Willingness to Use Mobile Health in Glaucoma Patients

Abstract

Introduction:

Development of mobile health (m-health) in China carries tremendous potential, especially for glaucoma, one of the major chronic ophthalmic diseases afflicting millions of people. However, little research has been undertaken to investigate the willingness of glaucoma patients to use m-health and the factors influencing their decisions.

Subjects and Methods:

This was a cross-sectional study. A self-administered or face-to-face interview survey was performed on 1,487 patients with glaucoma at the outpatient glaucoma service, Zhongshan Ophthalmic Center, Sun Yat-sen University. Questionnaires captured patients' demographic data, WeChat access, and willingness to receive m-health. The data were analyzed by single factor chi-square test. Multiple logistic regression revealed the motivators and barriers to accept m-health adoption.

Results:

One thousand ninety-seven valid questionnaires were obtained. Seven hundred twenty-five respondents (66.1%) were willing to participate in m-health programs. 65.4% were younger than 60 years old. 40.9% had travel time from home to hospital of >3 h. 63.6% had more than four follow-up visits for glaucoma. 86.5% experienced trouble events during clinic visits. The overall WeChat usage rate was 61.7%. Age, travel time, number of visits, trouble events in clinic, and WeChat access in patients with glaucoma were related to the willingness to use m-health (p < 0.05).

Conclusions:

Most patients with glaucoma were willing to participate in m-health programs, which are essential to increasing and improving access to care.

Introduction

Mobile health delivery (m-health) has emerged as a subsegment of e-health (electronic healthcare) over the past several years. It is supported by mobile communication and network technologies and is becoming more popular in the practice of medicine and public health.^1,2 Many studies have demonstrated that m-health can make healthcare more convenient and reduce a patient's economic burden of disease.³ There were 1.3 billion mobile phone users in 2016 in China.⁴ Smartphones, one of the most important mobile devices, have played an increasingly indispensable role in modern life. Many studies have shown that smartphones can make health management much more convenient for patients with chronic disease.⁵

Ophthalmology, an image-oriented specialty, would benefit disproportionately from mobile devices. Diagnostic and even therapeutic decisions in ophthalmology are often based on review of photographic studies captured by technicians.⁶ Compared with other disciplines in telemedicine, teleophthalmology is among the most active. Nowadays, screening, monitoring, following up, and consulting services can be facilitated by teleophthalmology,^7,8 with numerous m-health applications designed for eye care.^9,10 Most commonly, mobile application software (app) is used for diabetic retinopathy screening.¹¹

Glaucoma is an important chronic disease that causes irreversible vision loss.¹² Protection against visual field loss requires regular monitoring and self-management throughout a lifetime.¹³ However, patients' compliance and follow-up are generally suboptimal, especially in rural china.¹⁴ Some telemedicine devices had been implemented in glaucoma monitoring and management, such as telemetric intraocular pressure sensors,¹⁵ telecommunication-based reminders,¹⁶ teletransmission of stereoscopic images of the optic nerve head,¹⁷ as well as telemedicine friendly devices evaluating cup-to-disc ratios and visual fields.¹⁸ In fact, many examination results can be saved and transmitted through mobile devices such as smartphones.⁹ Utilization of mobile technology may have a significant potential to benefit glaucoma patients by fulfilling remote monitoring function, preventing disease progression, and reducing burden on an overstretched healthcare system.^19,20

Although current studies showed potential benefits of m-health, the attitude toward and potential demand for its use in glaucoma patients in China are unknown. In addition, privacy and security issues need to be considered.²¹ Therefore, the aims of this cross-sectional study were (1) to examine Chinese glaucoma patients' use of and access to new technology, (2) to investigate the willingness to receive m-health services among Chinese glaucoma patients, and (3) to identify motivators and barriers to participating in m-health.

Subjects and Methods

Study Design

In this cross-sectional survey, participants were asked to complete a self-administered questionnaire. Glaucoma patients were queried at the glaucoma outpatient service in Zhongshan Ophthalmic Center of Sun Yat-sen University (Guangzhou, China) from January 2015 to February 2015. There were seven glaucoma specialists in the division of glaucoma, five of whom were in the outpatient service on an average working day. Each glaucoma specialist encounters 40–60 patients daily, with most being walk-ins without appointments. Patients included in the survey were 18 years of age or older and volunteered to complete the questionnaire. Visually impaired patients could complete the questionnaire with the help of their accompanying relatives or friends, who were asked to read the surveys to the patients and write down answers without their own opinions. Patients who had severe psychological or psychiatric deficiencies, cognitive deficiencies, or the inability to read at a basic level were excluded. The study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board. Informed consent was obtained from all patients.

All participants were approached in the clinic waiting room by one physician and two nurses. The investigators had been uniformly trained on the concept of m-health before surveying patients. The investigator gave participants a brief verbal description of the study before commencing. The participants completed the questionnaire with their signature indicating their consent and handed it to one of the investigators. On average, the entire process took 5 min. Data analysis only included completed questionnaires.

Questionnaire Design

Questionnaires were based on a literature review of e-health, m-health, and the attitudes toward this technology in patients with chronic disease.^22,23 Contents of the questionnaire were also discussed in detail with glaucoma specialists and experts on m-health. Items in our questionnaire included demographic characteristics (age and gender), usage of WeChat (a popular mobile network application in China), visit characteristics (travel time from home to hospital, total numbers of visits within the past year, and kinds of trouble events encountered at outpatient service), and opinions about the use of m-health during follow-up visits. The options to each item in the questionnaire were standardized; patients chose their answers among “yes,” “no,” and “don't know/not sure.” In the current study, the concept of willingness to use m-health among glaucoma patients includes two aspects—medicine reminders and mobile medical consultation. Potential barriers to m-health adoption were divided into medical information security and willingness to pay for medical consultation (Cronbach's alpha = 0.702).

Before the initiation of the survey, draft questionnaires were handed out to 30 patients in a pilot survey. After modification, the final version with 11 items was confirmed. Eight items in the questionnaire were in multiple choice format. The last question was in short answer format, allowing respondents to add free text comments.

Data Analysis

Valid questionnaires were defined as (1) clear and completed questionnaires, (2) only one answer was chosen in each item, and (3) confirmed with the responder's signature. We assigned the four willingness-related questions (medicine reminders, mobile medical consultation, medical information security, and willingness to pay for medical consultation) at weight of 1:1:1:1. In each question, a “yes” answer was given 1 point, “not sure” 0.5 points, and “no” 0 points. Therefore, the maximum total score was 4 and minimum was 0. A respondent whose total score was >2 was deemed willing or tend to be willing to use m-health, while those with total score of ≤2 were deemed not willing.

Statistical analyses were performed using SPSS software version 20.0 (SPSS, Inc., Chicago, IL). The chi-square test was used to compare categorical data between independent groups. Multiple logistic regression analysis was used to evaluate the factors (age, travel time from home to hospital, total number of visits, trouble events, and WeChat usage) impacting patients' willingness to participate in m-health. p < 0.05 was considered statistically significant.

Results

One thousand ninety-seven valid questionnaires obtained from 1,487 respondents were included in the final dataset. A valid questionnaire was defined as a survey that was complete without any missing information.

Sociodemographic Characteristics and Medical Situation

The demographic data and medical situations are shown in Table 1. Seven hundred eighteen respondents (65.4%) were 60 years old or younger. Four hundred forty-nine respondents (40.9%) had travel time from home to hospital of >3 h. Six hundred ninety-eight respondents (63.6%) have had more than three visits to the hospital outpatient clinic for glaucoma follow-up within 1 year. Nine hundred forty-nine (86.5%) respondents had at least one kind of trouble events during their visits. Among them, 492 (44.8%) respondents considered the long waiting time the most troublesome aspect of their visits. Six hundred seventy-seven respondents (61.7%) claimed to use WeChat on their mobile devices.

Table 1.

Sociodemographic Data and Medical Situation for Patients with Glaucoma (n = 1,097)

CHARACTERISTIC	n (%)
Gender
Female	524 (47.8)
Male	573 (52.2)
Age group
≤30 years	259 (23.6)
31–60 years	459 (41.8)
≥61 years	379 (34.6)
Travel time from home to hospital
Within 2 h	648 (59.1)
3–9 h	324 (29.5)
>9 h	125 (11.4)
Total number of visits a year
1–3	399 (36.4)
≥4	698 (63.6)
Trouble events
None	148 (13.5)
High price for medicine and medical consultant	56 (5.1)
Long travel time from home to hospital	196 (17.5)
Tedious process	205 (18.7)
Long waiting time	492 (44.8)
Usage of WeChat
No	420 (38.3)
Yes	677 (61.7)

Willingness to Use Mobile Health

Table 2 displays the aggregate data on willingness to adopt m-health. Seven hundred twenty-five respondents (66.1%) were willing or tend to be willing to use m-health (total score of at least 2).

Table 2.

Questions Related to Willingness to Adopt m-Health in Glaucoma Patients

	YES	NO	I DON'T KNOW/I'M NOT SURE
QUESTIONS	n (%)	n (%)	n (%)
Do you think it will be useful for you, if you get medical advice and medicine reminder sent by your doctor through WeChat on your smartphone?	803 (73.2)	87 (7.9)	207 (18.9)
Are you willing to have a remote medical consultation by providing your medical examination records (picture form) to your doctor through the mobile platform?	645 (58.8)	174 (15.9)	275 (25.3)
Are you willing to save your medical examination records (picture form) through the Internet?	510 (46.5)	273 (24.9)	314 (28.6)
Are you willing to pay for a remote medical consultation through one mobile platform based on smartphone such as WeChat at half the cost of the face-to-face consultation?	569 (51.9)	227 (20.7)	301 (27.4)
Assignment/scores	1	0	0.5

Factors influencing the willingness to adopt m-health are shown in Table 3. Age, travel time, total number of visits, trouble events, and usage of WeChat were found to be statistically significant (p < 0.05), but gender was not. Patients' willingness decreased with age. Longer travel times were positively correlated. Interestingly, the more times the patients visited the hospital, the less inclined they were to use m-health. Further logistic regression analysis showed that age, travel time, total number of visits, and trouble events were correlated with willingness (odds ratio [OR] = 0.885, 1.149, 0.838, 1,701, p < 0.05), as demonstrated in Table 4.

Table 3.

Willingness of m-Health Use Among Glaucoma Patients

	YES/TEND TO YES (%)	n
Gender (p > 0.05, not significant)
Female	76.0	351
Male	65.3	374
Age (years) (p < 0.01, significant)
<23	74.2	115
23–30	67.3	70
31–40	79.2	99
41–50	69.7	101
51–60	61.4	116
61–70	59.2	135
>71	58.9	89
Travel time from home to hospital (p < 0.01, significant)
Within 1 h	62.4	219
1–2 h	60.3	179
3–5 h	70.6	168
6–9 h	69.8	60
>9 h	79.2	99
Total number of visits a year (p < 0.05, slightly significant)
1 time	75.4	132
2 times	68.0	85
3 times	61.6	61
≥4 times	64.0	447
Trouble events (p < 0.01, significant)
None	60.8	90
High price for medicine and medical consultant	55.4	31
Long travel time from home to hospital	76.5	150
Tedious process	61.5	126
Long waiting time	66.7	328
Usage of WeChat (p < 0.01, significant)
No	42.9	180
Yes	80.5	545

Table 4.

Multiple Logistic Regression Analysis of the Willingness of m-Health Use in Patients with Glaucoma

FACTORS	β	WALD	p	ODDS RATIO	95% CONFIDENCE INTERVAL
Age	−0.123	13.070	0.000^a	0.885	0.828–0.945
Travel time from home to hospital	0.139	6.467	0.011^a	1.149	1.032–1.279
Total numbers of visit times	−0.177	8.787	0.003^a	0.838	0.746–0.942
Trouble events		11.496	0.022^a
None				Ref
High price for medicine and medical consultant	−0.297	0.845	0.358	0.743	0.394–1.400
Long travel time	0.532	4.537	0.033^a	1.701	1.043–1.400
Tedious process	−0.049	0.048	0.827	0.952	0.611–1.482
Long waiting time	0.281	2.030	0.154	1.324	0.900–1.949

p < 0.05 indicates a significant difference.

Discussion

The purpose of this study was to investigate the willingness to adopt m-health among Chinese glaucoma patients. We found that most were willing and two-thirds had smartphones. These two findings bode well for the potentials of m-health in the study population.

Development of M-Health

For glaucoma patients, poor adherence to treatment is a serious issue, which could lead to progressive visual field loss.¹³ Factors associated with poor adherence include environmental factors (time and distance of travel, cost, long waiting time, etc.), patient factors (forgetfulness, knowledge, doubt, and denial), the treatment regimen (complexity and side effects), and physician responsibility (relationship with patients).²⁴ Many of our patients encounter several of these barriers to care. To improve adherence to treatment, much work remains to be done within the healthcare system, such as offering education and counseling, developing new drug delivery systems, utilizing medication reminders, and improving access.^25
–27

The pervasiveness of smartphones suggests that m-health may play an important role in healthcare delivery in China. A majority of glaucoma patients in our study felt that medication reminders and consultation with doctors through m-health, both of which have shown to improve patient compliance, would be helpful. For the half of the glaucoma patients who were not willing or were hesitant to adopt m-health due to privacy concerns, the complexity of and the lack of familiarity with the technology were likely significant barriers.²⁸ Thus, making the m-health system easy to use and offering some training may encourage wider adoption.²⁹ When it came to the cost, 51.9% of respondents were willing to accept m-health consultation at half the cost of face-to-face consultation. Further study is needed to set a reasonable price structure. As expected, one study showed that m-health would be much more accepted if it can be offered at no cost to the patient.²⁹

Motivation and Barriers to Participation

Our study revealed several factors influencing glaucoma patients' decisions to participate in m-health. Consistent with previously published works,^30,31 the younger the patients, the greater the acceptance rate. Younger patients may be more open to novel technology or methods of healthcare delivery. Older patients with visual impairment face higher barriers. Older patients also tend to be more concerned about privacy and more cautious in making healthcare decisions.³² Gender did not appear to play role in attitudes toward m-health in our study. However, previous studies reached different conclusions among healthy people. One study reported that women were more likely to use m-health for health maintenance.³³ Another study claimed that men were more positive about m-health because of greater confidence in handling the new technology.³⁴ The divergent results may be due to different ways that the questions were asked.

Difficulties during the clinic encounters were another major motivating factor. Increasing mobile healthcare delivery may reduce waiting time in the clinic and improve patient satisfaction.³⁵ Our study showed that patients with longer travel time were more willing to engage in m-health. One researcher also reported that longer travel time encouraged m-health adoption.³⁶ Another study highlighted the importance of mobility impairments and increased falling risk during traveling for old patients with visual field loss.³⁷

In our study, the number of clinic visits also played an important role. Glaucoma patients with ≥4 visits annually were less willing to use m-health than those with ≤3 visits. This may be due to a stronger therapeutic relationship between patients and doctors built during those visits.¹⁸ Alternatively, this may be due to selection bias. Patients who prefer face-to-face consultation would naturally choose more clinic visits.

In the past few years, WeChat has become one of the most popular social communicating apps, with 600 million users in China.³⁸ In our study, 61.7% respondents were using WeChat. It was logical that they were more willing to use m-health as a result of their greater familiarity and confidence in new technology.

Limitations

There were several limitations to this study. First, the results of this survey may not be applicable in other countries with different healthcare and technological landscapes. Second, selection bias in our questionnaire might have influenced the results. Voluntary participants in this study may have an inherent bias toward or against m-health. Third, all respondents were from a single outpatient glaucoma service, and thus, sample size was somewhat limited and might not be representative of all glaucoma patients. Finally, our questionnaire contained only 11 items, which might not cover all relevant aspects of m-health. However, the simplicity of the questionnaire may improve the response rate and save patients' time. Despite these limitations, the study shed some light on attitudes toward m-health among glaucoma patients.

Conclusion

The current study reveals a potential demand for m-health services among glaucoma patients. The study results may also help information technology providers design and deliver patient-centered m-health interventions that could improve health outcomes. Addressing privacy concerns, ease of use, and other barriers may improve patients' satisfaction, as well as increase acceptance, of m-health in the future. Further research is required in using a novel use of health information technology through m-health services to deliver and receive health information between glaucoma patients and their doctors or healthcare providers in patient-centered care in China.

Footnotes

Acknowledgments

This work is supported by the National Natural Science Foundation of China (No. 81670850) and Guangzhou Science Technology and Innovation Commission in China (No. 201607010321).

Disclosure Statement

No competing financial interests exist.

References

Organization WH. M-Health: New horizons for health through mobile technologies. Soc Indic Res, 2011; 64:471–493.

Istepanian

, Laxminarayan

, Pattichis

. M-health: emerging mobile health system. Berlin: Springer Science, 2006.

Bastawrous

, Armstrong

. Mobile health use in low- and high-income countries: An overview of the peer-reviewed literature. J R Soc Med, 2013; 106:130–142.

Ministry of Industry and Information Technology of the People's Republic of China: Mobile Phone Usage in China. 2016. Available at www.miit.gov.cn/n1146312/n1146904/n1648372/c5275691/content.html (last accessed October 7, 2016 ).

Wang

, Wang

, Wei

, Yao

, Yuan

, Shan

, et al. Smartphone interventions for long-term health management of chronic diseases: An integrative review. Telemed J E Health, 2014; 20:570–583.

Chiang

, Wang

, Kim

, Scott

, Richter

, Kane

, et al. Diagnostic performance of a telemedicine system for ophthalmology: Advantages in accuracy and speed compared to standard care. AMIA Annu Symp Proc, 2010; 2010:111–115.

Kanjee

, Dookeran

, Mathen

, Stockl

, Leicht

. Six-year prevalence and incidence of diabetic retinopathy and cost-effectiveness of tele-ophthalmology in Manitoba. Can J Ophthalmol, 2016; 51:467–470.

Tan

, Poh

, Srinivasan

, Lim

. A pilot trial of tele-ophthalmology for diagnosis of chronic blurred vision. J Telemed Telecare, 2013; 19:65–69.

Tahiri

JHR

, El

, Dupont-Monod

, Baudouin

. Smartphones in ophthalmology. J Fr Ophtalmol, 2013; 36:499–525.

10.

Cheng

, Chakrabarti

, Kam

. iPhone applications for eye care professionals: A review of current capabilities and concerns. Telemed J E Health, 2014; 20:385–387.

11.

de la Torre-Diez

, Martinez-Perez

, Lopez-Coronado

, Diaz

, Lopez

. Decision support systems and applications in ophthalmology: Literature and commercial review focused on mobile apps. J Med Syst, 2015; 39:174.

12.

Tham

, Li

, Wong

, Quigley

, Aung

, Cheng

. Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis. Ophthalmology, 2014; 121:2081–2090.

13.

Sleath

, Blalock

, Covert

, Stone

, Skinner

, Muir

, et al. The relationship between glaucoma medication adherence, eye drop technique, and visual field defect severity. Ophthalmology, 2011; 118:2398–2402.

14.

Huang

, Zheng

, Foster

, Huang

, He

. Prevalence and causes of visual impairment in Chinese adults in urban southern China. Arch Ophthalmol, 2009; 127:1362–1367.

15.

Koutsonas

, Walter

, Roessler

, Plange

. Implantation of a novel telemetric intraocular pressure sensor in patients with glaucoma (ARGOS study): 1-year results. Invest Ophthalmol Vis Sci, 2015; 56:1063–1069.

16.

Boland

, Chang

, Frazier

, Plyler

, Jefferys

, Friedman

. Automated telecommunication-based reminders and adherence with once-daily glaucoma medication dosing: The automated dosing reminder study. JAMA Ophthalmol, 2014; 132:845–850.

17.

Bergua

, Mardin

, Horn

. Tele-transmission of stereoscopic images of the optic nerve head in glaucoma via Internet. Telemed J E Health, 2009; 15:439–444.

18.

Kumar

, Giubilato

, Morgan

, Jitskaia

, Barry

, Bulsara

, et al. Glaucoma screening: Analysis of conventional and telemedicine-friendly devices. Clin Exp Ophthalmol, 2007; 35:237–243.

19.

Thomas

, Jeyaraman

, Hodge

, Hutnik

, Costella

, Malvankar-Mehta

. The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: A systematic review and meta-analysis. PLoS One, 2014; 9:e113779.

20.

Strouthidis

, Chandrasekharan

, Diamond

, Murdoch

. Teleglaucoma: Ready to go?. Br J Ophthalmol, 2014; 98:1605–1611.

21.

Luxton

, Kayl

, Mishkind

. mHealth data security: The need for HIPAA-compliant standardization. Telemed J E Health, 2012; 18:284–288.

22.

Dudas

, Pumilia

, Crocetti

. Pediatric caregiver attitudes and technologic readiness toward electronic follow-up communication in an urban community emergency department. Telemed J E Health, 2013; 19:493–496.

23.

Piette

, Mendoza-Avelares

, Milton

, Lange

, Fajardo

. Access to mobile communication technology and willingness to participate in automated telemedicine calls among chronically ill patients in Honduras. Telemed J E Health, 2010; 16:1030–1041.

24.

Nordmann

, Akesbi

. Improve adherence in glaucoma patients: A doctor's duty. J Fr Ophtalmol, 2011; 34:403–408.

25.

Ung

, Spaeth

, Lin

, Singh

. Failure of glaucoma follow-up compliance. Am J Ophthalmol, 2015; 160:1089–1090.

26.

, Lyu

. Progression of drug delivery system for glaucoma. Zhonghua Yan Ke Za Zhi, 2014; 50:946–951.

27.

Sleath

, Blalock

, Carpenter

, Sayner

, Muir

, Slota

, et al. Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence. Ophthalmology, 2015; 122:748–754.

28.

Pinnock

, Slack

, Pagliari

, Price

, Sheikh

. Professional and patient attitudes to using mobile phone technology to monitor asthma: Questionnaire survey. Prim Care Respir J, 2006; 15:237–245.

29.

McGillicuddy

, Weiland

, Frenzel

, Mueller

, Brunner-Jackson

, Taber

, et al. Patient attitudes toward mobile phone-based health monitoring: Questionnaire study among kidney transplant recipients. J Med Internet Res, 2013; 15:e6.

30.

James

, Harville

, Whitehead

, Stellefson

, Dodani

, Sears

. Willingness of African American women to participate in e-Health/m-Health research. Telemed J E Health, 2016; 22:191–197.

31.

Torous

, Friedman

, Keshavan

. Smartphone ownership and interest in mobile applications to monitor symptoms of mental health conditions. JMIR Mhealth Uhealth, 2014; 2:e2.

32.

Deng

, Mo

, Liu

. Comparison of the middle-aged and older users' adoption of mobile health services in China. Int J Med Inform, 2014; 83:210–224.

33.

Guo

, Han

, Zhang

, Dang

, Chen

. Investigating m-health acceptance from a protection motivation theory perspective: Gender and age differences. Telemed J E Health, 2015; 21:661–669.

34.

Zhang

, Guo

, Lai

, Guo

, Li

. Understanding gender differences in m-health adoption: A modified theory of reasoned action model. Telemed J E Health, 2014; 20:39–46.

35.

Aleo

, Hark

, Leiby

, Dai

, Murchison

, Martinez

, et al. Ophthalmic patients' utilization of technology and social media: An assessment to improve quality of care. Telemed J E Health, 2014; 20:887–892.

36.

Bradford

, Kleit

, Krousel-Wood

, Re

. Comparing willingness to pay for telemedicine across a chronic heart failure and hypertension population. Telemed J E Health, 2005; 11:430–438.

37.

Freeman

, Munoz

, Rubin

, West

. Visual field loss increases the risk of falls in older adults: The Salisbury eye evaluation. Invest Ophthalmol Vis Sci, 2007; 48:4445–4450.

38.

China Internet Network Information Center: China's Internet statistics report. 2016. Available at www.cnnic.net.cn/hlwfzyj/hlwxzbg/hlwtjbg/201608/P020160803367337470363.pdf (last accessed October 7, 2016 ).