overwhelming the users. Another barrier that was mentioned was the lack of app interest, especially by the elderly population, possibly limiting their uptake, which was a previously reported assumption and barrier.^27,28 However, age should not be a perceived barrier, as our patient stakeholder had an average age of 68.2 years and were interested in using apps. The true facilitators of app use were whether apps addressed users' needs,²⁸ without bombarding them with constant notifications and reminders. Stakeholders emphasized that introducing apps to patients must be a balance of motivation and considerations for their feelings of overwhelmingness, which could be mitigated with adequate education and digital health support.^19,21,22,27 Implementing mobile apps into COPD self-management care is an intricate process and must meet needs without being overbearing as overwhelming the user would not engage them in their care.^36,37,57 These facilitators align with the previous report by Alwashmi et al., where patients stated that apps are likely to be adopted if they have the potential to address their needs without a steep learning curve.²⁸ The facilitators and barriers from our study provide a contrasting view between people with COPD and healthcare professionals. This knowledge enrichment strongly dictates the need for future research to consider both perspectives in a co-design approach to successfully implement app adoption.⁶⁰

There was broad agreement with the idea that an app would have the capability to provide multiple features but also be customized based on users’ requirements.^36,55,58 Healthcare professionals noted that the needs and preferred engagement styles of people with COPD likely varied from theirs.^35,59 Healthcare professionals advocated for app development through partnership and consultation with people with COPD.^18,21,22 Stakeholders also emphasized the desire for having one app that can address all of the patients’ needs, satisfying the “one size fits all” ideology. This app would have the capability to provide multiple features but can be customizable based on the user's wants and needs.^55,58 In addition, stakeholders elaborated that the role of apps should be supplementary to clinical care plans rather than a substitute. App inclusion is stressed to be complementary, and should be fitted into existing plans to minimize challenges in starting new routines.⁶⁰ This is especially important when there are interests from both parties in using apps for self-monitoring and patient engagement.^27,35 Another consideration discussed is mindfulness of the existing inequalities and limitations to app accessibility, as these resources will require ownership of mobile devices and established infrastructure for successful uptake.^10,56 There is a need for further research on the use of apps for COPD self-management as supplemental resources for aging populations with diverse background education, language skills and comfort in technology. These considerations emphasize the need to clearly identify both stakeholders’ desired app qualities, and to leverage known facilitators and mitigate barriers to ensure successful app adoption.

Study strengths included having people with COPD and healthcare professionals participate, evaluating the quality of apps easily accessible in the public domain and utilizing the MIND evaluation framework to identify potentially desirable features. Furthermore, we explored the public domain of COPD apps, a non-traditional area of focus, but an important one as the marketplace is dynamic and need constant evaluation. Our sample size enabled us to organize multiple focus groups rather than one group usually used in the RAM. This promoted participant expression and ensured that people with COPD could share their opinions without being influenced in the presence of healthcare professionals.⁴³ The focus groups provided a rich source of information that supplemented the questionnaire responses.

Although our study included a multidisciplinary panel, the feedback shared from our moderately sized stakeholders, especially the small patient stakeholder sample may not be representative or generalizable to the greater population. Another perspective that was not captured in our study was the caregivers’ which would have generated interesting feedback. Their input may have further confirmed and identified insights missed by healthcare professionals and people with COPD. Future work should consider this additional perspective when evaluating apps for their characteristics and usability. Participant bias may also be present as we had a small group of people with COPD and narrow age range. However, the lived experiences of people with COPD provided valuable insights to our findings, emphasizing the need for patient engagement and a co-design approach, subsequently facilitating future app development. Since the apps did not have to be downloaded and trialed, the collected feedback may have missed stakeholders’ open perspectives on app usability and feasibility. As the public mobile app domain is dynamic, it is possible that newer products with more of the identified desirable features might have become available since study commencement. The list of public mobile COPD apps in this study were based on our previous study as we wanted to maintain a consistent list to observe the similarities and differences between the research team and stakeholders’ assessments.

Conclusion

Responding to a combination of survey questions and focus groups, people with COPD and healthcare professionals rated only one of a small number of mobile apps for COPD in the public domain as appropriate for self-management. This app incorporated features such as peer support, self-monitoring and education, which had been identified by participants as desirable components in a COPD app, developed by a credible non-profit professional organization. Stakeholders emphasized the need for apps to be customizable to address the patient stakeholder's needs and that apps should be supplementary resources, rather than replacements for clinical management. Future studies will need to further elaborate and confirm these findings with other people living with COPD, from various demographic backgrounds to have a wholistic understanding of their values and needs. As the public mobile COPD app market grows, it is important to have a standardized system for evaluation that will direct users to the apps most likely to enhance their wellbeing.

Supplemental Material

Supplemental Material - Public mobile chronic obstructive pulmonary disease applications for self-management: Patients and healthcare professionals’ perspectives

Supplemental Material for Public mobile chronic obstructive pulmonary disease applications for self-management: Patients and healthcare professionals’ perspectives by Shirley Quach, Adam Benoit, Tara L Packham, Roger Goldstein, Dina Brooks in Health Informatics Journal.

Supplemental Material

Supplemental Material - Public mobile chronic obstructive pulmonary disease applications for self-management: Patients and healthcare professionals’ perspectives

Footnotes

Acknowledgements

We would like to thank all the participants for their time and commitment to this project.

Author contributions

SQ performed the literature search, data search, data extraction, summarized the results, drafted the initial manuscript, reviewed, revised and finalized the manuscript. AB performed the data search, data extraction, reviewed, revised and finalized the manuscript. TLP and RG reviewed, revised and finalized the manuscript. DB was involved in all stages of this review, including the literature search, data summarization, reviewed, revised and finalized the manuscript. All authors approved of the final manuscript and agreed to be accountable for all aspects of the work.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Canadian Society of Respiratory Therapists (#20019640) and Canadian Lung Association (#20017988). S. Quach received financial support from the Canadian Lung Association (Allied Health Fellowship) and the Canadian Respiratory Research Network (Studentship) for this research work. D. Brooks holds a National Sanatorium Association (NSA) Chair in Respiratory/Pulmonary Rehabilitation Research.

Ethical statement

ORCID iDs

Shirley Quach

Tara L Packham

Data availability statement

The data that support the findings of this study are available from the corresponding author, SQ, upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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