Document Type : Original Research Article
Authors
- Seyed Mohammad Ayyoubzadeh 1
- Mahnaz Ahmadi 2
- Fariba Khounraz 3
- Marjan Ahmadi 4
- Rashed Pourhamidi 5
- Sakineh Abbasi 6
1 Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Pharmaceutics, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Administration and Resources Development Affairs, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
5 Non-Communicable Diseases Research Center, Bam University of Medical Sciences, Bam, Iran
6 Department of Laboratory Science, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
Abstract
Background & Objective: There are a lot of apps for pregnancy care using mHealth technologies. However, it has not been studied which criteria in these apps are essential for increasing the quality of these mHealth programs in pregnant women. Thus this study aimed to review the desirable features of mobile-based pregnancy care applications and provide a model to evaluate existing applications.
Materials & Methods: Features of a mobile-based pregnancy app were designed using a qualitative approach. In this research, an open questionnaire was developed. Obstetricians and gynecologists filled out this questionnaire. After thematic analysis of the questionnaires, the obtained items are embedded into a general framework for evaluation mHealth.
Results: Fifteen gynecology and obstetrics experts participated in this study. Eight themes were obtained from 34 items mentioned by the experts. Finally, a specialized framework for evaluating mHealth apps for pregnancy care is proposed.
Conclusion: To design mobile-based pregnancy care app and evaluate the existing apps in the field of pregnancy, the provided indicators can be used. This framework and other similar specialized frameworks could be developed to improve the quality of the mHealth apps.
Keywords
Main Subjects
ODue to the high demand of patients for being visited by medical experts and place or time barriers, they cannot regularly use face-to-face consultation. Therefore, patients may face challenges in identifying priorities to address their clinical concerns. In this regard, the Internet and smartphones have received much attention for accessing health care information as a tool for managing health care. Mobile health (mHealth) technologies, as one of the healthcare approaches, could reduce the pressure on the healthcare system and improve the quality of care for patients (1-4). The World Health Organization (WHO) has defined mHealth as mobile devices, including mobile phones, patient monitoring devices, and personal digital assistants to achieve health purposes (5). mHealth, as a self-management tool, could be used to support patients via monitoring and managing health, resulting in an improved healthy life (6).
Among mHealth platforms, besides mHealth apps in women's health (7), numerous studies have been conducted worldwide to confirm the effectiveness of mHealth in promoting the health of the mother and fetus during pregnancy (8, 9). For example, several studies have reported the advantages of mHealth monitoring apps for controlling diabetes during pregnancy (10). mHealth also provides a platform for obstetricians and midwives to overcome their time and place limitations and enhance the health of pregnant women during pregnancy (11).
Systematic monitoring, including examination and consultation about pregnancy issues, education and support of the pregnant woman, and preparation of a continuous clinical screening program, are essential to prevent possible complications during pregnancy (12). Studies in different world areas consider the amount of inadequate prenatal care (13). Due to the importance of continuous care for pregnant women, the benefits of mHealth can be increasingly understood (10).
Women need information during their pregnancy. According to the literature, many pregnant women worldwide use the Internet as a source of information (14). Instead of using paper and face-to-face techniques to obtain information, they have used mHealth technology (15). Studies have shown that more than 50% of pregnant women download pregnancy-based apps, and these women have fewer pregnancy visits (16). For example, Chan et al. demonstrated that social media and mHealth apps could be widely used for improving the quality of life during pregnancy (17). In recent years, mHealth technology has grown quickly, and mobile phones are used in various aspects such as healthcare services (18). In developing countries, mHealth is highly used among women to get healthcare services, especially prenatal care (19).
Furthermore, the necessity of mHealth apps during the COVID-19 pandemic has also been observed more than ever for reducing the need for visits due to the adverse effects of COVID-19 on pregnant women (20). For example, it was reported that 21% of prenatal visits in March 2020 and 26% of prenatal visits in April 2020 were canceled, postponed, or performed remotely (21).
In addition to all of the above, exposure to incorrect information and nonevidence-based mobile apps causes problems for pregnant women due to the high sensitivity of maternal to external impacts; therefore, these issues should be carefully considered (22). Also, it requires to be considered that many medical Web sites and smartphone mHealth apps are not transparent in providing accurate health information (23). Wallwiener et al. reported that despite the great importance of mHealth apps, many smartphone applications are not reliable sources (10). Henriksson et al. evaluated the effectiveness of a smartphone app for reducing excess weight gain, dietary habits, physical activity, and glycemia during pregnancy (24).
All in all, there are a lot of apps for pregnancy care using mHealth technologies. However, it has not been studied which criteria in these apps are essential for increasing the quality of these mHealth programs in pregnant women. Thus, this study aimed to determine a model to identify the desirable features of mobile-based pregnancy care apps for improving maternal well-being.
Data Collection
In this research, a qualitative study has been conducted. A questionnaire with one general open question from experts was asked. The question was, "what features should a good mobile-based app contain?". The questionaries were designed in Google Forms. Next, a gynecology and obstetrics expert shared the link in specialized Telegram groups with her colleagues.
Data Analysis
The codes were extracted from the answers manually. In the next step, the themes were identified based on the codes and regarding items in the general framework for mHealth apps developed by Nouri et al. (25) (Figure1).
Figure 1. Criteria for evaluating the quality of mHealth programs
Data Collection
Fifteen experts filled out the questionnaire. The specialist and the experts were all gynecologists and obstetrics. The work history of the experts is listed in Table 1.
Data Analysis
The new codes are listed in Table 2. The themes extracted from the codes using Nouri's framework are shown in Table 3.
Table 1. Years of working in the field of the experts
| Work history (year) | Number of experts |
| 2 | 1 |
| 3 | 3 |
| 4 | 6 |
| 5 | 2 |
| 7 | 1 |
| 10 | 1 |
Table 2. Codes extracted from the answers
| Code extracted |
| Updated with the science of the day |
| Contains pregnancy care training tips |
| Ease to understand |
| Access to patient information via simplified code |
| Ability to work offline |
| Easy and permanent access |
| Ability to install on various devices and operating systems |
| Data transmission speed |
| Connect to the patient file |
| special diseases |
| Medications |
| Record the patient's main complaint |
| Registration of symptoms |
| Registration of Vital Signs |
| Registration of Feeling the movement of the fetus |
| Registration of Vaginal bleeding |
| Registration of Feeling of a ruptured bladder and wet underwear |
| Registration of Pain in the lower abdomen or back |
| Registration of Headache |
| Registration of Heartburn |
| Registration of Blurred vision |
| Registration of Ultrasound report image |
| Save patient records for physician |
| Reminders of the necessary screening references and tests in each term |
| Recall supplements every trimester of pregnancy |
| Ability to message the doctor |
| Perform calculations |
| Calculate gestational age based on test results |
| Calculate BMI |
| Calculate the date of screening |
| It should not cause you not to see a doctor |
| Ease of use |
| Comprehensive |
| Reminder |
Table 3. Themes extracted from the codes
| Code extracted |
| Ease to understand |
| Simplicity |
| Comprehensive |
| Accessibility |
| Cross-platform |
| Reminder |
| Performing calculations |
| It should not cause you not to see a doctor |
The specialized framework for evaluating pregnancy care mHealth apps framework is represented in Table 4. New items extracted from the codes are shown in green color. Also, the items already existed in the framework and mentioned in the answers are colored blue.
Table 4. The specialized framework for evaluating pregnancy care mHealth apps
| Category | Items | Subitems | Subitems child |
| Design | Suitability of design | ||
| Aesthetic | |||
| Appearance | |||
| Data consistency | |||
| Information/Content | Creditability | ||
| Accuracy | |||
| Quality of information | Updated with the science of the day | ||
| Quantity of information | Contains pregnancy care training tips | ||
| Understandable | |||
| Usability | Ease of use | Access to patient information via simplified code | |
| Ability to work offline | |||
| Operability | |||
| Visibility of system status | |||
| User control and freedom | |||
| Consistency and standards | |||
| Error prevention | |||
| Completeness | |||
| Information needs | |||
| Flexibility / customizability | |||
| Competence | |||
| Style | |||
| Behavior | |||
| Structure | |||
| Easy and permanent access | |||
| Ability to install on various devices and operating systems | |||
| Functionality | Performance | Data transmission speed | |
| Health warnings | |||
| Feedback | |||
| Connectivity and interoperability | |||
| Record | Connect to the patient file | ||
| special diseases | |||
| Medications | |||
| Record the patient's main complaint | |||
| Registration of symptoms | Registration of Vital Signs | ||
| Registration of Feeling the movement of the fetus | |||
| Registration of Vaginal bleeding | |||
| Registration of Feeling of a ruptured bladder and wet underwear | |||
| Registration of Pain in the lower abdomen or back | |||
| Registration of Headache | |||
| Registration of Heartburn | |||
| Registration of Blurred vision | |||
| Registration of Ultrasound report image | |||
| Save patient records for physician | |||
| Display | |||
| Guide | |||
| Remind/alert | Reminders of the necessary screening references and tests in each term | ||
| Recall supplements every trimester of pregnancy | |||
| Communicate | Ability to message to the doctor | ||
| Perform calculations | Calculate gestational age based on test results | ||
| Calculate BMI | |||
| Calculate the date of screening | |||
| Ethical Issues | Beneficence | ||
| Non-maleficence | |||
| Autonomy | |||
| Justice | |||
| Legal obligations | |||
| Security and Privacy | Security | ||
| privacy | |||
| User- Perceived Values Designing |
It should not cause you not to see a doctor |
As a result, by integrating the general framework model for mHealth apps and the new specialized features obtained using experts' opinions, the developed model was redesigned, as shown in Figure 2.
Figure 2. Criteria for evaluating the quality of mHealth programs for pregnancy care applications
In this study, a mHealth evaluation framework for pregnancy care was designed based on a previous general framework for evaluating mHealth apps. The specific domain features required by obstetrician experts had been embedded into the previous general model, resulting in a mHealth pregnancy-specific evaluation framework. The main categories of the original framework were not changed; however, specialized features required for pregnancy apps were added to subcategories of the original framework. The survey results showed that this mHealth evaluation framework could be used in pregnancy care.
A previous study by Hussain et al. (26) uses Jakob Nielsen's usability principle as the evaluation framework for a mHelath pregnancy app. The principles contain a subset of the usability category in the proposed framework. Some criteria such as abling to install on multiple devices and the ability to work offline are in the proposed framework that could be used in the evaluation of similar apps.
In another study by Lee et al. (27), the authors used general website confidence and satisfaction evaluation tools to evaluate mHealth pregnancy-related tools (28). This tool contains four categories and 19 items, including content components, information clarity and protection, content management, and information source. These categories could be mapped to Information/Content and security and privacy categories of the proposed framework.
In the mentioned studies, like most research in the literature, the authors used a general framework for evaluating the pregnancy apps. The authors believe that the suggested framework could be used to evaluate the mHealth apps from a general and a specific point of view, and this framework could help the experts to have a clear image of the status of their apps. Also, this framework could help authors to prevent mistakes in the development of the pregnancy-related app. For example study by Halili et al. (29), the authors derived multiple themes using two focus groups for the evaluation of a pregnancy app. The items they categorized in the "Critique of the SmartMoms app" include design and aesthetic, Interactivity, Feedback, Emphasis on weight gain, and Developmental and technical issues. Some of these shortcomings could be prevented if the developers considered the suggested framework for the app development.
As a qualitative study, this study investigated essential criteria for pregnancy care mHealth apps. To this end, a general framework for evaluating mHealth app was adopted, and specialized features related to pregnancy were added to the model based on expert opinions. The findings provide an innovative perspective on the evaluation of pregnancy apps that enable the maternal to monitor and manage their health and reduce complications. Future works could focus on creating a quantitative tool derived from the current framework. Future work can also incorporate the findings of this study into the design and implementation of a comprehensive mobile app for pregnancy care.
We would like to offer our special thanks to all the obstetrician-gynecologist experts participating in this study.
The authors declare no conflict of interest.
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