key: cord-0806732-78nry9y3 authors: Kiani, Shamim; Abasi, Sanaz; Yazdani, Azita title: Evaluation of m‐Health‐rehabilitation for respiratory disorders: A systematic review date: 2022-04-01 journal: Health Sci Rep DOI: 10.1002/hsr2.575 sha: 079f692d7e2299bbef638b1ee56ba1c10397cc15 doc_id: 806732 cord_uid: 78nry9y3 BACKGROUND AND AIMS: Chronic respiratory diseases are prominent causes of morbidity worldwide that impose significant social and economic burdens on individuals and communities. Pulmonary rehabilitation is one of the main aspects of medical rehabilitation. Nowadays, mobile health apps deliver pulmonary rehabilitation support via smartphones. This article presents a systematic review of the literature on m‐Health apps used in respiration disorders rehabilitation. METHODS: A systematic search was performed on MEDLINE (through PubMed), Web of Science, and Scopus in May 2021 without any date limitation. This study was using a combination of keywords and MeSH terms associated with pulmonary rehabilitation. Relevant studies were selected by two independents and were categorized studies results. The inclusion criterion was m‐Health apps for pulmonary rehabilitation and exclusion criteria mobile‐based interventions, by voice call or short message service and cardiopulmonary articles. RESULTS: Searching scientific databases yielded 161 relevant articles. Then, 27 articles were included in the study with a complete evaluation of the articles. Sixty percent of them were related to patients with chronic obstructive pulmonary disease (COPD). Rehabilitation aiming to improve the quality of life, promote self‐management, encourage physical activity, and reduce the symptoms as the most common goals of pulmonary rehabilitation using m‐Health apps; 89% of these studies showed that m‐Health apps can be effective in improving pulmonary rehabilitation. In addition, 37% of studies reported high usability and acceptance. However, the results of some studies show that adherence to apps decreases in the long run. CONCLUSION: Our study shows that m‐Health pulmonary rehabilitation apps are effective in improving the quality of life, self‐management, and physical activity. According to the results, it seems that using the m‐Health apps for pulmonary rehabilitation can be useful in the COVID‐19 pandemic and help reduce respiratory disorders in patients with COVID‐19 disease. Chronic respiratory diseases (CRD), as a major public health issue worldwide, impose significant social and economic burdens on individuals and communities. 1 According to the Global Burden of Diseases Study (GBD), in 2017, the prevalence of CRD was 545 million people of all ages, of which about 50% were due to chronic obstructive pulmonary disease (COPD) and about 50% due to asthma. Due to the rapid aging of the population, CRD is becoming a more prominent problem in the world. 2 Pulmonary rehabilitation is a comprehensive therapeutic intervention for patients with respiratory disorders, 3 which is effective in improving their quality of life. 4 Pulmonary rehabilitation is defined as "a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include but are not limited to, exercise training, education, and behavior change designed to improve the physical and psychological condition of people with chronic respiratory disease and promote the long-term adherence to healthenhancing behaviors." 5 The benefits of pulmonary rehabilitation do not last over time and gradually disappear between 6 and 12 months after the end of pulmonary rehabilitation. Lack of commitment to rehabilitation seems to be one of the possible reasons for losing these benefits. Therefore, developing effective strategies to increase adherence to such interventions is key to maintaining the effects obtained after pulmonary rehabilitation. 5 On the contrary, one of the greatest challenges of humanity in the 21st century is the coronavirus (COVID- 19) epidemic. The severity of the disease varies from moderate to severe, and with any severity, it requires pulmonary rehabilitation. Therefore, physiatrists should investigate effective management plans for COVID-19 survivors with extrapulmonary involvement. 6 In patients with COVID-19, the goal of pulmonary rehabilitation is to improve the symptoms of shortness of breath, relieve anxiety, reduce complications, minimize disability, maintain function, and improve quality of life. 7 Due to its high speed of transmission, remote control, and management of this disease have become important. 8, 9 In this regard, the importance of using information and communication technology (ICT) as a tool for motivation and human interaction from afar has been emphasized. 10, 11 ICT can be useful to increase access to health services. 12, 13 m-Health apps are one of the ICT that can be used for health care. 12, 14 m-Health is defined by the World Health Organization (WHO) as "the function of medical and public health supported by mobile devices such as cell phones, patient monitoring devices, personal digital assistants and other wireless devices." 15 Today, the use of smartphones has increased, and m-Health uses smartphones as a complement to medical health care because some of its benefits extend beyond specific barriers to clinical health care. 16, 17 m-Health apps offer new opportunities for access to health care, learning, selfmanagement, and communication. 18, 19 Based m-Health apps enhance self-management outcomes by providing support (e.g., information, education, and reminders) to patients. 20, 21 Various systematic reviews have been conducted on m-Health apps for COPD and asthma patients, but questions remain about the effectiveness of mobile use for pulmonary rehabilitation in various respiratory disorders. According to the COVID-19 epidemic, identifying effective studies in pulmonary rehabilitation using m-Health apps can be useful for the development of m-Health apps to reduce the complications of respiratory disorders after COVID-19. Therefore, this review addresses the following research questions: (1) How effective are m-Health apps in improving pulmonary rehabilitation?, (2) What are the objectives of using m-Health apps in pulmonary rehabilitation?, (3) How is adherence to m-Health apps in pulmonary rehabilitation?, (4) What are the capabilities and functions of apps?, and (5) What are the evidence and outcomes about the acceptability and usability of m-Health apps in pulmonary rehabilitation? By answering these questions, we achieve our aim of assessing the efficacy of mobile health in pulmonary rehabilitation. The current systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to ensure the inclusion of relevant studies. 22 A systematic search was conducted through MEDLINE (through PubMed), Web of Science, and Scopus in May 2021 without any date limitation. In this study, a combination of keywords and MeSH terms related to pulmonary rehabilitation have been used to retrieve studies (Table 1) . A flow chart of search results is presented in Figure 1 . Articles were retrieved based on this search strategy. The inclusion criterion was m-Health apps for pulmonary rehabilitation. Exclusion criteria were (1) mobile-based interventions by voice call or short message service (SMS), (2) cardiopulmonary articles, and (3) thesis, book chapters, letters to editors, short communications, technical reports, reviews, or meta-analyses. After retrieving the articles based on the search strategy, S. A. and S. K. reviewed all the titles and abstracts to find relevant articles. Then, Searching scientific databases retrieved 161 relevant articles. The initial evaluation was based on the title and abstract of the articles then, 27 articles were included in the study with a complete evaluation of the articles. The procedure of screening articles based on the PRISMA method is displayed in Figure 1 . From selected studies 16 articles related to patients with COPD, 5,23-37 three articles related to asthmatic patients, 18, 38, 39 six articles about cancer patients, 3, 40, 41 and lung transplantation [42] [43] [44] and one related to cystic fibrosis (CF) 45 and the last to patients with acute respiratory diseases. 46 The frequency of studies according to respiratory disorders is shown in Figure 2 . Most studies have focused on COPD, and few studies have examined the role of comorbidity in acute respiratory disease. The objectives, functionality, and outcomes of each study are presented in Table 2 . According to the literature review, the following categories were extracted to respond to research questions and achieve the objectives: 3.1 | The effectiveness of using m-Health apps in pulmonary rehabilitation As a response to the first question, we concluded that in 89% of the selected studies, the use of m-Health apps in pulmonary rehabilitation was effective in improving the quality of life, self-management, This will be explained more in the following section: Self-management is defined as an individual's ability to manage the symptoms, treatment, physical, psychological, and social consequences of chronic disease. 49 The results of the study showed a significant positive change in self-management that is associated with patient empowerment and participation in treatment. 29 To find the response to the third research question, we examined the degree of adherence to pulmonary rehabilitation m-Health apps. Lack of adherence to rehabilitation intervention seems to be one of the possible reasons for the loss of health benefits and creating effective strategies to increase adherence to such apps is key to maintaining the effects of pulmonary rehabilitation. 5 To respond to the fourth question, we considered the sensors, integration with electronic health care systems (e.g., electronic health records [EHR]), alerts, and reminders. According to Table 2 , the sensors can be roughly divided into two categories: (1) physical activity sensors, which included accelerometers, mobile sensors, wearable trackers, and so forth. (2) blood oxygen level sensors, which were most used. Ten studies used pulse oximeter sensors to measure blood oxygen saturation levels. 24, 25, [27] [28] [29] 35, 37, 47 In just one study, the m-Health app was integrated with the EHR through TELUS Health Space, the local version of Microsoft HealthVault (a web-based personal health record created by Microsoft). 18 An important factor for the successful implementation of the electronic intervention is the involvement of users in the design process. Design defects can affect the ease of use usability, and acceptability of the system. That may reduce the user's willingness to use these technologies for interventions. 32 The purpose of usability testing is to identify performance problems, observe user performance and determine user satisfaction. 53 Therefore According to three studies, m-Health apps help asthma control and management. 18 Self-monitoring was associated with a reduced risk of mortality. 43 According to the results of the studies, adherence to m-Health apps is a prerequisite for changing positive behavior and improving health outcomes. User-centric design is important to increase adherence. The purpose of this type of design is to create and maintain a certain level of adherence. 18 Despite the high level of ease of use and satisfaction of m-Health apps, the actual use of these apps decreases over time. According to studies, the following solutions can help improve adherence to apps: -Reduce duplicate content and eliminate heavy inputs. -Automatic alerts and motivational messages via app notifications. -Consideration of factors such as age, technology experience, level of education, and possible comorbidities when developing m-Health programs. -Interact with patients, especially the elderly, in designing and testing to ensure ease. -Providing support and advice (counseling is divided into two categories: social support and technical support). The functionality review of apps shows that spirometry has been considered. Measurement of lung function is the cornerstone of pulmonary diagnosis, treatment evaluation, and prognosis. Without access to pulmonary function tests, many patients will not be properly diagnosed or treated incorrectly. The use of spirometry seems to be because studies have shown that daily home spirometry is an effective tool for diagnosing the progression of idiopathic pulmonary fibrosis and is involved in the early diagnosis of infection. 55 Also, in some patients, such as those with asthma, repeated measurements of pulmonary function at home can help assess symptoms and thus better control. In addition, we examined the integration of apps with other health systems. In just one study, the app was integrated with EHR. While this issue should be given more attention. The EHR provides information about an individual's health status in a computerprocessable manner to professionals, enabling real-time access to clinical records. EHR systems reduce errors through allergy alerts, access to laboratory data. 56 The collection and effective use of clinical information is essential for the provision of quality healthcare services. HER data can be used for this purpose. Patients' data collected through EHR can be used in research and provide an opportunity to study diseases and extract clinical knowledge. 57 Integrating EHR with other systems and software, including mobile apps, can further enhance its potential benefits. When apps are integrated with the EHR, they fully optimize its efficiency. 58 One limitation to our study is that most studies did not report detailed app capabilities such as alerts, sensors, and so on. So no conclusions can be drawn about the impact of these factors on app effectiveness. The Yazdani had full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis. We express our gratitude to Shiraz University of Medical Sciences. This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest. All data analyzed for and presented in this paper are from the twentyseven studies we reviewed. The data is accessible via referenced articles. 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