mHealth applications as an educational and supportive resource for family carers of people with dementia: An integrative review

Abstract

Family carers encounter several challenges related to caring for people with dementia, and they need support in managing care recipients’ health needs. This study aims to identify, appraise and synthesise the existing evidence on the use of mHealth/smartphone applications as an educational and supportive resource for family carers of people with dementia. An integrative literature review approach was used. Seven databases were searched. The search generated 117 articles, with seven meeting the inclusion criteria. Three categories and their attendant sub-categories emerged from the literature. The categories are ‘carer support’, ‘evaluation strategies’ and ‘barriers and challenges’. mHealth applications appear to be a feasible intervention for family carers of people with dementia despite the limited available research and barriers for their development and implementation. Further research on mHealth applications with strong methodological rigour and more research on mHealth applications as an educational and supportive resource for carers of people with dementia are needed.

Keywords

carer dementia educational resource integrative review mHealth application

Background

Dementia is one of the most challenging conditions in older age that impacts not only the people affected but also their families, carers and society. It is a complex syndrome with progressive deterioration of cognitive functions and activities of daily living (Grand, Caspar, & Macdonald, 2011). Globally, over 46 million people live with dementia, and this number is expected to increase to 131.5 million by 2050 (Alzheimer’s Disease International, 2015). The global estimated cost of dementia in 2015 was USD 818 billion (Alzheimer’s Disease International, 2015). The World Health Organization (2016) recognises dementia as a public health priority and aims to focus on improving care and support for people with dementia and their carers.

People with dementia have a wide variety of clinical manifestations that require increased levels of care, most of which is provided by family carers (Brodaty & Donkin, 2009) who are usually untrained for this demanding role (Peterson, Hahn, Lee, Madison, & Atri, 2016). Family members are frequently the main source of support for the provision of physical, emotional, social, psychological and financial support (Bamm & Rosenbaum, 2008; Janzen, 2001). However, they encounter several challenges related to care of people with dementia. Empirical evidence indicates that carers of people with dementia present with moderate to high levels of burden (Abdollahpour, Noroozian, Nedjat, & Majdzadeh, 2012; Medrano, Rosario, Payano, & Capellán, 2014; Muangpaisan et al., 2010) as well as burnout, anxiety, depression, hopelessness and poor quality of life (Bandeira et al., 2007; de Oliveira, Vass, & Aubeeluck, 2015; Medrano et al., 2014; Truzzi et al., 2012). Subsequently, they often need additional support especially in seeking information about dementia, how to cope with symptoms of dementia, how to deal with behavioural problems and how to find support systems (Zwaanswijk, Peeters, Beek, Meerveld, & Francke, 2013). Studies have found that carers receive insufficient information related to managing problems of their care recipients (Livingston et al., 2010; Peterson et al., 2016). They may have limited education and care skills related to dementia as well as insufficient coping skills and limited information about available support services in the community (Black et al., 2013; DiZazzo-Miller, Pociask, & Samuel, 2013; Karpathiou, 2015; Lai & Chung, 2007; Scott, Lewis, Loughlin, & Chambers, 2005). Consequently, it may be beneficial to develop user-friendly educational resources for carers of people with dementia.

In recent history, there has been a rapid increase in the use of mobile technology in health . This unprecedented use of mobile technology with its innovative applications in addressing health needs has generated a new field called mHealth (World Health Organization, 2011). mHealth or mobile health is defined as ‘medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices’ (World Health Organization, 2011, p. 6). The use of mobile technology in healthcare is advantageous because these devices are highly personal, intelligent, cost-effective, highly accessible and always with people (Fiordelli, Diviani, & Schulz, 2013; Handel, 2011). The smartphone is the most attractive and well-known mobile device in mHealth (Lee, 2016) that combines mobile communication and computation (Mosa, Yoo, & Sheets, 2012).

mHealth/smartphone applications (apps) are applications designed for smartphones and are rapidly emerging as effective health information sources (Handel, 2011). A recent systematic review found that there were more than 3673 mHealth applications related to the most prevalent health conditions, for example, diabetes, asthma, depression, hearing loss, low vision, osteoarthritis, anaemia and migraine (Martínez-Pérez, Torre-Díez, & López-Coronado, 2013). A systematic review by Mosa et al. (2012) reported that the major areas addressed through mHealth applications were disease diagnosis, drug reference, medical calculations, literature search, clinical communication, hospital information system client applications, medical training, medical and nursing education and chronic disease management. Moreover, recent studies have found that mHealth applications are effective in a wide variety of health fields, for example, patient education (Sureshkumar, Murthy, Munuswamy, Goenka, & Kuper, 2015), chronic disease management (Kirwan, Vandelanotte, Fenning, & Duncan, 2013; Quinn et al., 2011), health promotion (Glynn et al., 2014), mental health (Kinderman et al., 2016), nursing education (Kim, Shin, Lee, Kang, & Bartlett, 2017) and medical practice (Man, Nguyen, & Lin, 2014). As the use of mHealth applications rises, it is both timely and appropriate to review the literature on mHealth applications as an educational and supportive resource for carers of people with dementia. Exploring new knowledge related to the design, development and effectiveness of mHealth applications for carers of people with dementia will help to plan future mHealth interventions.

Review questions

This integrative review aims to identify, appraise and synthesise the existing evidence on the use of mHealth applications as an educational resource and support for carers of people with dementia in order to answer the following questions:

What is the contribution of mHealth applications as an educational resource and support for carers of people with dementia?

What are the related barriers and challenges in the development and implementation of mHealth applications for carers of people with dementia?

Method

Design

In this study, an integrative literature review approach using the framework of Whittemore and Knafl (2005) was used. Whittemore and Knafl (2005) claim that an integrative literature approach allows for the simultaneous inclusion of qualitative and quantitative studies in order to more fully understand the phenomenon of interest and combines data from the theoretical as well as empirical literature. The protocol for the integrative review has been registered in the International Prospective Register of Systematic Reviews (Rathnayake, Moyle, Jones, & Calleja, 2017).

Literature search

Seven electronic databases were searched: MEDLINE, CINAHL Plus with Full Text, Cochrane Library, PsycINFO (via Ovid), Embase, Scopus and PubMed. Search terms were organized into three conceptual areas: dementia OR Alzheimer* AND carer* OR caregiver* OR famil* OR spous* AND “smartphone application*” OR “mobile health application*” OR “mHealth application*” OR “smartphone app*” OR “phone app*”, “mobile app*” OR “mobile health app*” OR “mHealth app*” OR “handheld computer*” OR “personal digital assistant*”. The mesh terms included were ‘dementia’, ‘Alzheimer’s disease’, ‘caregivers’, ‘spouses’, ‘family’, ‘smartphone’, ‘mobile application’ and ‘computer handheld’. Keyword searches were performed on title, abstract and keywords using Boolean. The reference lists of selected articles were searched further to find any additional relevant articles and none were found.

Inclusion and exclusion criteria

In this integrative review, peer-reviewed, full text, journal articles published in English from 2007 to 2017 and related to mHealth applications for carers of people with dementia were included . Articles were included if they were related to the evaluation of mHealth applications or identify possible barriers and challenges in developing and implementation of mHealth applications. This review excluded editorials, trial registration materials, technical notes and articles that only described the content development process for an application without a clear discussion of the study methodologies. Furthermore, articles discussing interventions that were based on other features of smartphones such as text messaging or tracking systems were excluded.

Search outcomes

The literature search combining the mesh terms, specific terms and keywords found a total of 117 articles including 10 from PubMed, 15 from Medline, 19 from CINAHL Plus with Full Text, 2 from Cochrane Library, 6 from PsycINFO (via Ovid), 25 from Embase and 40 from Scopus. After removing duplicates, 66 titles and abstracts of each information source retrieved were assessed for inclusion and exclusion criteria. Based on the preliminary review of the title and abstract content, 26 sources which did not meet the study inclusion criteria were excluded. Finally, a total of 40 articles were included in the full-text review using the same inclusion criteria. Three authors (SR, CJ and PC) reviewed content for appropriateness for inclusion. Initial average Kappa value showed 0.696 indicating substantial agreement among the three authors (McHugh, 2012). Any discrepancies were discussed, and seven articles which satisfied the inclusion criteria were included in the final analysis (Figure 1).

Figure 1.

Integrative review flowchart: selection of studies.

Data extraction and quality appraisal

Information from all included articles was entered into an Excel data spreadsheet including authors, publication year, country, title, study aims, research methods and key findings. Based on the review questions and literature, two broad categories were identified: evaluation of the efficacy of mHealth applications and barriers and challenges experienced in relation to the development of applications. The quality of the primary sources was evaluated using a method suggested by Whittemore and Knafl (2005). The primary sources were coded according to two criteria relevant for the study: (1) methodological rigour and (2) data relevance (Whittemore & Knafl, 2005). Methodological rigour was assessed based on the Mixed Methods Appraisal Tool-Version 2011 (Pluye et al., 2011) by three authors (SR, WM and CJ). Two studies showed a moderate level of methodological rigour (Brown et al., 2016; Callan et al., 2016) and the others had poor rigour (Cho et al., 2016; Davis, Nies, Shehab, & Shenk, 2014; Davis, Shehab, Shenk, & Nies, 2015; O’Connor, Bouamrane, O’Donnell, & Mair, 2016; Reyes, Camargo, & Díaz, 2016). Data relevance was assessed based on a two-point scale (high or low) (Whittemore & Knafl, 2005). All included articles recorded high information values; therefore, they were included in the review.

Data synthesis

As this integrative review includes both qualitative and quantitative studies, a narrative analysis was conducted as a way to integrate the identified evidence. The data was systematically organised using a data spreadsheet and was then compared and contrasted by two authors (SR and WM) to identify visible patterns and relationships between the studies. This process involved the identification of key evidence centred on three predetermined categories that are based on the review questions and literature; such as ‘carer support’, ‘evaluation strategies’ and ‘barriers and challenges’. Sub-categories were generated based on the evidence identified under the major categories (see Table 1).

Table 1.

Categories and sub-categories.

Categories	Sub-categories
Carer support	Carer education
	Monitoring
	Cognitive training
Evaluation strategies	Feasibility testing
Evaluation strategies	Outcome assessment
Barriers and challenges	Technology barriers
	Literacy barriers
	Time barriers

Results

Study characteristics

Of the seven included articles, the earliest published paper was in 2014. A summary of the selected articles is presented (see Table 2). Two papers were based on the same study which focused on the design and piloting of a storytelling mHealth application for carers of people with dementia (Davis et al., 2014, 2015). Of the six studies, three were based in the USA and one each in South Korea, United Kingdom and Colombia. The main objectives of the studies were design and testing feasibility of the applications and identifying related barriers and challenges. Of the selected articles, six of the articles discussed both design and evaluation of applications (Brown et al., 2016; Callan et al., 2016; Cho et al., 2016; Davis et al., 2014, 2015; Reyes et al., 2016), and one article identified the possible barriers and challenges with respect to the design of the applications (O’Connor et al., 2016). The studies used either a mixed method approach (Brown et al., 2016; Reyes et al., 2016), quantitative approach (Callan et al., 2016; Cho et al., 2016; Davis et al., 2014, 2015) or qualitative approach (O’Connor et al., 2016). Only two studies used theory in the development of the applications: Family Centred Theory (Brown et al., 2016) and Resiliency Model of Family Stress, Adjustment and Adaptation (Davis et al., 2014). A user-centred approach to design was followed by only two research groups (Brown et al., 2016; Reyes et al., 2016).

Table 2.

Summary of the selected articles and methodological rigour.

Authors, publication year and country	Study aims	Theoretical framework	Research design	Setting and sample	Major findings/barriers and challenges	Methodological rigour (Pluye et al., 2011)
Brown et al. (2016), USA	To evaluate the implementation of a newly developed mHealth application to provide information and support for carers of people with Alzheimer’s disease or other forms of dementia.	Family centred theory and user-centred design.	Mixed method–quasi-experimental feasibility study. Web-based carer survey, the primary care providers’ survey and focus group discussion were conducted.	Community in collaboration with home health care agency. 11 carers of Alzheimer’s disease, six case managers, and five primary care providers participated. Application was used for 11 weeks at home.	Ten out of 11 carers completed the survey. Six carers agreed or somewhat agreed that the application helped with their ability to organize and keep track of care recipients’ health information. Five carers agreed or somewhat agreed that the application helped them to understand their choices and make better decisions about the health of care recipients. Five carers agreed that the application helped them feel more confident as they can figure out solutions when new situations or problems arise. Carers were satisfied or somewhat satisfied with the following sections of the application: carers corner (n = 7), alert function (n = 7), assessment of behavioural and mood disturbances function (n = 7), and information about available services (n = 7). Carers reported the application was great (n = 6), easy to use (n = 7), and the tasks were straightforward (n = 7). Barriers and challenges Having time to use application with busy schedules, poor technical orientation among older adults, poor computer skills, fear of technology and lack of skills in using application.	Moderate
Callan et al. (2016), USA	To test the feasibility of administering a handheld computer-based self-administered cognitive training application (Adaptive Paced Visual Serial Attention Task) with minimal clinician intervention for spousal carers of people with dementia.	None reported.	Randomized control trial. Feasibility testing as a part of the trial. The application was used at least three times per week for 4 weeks from week 4 to week 8. Feasibility was measured by frequency of and performance in using application. Additionally, level of worry, subjective stress, depression, anxiety, intrusive thoughts, and rumination, and sleep quality were assessed.	The primary carers of a spouse with dementia from the community were recruited through the Memory Disorders Clinic. 60 participants were recruited and randomised (i.e. 30 in intervention group and 30 in control group). For feasibility testing a subset of 27 people participated from the intervention group.	In the feasibility study, the minimum and maximum use of the application was 4 and 113 times. 22 participants used it for at least 3 weeks (81.48%), and 15 participants used it for at least 4 weeks (55.56%), demonstrating there was considerable regularity of use. Study results showed self-directed cognitive training was feasible through the application for spousal carers. Based on the results of the randomized control trial, use of the handheld computer was not adversely associated with stress, worry and sleep quality. Use of the application (tasks performance) increased from the beginning to the end of the intervention. Barriers and challenges Use of technology is a barrier to many older adults due to wide individual differences in age-related decline in cognitive abilities.	Moderate
Cho et al. (2016), South Korea	To test the validity and usability of a health care application on wearable and mobile devices for carers of people with dementia and to evaluate its usefulness.	None reported.	Quantitative approach. A survey was conducted to assess overall usefulness and satisfaction with the application.	Setting not reported. 17 experienced users participated in a survey following use of the application.	The application focused on dementia testing, reviewing dementia test history, and searching location of public health centres in the vicinity. None of the participants had tried a dementia screening test service previously. The majority of the participants indicated the application was easy to use. Dementia screening is more convenient through mobile application than the traditional pen-and- paper type. Barriers and challenges The small font size on the smart watch and difficulties with understanding the questions.	Weak
Davis et al. (2014), USA	Developed a Story-Call smartphone application which allows participants to watch, record, and rate stories of success with caring challenges including personalised story telling support, dementia care information, and community resources.	Resiliency Model of Family Stress, Adjustment and Adaptation.	Quantitative approach-pilot testing using pre-test post-test design. Outcome measures were perceived burden using Zarit Short Burden Screen, and willingness to seek social support using Kaye's Gain through Group Involvement Scale.	Five female carers who are caring for community dwelling people with dementia participated.	Four participants completed the intervention. All participants stated that using the story call application would enable them to handle stress and family relationships more effectively and to find community health care resources. High positive responses on the Kaye’s Scale. Learning to access and use the application seemed easy. Recommendations made under five areas: evaluation, recruitment, recruitment materials, augmentation of application and outreach enhancement. Barriers and challenges None reported.	Weak
Davis et al. (2015), USA	To pilot how well carers would be able to use minimal instructions to access the storytelling application prototype and successfully record stories of their successes with dementia-care challenges.	None reported.	Quantitative approach Pilot testing with pre-test post-tests design Outcome measures were perceived burden using Zarit Short Burden Screen, and Willingness to seek social support using Kaye’s Gain through Group involvement scale.	Two-week pilot assessment in the community with five carers of community dwelling older people to investigate the use of minimal instruction to access application prototype and successfully record stories.	Four participants completed the intervention. Developed an interactive mobile application that records, archives and presents video by carers who share success stories about how they handle common dementia home care situations. The minimal directions enabled four of the five participants to easily access the mobile application, to record carers success stories, and to view others’ stories. A desire for greater anonymity and security was voiced by all five. One participant withdrew, citing nervousness about being photographed as potentially leading to availability of personal identification. Post-tests identified high satisfaction with the application and ease of use, and suggest that measuring outcomes for carer burden across a larger group will be feasible. Barriers and challenges None outlined.	Weak
Reyes et al. (2016), Columbia	To develop a mobile application for helping carers in non-pharmacological therapies to use with people with early and moderate Alzheimer’s disease and to test its usability.	Theoretical framework – none reported. User centred design was used in designing the application.	Quantitative approach. To validate the proposed system, task completion with thinking aloud technique and questionnaire survey were used.	This study focused on people with Alzheimer’s disease and their carers living in the community. Five carers evaluated the mobile application.	Application facilitates therapists and carers to track non-pharmacological therapies and provide carers with a tool to control patient daily activities and, at the same time, to allow patients to perform cognitive exercises with the assistance of carers. It consists of a Reminiscence Therapy module, Reality Orientation Therapy Module, Psycho-Social Therapy Module and Cognitive Rehabilitation Therapy Module. Four participants completed the tasks correctly. One participant stated unclear instructions which were not descriptive enough in task completion. The following problems were reported by the participants: no direct access to the menu in ‘my exercise’ module; and the application does not have a return option in ‘my calendar’ module. Related to the terminology used in modules, average rating was 4.825 with best rating in ‘my memories’ module and worst rating in ‘my calendar’ module. All participants indicated the feasibility of the application for supporting therapeutic activities in people with Alzheimer’s disease. Barriers and challenges Difficulty with some of the tasks, mostly on the location and absence of signage due to inability to use the table computer.	Weak
O’Connor et al. (2016), UK	To explore the barriers experienced by participants during the co-design of the ‘My House of Memories app’ which focus on sharing memories together for people with dementia and their carers.	None reported.	Qualitative exploratory case study design.	An in-depth focus group interview (n = 10) and individual interviews (n = 6) with people involved in the co-design of the ‘My House of Memories’ application including four dementia patient-carer dyads were conducted.	Barriers and challenges Lack of digital literacy knowledge and skills among people with dementia and their carers were the main factors that affected co-design of the application. Becoming familiar with the tablet computer and negative attitudes toward technology. Difficulty understanding technical language by software development team.	Weak

Category 1: Carer support

The first category “Carer support” covers the main foci areas in the mHealth application studies. The following three sub-categories were identified: carer education, monitoring and cognitive training.

Carer education

In the selected studies, the mHealth applications focused on providing education for the carers of people with dementia. In three studies, education was one of the main objectives for the development of the mHealth applications (Brown et al., 2016; Cho et al., 2016; Davis et al., 2014, 2015). Brown et al. (2016) focused on improving knowledge in relation to caring for people with dementia and carer wellness through an mHealth application while Cho et al. (2016) focused on the status of the severity level of the problem and performing dementia screening tests to detect cognitive deterioration of the care recipients. In another study, learning from successful stories of the provision of care by carers through a storytelling application was used as an education intervention to improve knowledge and skills of carers (Davis et al., 2014, 2015). This study reported that the application enabled the participants to handle stress and family relationships more effectively. Additionally, mHealth applications provided links to websites and contact information for local, state and national caring resources and services as other important features (Brown et al., 2016; Cho et al., 2016).

Monitoring

The main support interventions used in applications were the provision of psychological and emotional support for carers. The mHealth applications provided opportunities for monitoring carers’ burden and depression (Brown et al., 2016). The carer supportive mHealth application by Brown et al. (2016) featured a carer alert function to notify case managers to call or email the carer for non-urgent matters.

In addition, mHealth applications have featured monitoring of care recipients to assist carers. Maintaining care recipients’ medication; observations related to memory and behavioural disturbances; as well as sharing of records with care professionals were featured in the mHealth application developed by Brown et al. (2016) for carers of people with dementia. Reyes et al. (2016) developed an mHealth application which focused on the development of a system for supporting non-pharmacological interventions including reminiscence therapy, reality orientation therapy, psycho-social therapy and cognitive rehabilitation therapy. In this application, carers can track non-pharmacological therapies and use these to manage a patient’s daily activities while patients can perform cognitive exercises with the assistance of carers.

Cognitive training

One mHealth application development study focused on testing the feasibility of handheld computer-based self-administered cognitive training, called Adaptive Paced Visual Serial Attention Task, with minimal clinician intervention for spousal carers to manage their distress and improving coping. Self-directed cognitive training was found to be useful for spousal carers in problem-solving, coping and adaptation, planning and persevering with goal-directed tasks (Callan et al., 2016).

Category 2: Evaluation strategies

The second category “Evaluation strategies” incorporates the evaluation strategies involved in design and implementation of the mHealth applications. In the process of mHealth application development, studies have focused on testing feasibility and assessing effectiveness based on outcomes.

Feasibility testing

The mHealth application studies involving the development of applications consistently reported positive outcomes in feasibility testing. Three of the application development studies focused on the feasibility of the applications (Brown et al., 2016; Callan et al., 2016; Reyes et al., 2016). In feasibility testing, the study period varied from 4 to 11 weeks. The main outcomes used in these studies were usability and user satisfaction, and the studies highlighted that users were satisfied and interventions were feasible. In a study by Brown et al. (2016), 11 carers of people with Alzheimer’s disease participated, and usability tasks were performed with potential users before starting the feasibility study. The researchers assessed usability tasks, utility of the application, the level of user satisfaction, the importance of the application, navigation and task completion. Participants perceived that the application was good, easy to use and tasks were straightforward. Callan et al. (2016) studied the feasibility of a self-administered cognitive training application among 27 carers as a part of a randomized control trial. User adherence was assessed through the regularity of use of the application. They found that the handheld computer-based application was feasible for cognitive training for spousal carers of people with dementia, and the usage of the application was not adversely affected by stress, worry or poor sleep quality. Reyes et al. (2016) used the think-aloud technique with task completion and a questionnaire that focused on terminology, graphical content and usefulness of the mHealth application. In this feasibility study, five carers participated. The study group found that the application was feasible in supporting therapeutic activities in care recipients.

Outcome assessment

There were no mHealth application studies evaluating education-related outcomes arising from the use of mHealth applications by carers of people with dementia. Three articles focused on the evaluation of carer related outcomes and reported positive results in relation to use of mHealth applications in carers’ activities (Callan et al., 2016; Davis et al., 2014, 2015). One randomized control trial study found that the task performance by participants in the cognitive training application increased from the beginning to the end of the intervention period (Callan et al., 2016). One pilot study found that carers had a high willingness to seek social support (Davis et al., 2014, 2015). In addition, they found that the measurement of outcomes for carer burden across a larger group would be feasible through an mHealth application intervention. Additionally, Cho et al. (2016) surveyed overall usefulness of the educational and supportive application among experienced users and found that the application was easy to use.

Category 3: Barriers and challenges

The third category “barriers and challenges” outlines the barriers and challenges in relation to development and implementation of the mHealth applications. The articles presented different barriers, and the following three sub-categories emerged: technology barriers, literacy barriers and time barriers.

Technology barriers

Four studies highlighted carers’ lack of experience and skills in using an mHealth application was a major barrier to its use (Brown et al., 2016; Callan et al., 2016; O’Connor et al., 2016; Reyes et al., 2016). Callan et al. (2016) postulated that use of technology was frequently presented as a barrier for many older adults due to their age-related cognitive decline. O’Connor et al. (2016) found that carers faced problems with becoming familiar with tablet computers and inaccurate perceptions of how carers use mobile technology. They further reported that negative attitudes towards technology were other important factors which limited carers’ participation in the design of the mHealth application. Brown et al. (2016) found that poor technical orientation and fear of technology among carers influenced the development and implementation of the applications. Reyes et al. (2016) identified that carers experienced difficulty with task completion, mainly in relation to the location, and absence of signage, which was attributed to poor skills in the use of tablet computers.

Literacy barriers

The main literacy barriers include the lack of digital literacy knowledge and skills (O’Connor et al., 2016). Small fonts used, for example, on a smartwatch and questions that were difficult to understand added to the literacy barriers (Cho et al., 2016). In addition, Reyes et al. (2016) reported that one participant out of five stated that unclear instructions which were not descriptive enough for task completion affected correct completion of the tasks in the application. Additionally, one study found that software engineers faced difficulties in grasping the technical language in designing an mHealth application (O’Connor et al., 2016).

Time barriers

Two studies identified time as a barrier for engaging with mHealth applications. Brown et al. (2016) found that lack of time was one of the major barriers to accessing and using the application. This was mainly attributed to busy schedules and difficulties in using technology as a part of their daily routine. Callan et al. (2016) also found negative views towards applications based on the time factor. They highlighted that carers initially viewed the mHealth application as a burden – just ‘one more thing to do.’

Discussion

The aim of this integrative review was to identify, appraise and synthesise the existing evidence on the use of mHealth applications as an educational and supportive resource for carers of people with dementia. All seven articles included in this integrative review contained clear descriptions of the evaluation process of mHealth applications for carers of people with dementia or identified possible barriers and challenges to the development and implementation of the applications. Three out of the six studies were from the USA and the oldest study was undertaken in 2014 indicating mHealth applications are relatively new and not a widely used intervention to educate and support carers of people with dementia. Although articles were appraised as having a high information value, their methodological rigour was poor or moderate and was a limitation of the studies. The use of theory in the process of intervention development is crucial to increase the effectiveness of interventions (Craig et al., 2008) but only two studies reported the theoretical basis for the development of the applications. Furthermore, few studies have used a user-centred design in the development of applications. User input and feedback in a systematic manner can facilitate the development of effective user interfaces (Buller et al., 2013). This situation raises the need for rigorously designed studies with a clear theoretical framework that adopt a user-centred approach in the development of mHealth applications for carers of people with dementia.

This review resulted in three major categories and their attendant sub-categories which may help in the planning of new mHealth applications and interventions for carers of people with dementia. The articles demonstrated that the mHealth applications were used for a wide variety of educational purposes, for example, improving knowledge in relation to caring of people with dementia, carer wellness, the severity level of the problem and performing dementia screening tests to detect cognitive deterioration. Although there is literature evidence that mHealth applications can be used for skill training (Gajecki et al., 2017; Srither & Lateef, 2016), in this review, there was no focus on skill training through mHealth applications for carers. A recent systematic review found that mHealth applications play a very important role in health education (Mosa et al., 2012). But, in this review, the efficacy of educational applications was not evaluated or aligned with educational outcomes and was a limitation of those studies. In addition, this review reported that mHealth applications were used for different purposes by carers of people with dementia. Some examples include monitoring of the psychological status of carers, monitoring of care recipients and cognitive training for spousal carers.

The second category ‘Evaluation strategies’ focused on different evaluative procedures involved in designing and implementation of the mHealth applications. The studies mainly focused on testing feasibility rather than an evaluation of the effectiveness of the mHealth applications. This is a major limitation of the studies. As mHealth application interventions are relatively new interventions, assessing effectiveness is essential to validate the mHealth applications for carers. These studies consistently reported positive results for testing usability and user satisfaction suggesting the mHealth applications were a feasible intervention for family carers of people with dementia. However, this review reveals a lack of high-quality research methodologies such as randomized control trials to evaluate the efficacy of mHealth applications. Making conclusions relevant to the outcomes of mHelath applications is difficult due to the limited assessment of outcomes. The inadequacy of the evaluative studies may be attributed to mHealth applications being a comparatively new intervention for modern health care and in particular for carers of people with dementia. This conclusion is supported by recent systematic reviews on modern technological interventions such as computer and Internet-based interventions for carers of people with dementia (Boots, Vugt, Knippenberg, Kempen, & Verhey, 2014; Godwin, Mills, Anderson, & Kunik, 2013; McKechnie, Barker, & Stott, 2014).

The third category ‘barriers and challenges’ examined the obstacles, barriers and challenges faced in designing and implementation of the mHealth applications for family carers of people with dementia. These studies mainly focused on identifying the barriers related to the usability of applications. There was a lack of information that identified any challenges related to implementation, for example, system integration and network access (Gurupur & Wan, 2017). There is a need to address usability barriers in the design of mHealth applications. Problems with readability, small font size and the lack of digital literacy were some of the problems perceived by carers. People with low health literacy face challenges to understand and act on health information when the mHealth applications are poorly designed (Broderick et al., 2014). It has been argued by Boulos, Brewer, Karimkhani, Buller, and Dellavalle (2014) that application designers and developers pay little attention to user’s general, digital and health literacy level. Consequently, the health literacy skills and abilities of the users need to be considered in the development of effective applications (Broderick et al., 2014; Monkman & Kushniruk, 2013). The principles of universal design for learning provide a response to technology barriers via the adoption of multiple and flexible presentations; enabling practice of tasks with different support; as well as the provision of interesting and varied learning opportunities that stimulate learning (Dalton, 2017). In addition, keeping the user interface simple and selecting appropriate font type and size are important when designing a user-friendly interface for applications (Gurupur & Wan, 2017). Moreover, time limitation was another barrier reported in the use of mHealth applications even though there is literature evidence that mHealth applications can be easily accessible online (Handel, 2011) and can provide real-time, demand-driven communication (Boulos et al., 2014). Barriers to time limitations may be overcome as the learner sees the value and can use mHealth applications for information at any feasible time.

Limitations

In this review, only publications published in English from seven databases were included which may not take account of studies published in other languages. Grey literature was not considered.

Conclusions

To date, mHealth applications are mainly used to improve the knowledge of carers of people with dementia, to monitor the health status of carers and any problems related to their care recipients, as well as cognitive training for spousal carers. However, the use of mHealth applications in education and support for carers of people with dementia is in an early stage of development. The main impediments related to the development and implementation of mHealth applications for carers of people with dementia are literacy and technology barriers, as well as time constraints. In spite of the difficulties reported of poor methodological studies to evaluate the effectiveness of mHealth applications for carers, the mHealth applications appeared to be a feasible intervention for carers of people with dementia. In particular, they will be useful if the barriers and challenges related to the development and implementation of mHealth applications for carers such as literacy barriers and technology barriers in the use of applications are addressed in any future developments. Further research is needed with not only a stronger methodological rigour but the adoption of a user-centred approach in the development of mHealth applications as an educational and supportive resource for carers of people with dementia.

Footnotes

Authors’ Contributions

Conception and design: SR. Acquisition of data, analysis, and interpretation of data: SR, WM, CJ and PC. Manuscript preparation and the first draft of the manuscript: SR. Critical review and editing of the manuscript: WM, CJ and PC. All authors have read and approved the final manuscript.

Acknowledgements

The authors would like to thank the health librarian, Griffith University, Nathan Campus for support with the literature search.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted as a part of the first author’s PhD study. His studies were supported by a Griffith University International Post Graduate Research Scholarship and Griffith University Post Graduate Research Scholarship.

Sarath Rathnayake is a PhD candidate at the School of Nursing and Midwifery, Griffith University. He is also a lecturer at Department of Nursing, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka. He is currently working on the development of an mHealth application for family carers of people with dementia to address needs related management of functional disability of their care recipients. His research interests are older people, disability, dementia care, health literacy and nursing education.

Wendy Moyle is a program director in the Menzies Health Institute Queensland and professor in the School of Nursing and Midwifery at Griffith University. Her research expertise is in ageing and innovative therapies and in particular in the areas of dementia, depression and delirium. She works with national and international teams to develop and evaluate assistive technologies and social robots.

Cindy Jones is a lecturer in the School of Nursing and Midwifery and a researcher in the Menzies Health Institute Queensland at Griffith University. She has expertise in biostatistics, and her research is focused on relationships and expressions of sexuality in aged care; assessment of engagement in people with dementia; and intervention research to improve quality of and evidence for dementia care.

Pauline Calleja is the director of Post Graduate Nursing Programs in the School of Nursing and Midwifery. Dr. Calleja’s research focuses include clinical teaching and learning, emergency and trauma care, rural and remote practice and clinical practice change specifically focused on information transfer, handover and documentation, and transition to practice.

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