Smartphones and Pediatric Apps to Mobilize the Medical Home

Arunjot Singh, MD, MPH, Sarah Wilkinson, MPH, and Sandra Braganza, MD, MPH

Objectives To assess digital access and mobile health in urban pediatric clinics by measuring demographics ofsmartphone ownership, primary uses of mobile devices by teens vs parents/caregivers, and interest levels in usingsmartphone health apps.Study design This cross-sectional survey studied teenagers and caregivers from 2 urban pediatric practices inBronx, New York; 148 surveys were administered verbally in waiting rooms using a 24-item “iHealthNYC” question-naire. A demonstration of smartphone health apps was then conducted and data analyzed using bivariate analysisand c2 statistics.Results Overall, 84% of subjects were smartphone owners, with 57% using smartphones as their primary internetsource. There was no statistical difference in smartphone ownership between age groups or demographics of sex,ethnicity, and socioeconomic status. Smartphone users had a mean 14.5 apps, with 70.4% accessing apps >3times a day. The majority of participants stated interest in medical apps, although caregivers were significantlymore motivated. Likewise, caregivers are more likely to search health topics via their phone (76.7% vs 47.9%,P < .01) and own medical apps vs teens (35.1% vs 16.9%, P = .02).Conclusion The prevalence of smartphone and app use in urban pediatric populations is high. With increasedinterest in mobile health, smartphones are an attractive modality for patient education, disease management,and streamlining health care communication in diverse settings, thus “mobilizing” the medical home. Furtherresearch is needed so that pediatricians can promote evidence-based apps, thus enabling patients to take owner-ship of their health. (J Pediatr 2014;165:606-10).

Integrating accessible and affordable health technology is essential to creating an effective health care system in the 21st cen-tury.1 This integration is especially important with vulnerable underserved pediatric populations in whom inadequate re-sources result in poor health outcomes.2 Traditionally, there has been a digital divide of internet use and mobile technology

for individuals from lower socioeconomic groups.3 With smartphones becoming more affordable, the potential to mobilize thepatient-centered medical home and eliminate health disparities may already be in our pockets.

Multifunctional mobile devices, smartphones have capabilities for e-mail, text messaging, web browsing, and running down-loadable applications or “apps.”4 This latter function holds intriguing possibilities in health promotion: customized programsfor patient-provider communication, medication compliance, and treatment plans to manage chronic childhood ailments likeasthma, ulcerative colitis, and sickle cell disease.5,6 Health apps may be a feasible method to deliver health information for allages, particularly adolescents, given their high-risk behaviors and truancy with preventative visits.

National data show a growing number of smartphone users. In 2013, the Pew Research Center estimated 56% of adults own asmartphone.7 Connectivity and internet usage also have climbed with development of smartphones, tablets, and laptops; 95%of teens are now “online.”8 Mobile access has correlated with health web searches—often before one seeks medical care.9,10 A2012 survey by Fox shows 1 in 3 adults look up health-related information using a phone.11 Health apps are popping up forpurchase on platforms such as the iTunes Store and Android Marketplace, but screening of these apps remains limited withscant evidence-based information.12 Although credible sources exist, it can be difficult for consumers to discern qualityfrom information that may be misleading or even dangerous.13 As health care professionals, it is our responsibility to notonly provide clinical expertise but also connect patients to reliable resources.

Limited data exist on the assessment of digital access and mobile health in teenagers and parents/caregivers in urban low-income populations. The objective of our study was to conduct a comprehensive assessment of mobile health resources bymeasuring: (1) demographics of smartphone ownership; (2) primary uses of mobile devices; and (3) interest in using healthapps and health information online.14

606

Methods

From theDepartment of Pediatrics, Children’s Hospital atMontefiore - Albert Einstein College of Medicine andMontefiore Medical Center, Bronx, NY

The authors declare no conflicts of interest.

An abstract of the study was presented at the PediatricAcademic Societies’ meeting, May 4-7, 2014, Vancou-ver, British Columbia, Canada.

0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc.

All rights reserved.

http://dx.doi.org/10.1016/j.jpeds.2014.05.037

A 24-item “iHealthNYC” questionnaire was developed according to published rec-ommendations for survey methodology from the US Census Bureau.6 This surveywas composed of demographic data, 6 items adapted from the PEWResearch Cen-ter, and remaining questions designed by the multidisciplinary research team tomeasure rates of smartphone/app ownership, internet use, and mobile health in-terest. Demographics included self-reported answers on sex, age, race, ethnicity,

Table I. Demographics of pediatric clinic samplepopulation

Teens (n = 71) Caregivers (n = 77)

Age, mean, y 15.9 30.1Sex, n (%)

Female 46 (64.8) 65 (84.4)Male 25 (35.2) 12 (15.6)

Ethnicity/race, n (%)Hispanic 43 (55.8) 46 (64.8)Black 26 (33.8) 20 (28.2)Other (White, Asian) 8 (10.4) 5 (7.0)

Household income, n (%)<$10 000 per year 10 (14.1) 27 (35.1)$10-25 000 per year 5 (7) 11 (14.3)$25 001-50 000 per year 16 (22.5) 25 (32.5)>$50 000 per year 4 (5.6) 8 (10.4)Refuse/don’t know 36 (50.7) 6 (7.8)

Education, n (%)K-eighth grade 16 (22.5) -Some high school 41 (57.5) 12 (15.6)High school grad/GED 8 (11.3) 16 (20.1)Some college 6 (8.5) 27 (35.1)College graduate - 21 (27.3)Postgraduate education - 1 (1.3)

Productivity, n (%)Currently in school 68 (95.8) 14 (18.7)Currently employed 10 (8.6) 38 (50)

Medical history, n (%)Positive med history 33 (46.5) 31 (40.3)No past medical 38 (53.5) 46 (59.7)No routine meds 56 (78.9) 57 (74)Take daily meds 15 (21.1) 20 (26)

GED, General Educational Development.

Vol. 165, No. 3 � September 2014

educational level, family size, and household income. Interestlevels on mobile health and specific pediatric health topicswere measured via 5-point based Likert scales (“no interest”to “very interested”). Qualitative data also were collected toidentify barriers, previous experience with apps, and feedbackon the survey and app demos. Despite extensive literature re-view in designing the survey tool, this questionnaire had notbeen validated for statistical significance.

A cross-sectional study was performed at 2 academic, ur-ban inner-city pediatric practices in Bronx, New York. ClinicA is a federally qualified health center for primary pediatriccare that serves almost 10 000 children in one of the poorestcongressional districts of the country. The second site, ClinicB is a hospital-based urban pediatric subspecialties clinic thathas a common waiting area for children requiring consulta-tion and subspecialty treatment in endocrinology, gastroen-terology, and cardiology among others. Both sites hadwaiting rooms where “iHealthNYC” surveys were conductedduring a 5-week period between July and August 2013. Thiswas a convenience sample of participants present for wellchild, sick, or consultation visits during that period. Targetgroups included teenage patients (13-19 years old) and par-ents/caregivers. Inclusion criteria were clinic affiliation andfluency in English. To minimize limitations of complianceand illiteracy, the research committee verbally administeredall surveys individually to participants.

Informed consent was obtained on forms approved by theAlbert Einstein College of Medicine Institutional ReviewBoard. No financial incentives were given for participation,and subjects’ answers were kept anonymous after the initialdata collection. After completion of surveys, a demonstrationof health and nutrition apps was conducted to educate par-ticipants of apps available for download. Contact numberswere requested so subjects could be called 1-2 weeks afterto participate in feedback. MyFitnessPal,15 a popular nutri-tion and fitness tracker app was selected for demonstrationbecause it targets principles of healthy eating and exercisethat are applicable to multiple age groups. The research com-mittee selected this particular app after physician reviewbecause of its user-friendly interface (based on positive con-sumer reviews) and availability (free of charge on multiplemobile operating systems).

Descriptive statistics were used to report prevalence ofsmartphone owners, primary use, and interest in healthapps in relation to their current app preferences and connec-tivity. Data were analyzed to compare differences betweenteen and caregiver groups as well as variation between the pri-mary care and subspecialty clinic sites. Analysis was per-formed using SAS statistical software (version 9.3; SASInstitute, Cary, North Carolina) for bivariate analysis, ORs,and chi-square statistics.

Results

Of the 270 individuals approached for this study, 164 (60.7%)agreed to participate as part of this convenience sample. In to-tal, 148 subjects completed the survey, that is, 71 teens and 77

caregivers. Sixteen additional surveys were not analyzedbecause they were incomplete (12 subjects discontinued afterbeing called in by nurse/physician, 4 because of fatigue).During the recruitment period, there seemed to be no sig-

nificant difference in patient demographics, although 78.4%of surveys collected came from Clinic A. This discrepancy be-tween sites was attributed to survey administrators spending70% of the data collection period at Clinic A as the result ofwork scheduling.Subjects were predominantly women (75%), identified

themselves as African American (40.5%) and/or Hispanic(60.1%), and stated English to be their primary language(89%) (Table I). Mean age was 15.9 years for teens and30.1 years for caregivers. Subjects appeared to reflect theunderserved locations of these clinics; 46% of those whoanswered had household annual incomes #$25 000 withthe median bracket at $10-25 000. Given an average 5.1members per household, the majority of families were wellbelow the federal poverty level.Overall, 85% of subjects were smartphone owners (91.2%

having active data plans) and 57% using them as their pri-mary internet source. There was no statistical difference insmartphone ownership in demographic variables such asage, sex, ethnicity, and income. Smartphone users hadvarious apps (mean = 14.5), with the top three being: (1)games; (2) social networking; and (3) music. Teens accessedapps more than caregivers (64.3% vs 55.8%), although teensowned fewer mean apps.

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Table II. Smartphone ownership and app use

Teens (n = 71)Caregivers(n = 77) P value*

Smartphone users 57 (80.3%) 69 (89.6%) .18iPhone 21 (29.6%) 35 (50.7%)Android 32 (45.1%) 33 (42.9%)Blackberry 3 (4.2%) 1 (1.3%)Windows 1 (1.4%) - (0%)

Primary internet .11Phone 39 (54.9%) 45 (58.4%)Computer/tablet 23 (32.4%) 15 (19.5%)Both equally 9 (12.7%) 17 (22.1%)

Mean apps owned 13.4 (SD 11.1) 15.4 (SD 14.2) .38App use >3�/day 45 (63.4%) 43 (55.8%) .11Medical info via smartphone 34 (47.9%) 59 (76.7%) <.01Medical app interest .01Not interested 13 (18.3%) 10 (13%)Neutral 17 (23.9%) 8 (10.4%)Some interest 36 (50.7%) 28 (36.4%)Very interested 5 (7.0%) 31 (40.3%)

Medical app owners 12 (16.9%) 27 (35.1%) .02

Note: Percentages (%) calculated using total n in each target group.*P values based on Student t test, nonparametric Wilcoxon test, or Pearson c2.

THE JOURNAL OF PEDIATRICS � www.jpeds.com Vol. 165, No. 3

Two of every 3 subjects (66.9%) had looked up medical in-formation using their phones; the aOR for caregivers vs teenswas 3.63 (95% CI 1.58-8.35). The majority of participantssurveyed had some interest in medical apps, although care-givers were significantly more motivated, that is, 40.3%answering “very interested” compared with 7% for teens(P = .01). Despite interest, ownership remains low, particu-larly in teens. Currently 16.9% teens own a medical app vs35.1% in caregivers (P = .02), with even fewer using themregularly (Table II).

Topics of interest for health apps varied between teens andadults. Using Likert scales to measure interest levels, wefound that teens favored apps on reproductive and mentalhealth, and caregivers identified with child development,nutrition, and physical activity (Figure). One commoninterest of both age groups was patient/medicationmanagement (naming medications, keeping track of doctorappointments, etc.) for which 45.9% were “veryinterested,” with an overall 76.4% at least somewhatinterested.

Discussion

Well above national estimates, 85% of caregivers and teenagersfrom these underserved urban pediatric clinics were smart-phone owners. App use is already prevalent in diverse pediatriccommunities, making it a viable digital platform of communi-cation in primary and subspecialty care. Because the majorityof participants affirmmedical app interest but only 26% (39 of148 total) own them, the challenge is converting interest to us-age. During feedback, participants cited “lack of awareness,affordability, privacy and limited data plans” as barriers fornot downloading or using medical apps.

To attract new users, health apps must be engaging andsustainable. Incorporating educational games, fun facts,trivia, and pictures are features to keep users interested.16 So-

608

cial networking capability could include digitally connectedsupport groups, supervised by pediatricians.17 Affordability,reliability, and ease of use will likewise determine successfulintegration.Identifying pediatric topics to be targeted is also essential.

Survey results showed teens favor adolescent issues, and par-ents were more interested in development and preventativecare. Most significant interest overall among all participantsthough, was medication management and patient logistics,suggesting this topic warrants an additional focus. Recentdata show <50% medication adherence in children, withone-third failing to complete even short-term treatment regi-mens.18 Multiple caregivers and pediatric weight-based dosingonly magnify likelihood of nonadherence. A simple pillboxreminder app linking a child’s health record would be oftremendous benefit.19 Apps could be password-protected forusers and tracked along with the medical team. Likewise,missed doctors’ appointments create gaps in communicationand wasted clinic expenditures.20 Secure patient-providerapps that integrate calendars may reduce “no-shows,” poten-tial visits to the emergency department, and increase treatmentadherence.21 Cost-effective and empowering patients and fam-ilies, mobile health makes medical and financial sense.22

Advocacy of medical apps by health care providers is vitalin getting patients and caregivers to click on download but-tons.23 With no regulation of evidence-based apps, however,an appropriate step would be creating a curriculum of smart-phone apps reviewed and endorsed by a panel of pediatri-cians or organization such as the American Academy ofPediatrics. Standardized apps covering common pediatrictopics would be a valuable toolkit for providers to offer pa-tients, which can be conveniently stored on their phones,instead of paper handouts, which often are thrown out mo-ments later. One example is Teens in NYC,24 an app recentlydeveloped by New York Department of Health that providessexual health information as well as locations for testing andbirth control.Our study has limitations. This was a convenience sample

targeting patients in waiting rooms, potentially creating selec-tion bias of survey participants. Although the sex discrepancyis skewed towards women, this finding is consistent with pri-mary caregivers tending to bewomen andmale teens being lesslikely tomake doctors appointments. Another limitation is theabsence of previously validated survey tools leading us tocreate questions de novo. After collaboration with the researchcommittee, questions were piloted on test subjects. Neverthe-less, a validated questionnaire would standardize data collec-tion, increasing the strength of statistical analysis onpopulation behaviors. Exclusion of non-English–speakingparticipants also may lead to a potential sampling bias. Doneto ensure consistency in administering surveys and medicalapp demonstrations (only available in English), this mayskew the representative sample limiting generalizability.Barriers that need to be addressed in medical app develop-

ment include the risk of patient confidentiality. Designingapps that contain personal information or link electronicmed-ical record systems will require encryptions and safety

Singh, Wilkinson, and Braganza

Figure. Comparison of interest between teens andparents in topics for potential health apps.Pt, physical therapy;Med,medical.

September 2014 ORIGINAL ARTICLES

measures tomaintain confidentiality.4 In themeantime, gener-alized health apps that provide evidence-based medical infor-mation and anticipatory guidance are valuable tools. Anotherhurdle in connecting with the urban, underserved populationis the periodic interruption in internet and smartphone ser-vice.9 Only 38% (30 of 79) of subjects contacted for follow-up answered their calls (maximum 3 attempts were made).Costs of data plans limit overall usage or cause interruptedinternet/phone service.2 Our survey was evidence of this,with 8.8% of smartphone owners answering “No” to currentlyhaving an active data plan. Creating apps that are download-able to other technologies (ie, tablets, computers) may provideflexibility to deliver information even when data plans are ex-hausted, thus allowing the health app to be available 24/7.

Further research in the development and efficacy of healthapps is necessary, but pediatricians need to be active collab-orators advocating this movement. Validated measurementtools and outcomes research will continue to build meaning-ful data for future areas of study. Only then can we promoteevidence-based, user-friendly apps to patients and familieshelping them take ownership of their health. n

The authors thank Galina Umanski, MS (Department of Family andSocial Medicine, Montefiore Medical Center), for her assistance withdata analysis.

Submitted for publication Jan 14, 2014; last revision received May 9, 2014;

accepted May 21, 2014.

Reprint requests: Arunjot Singh, MD, MPH, Children’s Hospital at Montefiore,

3544 Jerome Avenue, Bronx, NY 10467. E-mail: arunjot.singh@gmail.com

Smartphones and Pediatric Apps to Mobilize the Medical Home

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