Cynthia Hallensleben

Background/Objectives: Nursing informatics (NI) competence is becoming increasingly essential for nursing students; however, previous research has largely relied on quantitative surveys and provided limited insights into why positive attitudes may not be accompanied by practical competence. This study examined Chinese undergraduate nursing students’ self-assessed NI competence and qualitatively explored their conceptual understanding, perceptions, and experiences related to NI and digital health. Methods: A convergent parallel mixed-methods design was employed in Guangzhou, China. Quantitative data were collected from 149 undergraduate nursing students across two nursing schools using the Chinese Self-Assessment of Nursing Informatics Competencies Scale (SANICS), whereas qualitative data were gathered from 23 students at one of the participating schools through six semi-structured focus groups. Quantitative data were analyzed using descriptive statistics and exploratory Spearman correlations, while qualitative data were analyzed thematically. Findings from both strands were integrated during interpretation using a joint display matrix. Results: The mean self-assessed NI competence score was 2.78 ± 0.54 (scale 1–5). Among the five SANICS subscales, attitudes toward NI scored highest (4.16 ± 0.76), whereas applied computer skills scored lowest (2.02 ± 0.80), confirming an attitude-competence paradox. Exploratory correlation analyses showed neither year of study nor clinical exposure was significantly associated with the total competence score, although both were negatively associated with attitudes. Three qualitative themes contextualized this paradox: (1) a fragmented conceptual understanding centered primarily on basic functions and tools; (2) positive but cautious perceptions that recognized the value of NI while expressing concerns about humanistic care; and (3) passive skill acquisition, limited hands-on learning, and insufficient awareness of higher-order informatics roles. Conclusions: In this two-school sample, students valued NI but reported limited applied and clinically situated competence. The findings suggest that curricula should move beyond generic computer courses and unstructured exposure toward practice-embedded NI education, including electronic health record simulation, digital documentation, data security, and clinically relevant digital skills.

Background: Chronic lung disease (CLD) is one of the most prevalent noncommunicable diseases globally, significantly burdening patients and increasing health care expenditures. Digital health education (DHE) is increasingly important in chronic disease prevention and management. However, DHE characteristics and impacts in CLD are rarely reported. Objective: This study aimed to provide an overview of the existing literature on DHE for CLD, with a focus on exploring the DHE mediums, content, mechanisms, and reported outcomes in patients with CLD. Methods: We searched PubMed, Web of Science, Embase, PsycINFO, and The Cochrane Library with the assistance of a librarian specialist. Articles were screened by the reviewer team with ASReview (Utrecht University) and EndNote X9 (Clarivate Analytics) based on predefined inclusion and exclusion criteria and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Quality assessment was conducted with the Critical Appraisal Skills Program tool. A descriptive analysis was used to summarize the study characteristics, DHE characteristics, and outcomes. Results: A total of 22 studies were included in this review with medium or high quality. They were published between 2000 and 2022, showing an increasing publication trend with the year, mostly in developed countries (16/22, 73%). Websites and mobile apps (10/22, 45%) were the most widely used DHE medium. Education on self-management skills of CLD was the primary topic (21/22, 95%), 4/22 (18%) of which mentioned DHE mechanisms. The majority of studies reported positive changes in CLD awareness (14/16, 88%), clinical outcomes (3/6, 50%), DHE feasibility, acceptability, and satisfaction (6/8, 75%), lifestyle outcomes (3/3, 100%), and psychosocial outcomes (7/8, 88%). Only 2 studies reported cost-effectiveness (2/22, 9%). Conclusions: Despite the heterogeneity of the study situation, some aspects can be concluded. DHE can improve disease awareness and clinical outcomes in patients with chronic lung disease, with good feasibility, acceptability, and satisfaction through different mediums and learning content. There is still relatively little research among people in low- and middle-income countries. Future research should consider the impact on cost-effectiveness, duration, frequency, and theoretical mechanisms of the DHE to maximize the potential impact. It should also be conducted in the context of health services research to better reflect the real world.

Background: Approximately 262 million people worldwide are affected by asthma, and the overuse of reliever medication—specifically, short-acting beta2-agonist (SABA) overuse—is common. This can lead to adverse health effects. A smartphone app, the Asthma app, was developed via a participatory design to help patients gain more insight into their SABA use through monitoring and psychoeducation. Objective: This pilot study aims to evaluate the feasibility and usability of the app. The preliminary effects of using the app after 3 months on decreasing asthma symptoms and improving quality of life were examined. Methods: A mixed methods study design was used. Quantitative data were collected using the app. Asthma symptoms (measured using the Control of Allergic Rhinitis and Asthma Test) and the triggers of these symptoms were collected weekly. Quality of life (36-Item Short-Form Health Survey) was assessed at baseline and after 3, 6, and 12 months. User experience (System Usability Scale) was measured at all time points, except for baseline. Furthermore, objective user data were collected, and qualitative interviews, focusing on feasibility and usability, were organized. The interview protocol was based on the Unified Theory of Acceptance and Use of Technology framework. Qualitative data were analyzed using the Framework Method. Results: The baseline questionnaire was completed by 373 participants. The majority were female (309/373, 82.8%), with a mean age of 46 (SD 15) years, and used, on average, 10 SABA inhalations per week. App usability was rated as good: 82.3 (SD 13.2; N=44) at 3 months. The Control of Allergic Rhinitis and Asthma Test score significantly improved at 3 months (18.5) compared with baseline (14.8; β=.189; SE 0.048; P<.001); however, the obtained score still indicated uncontrolled asthma. At 3 months, there was no significant difference in the quality of life. Owing to the high dropout rate, insufficient data were collected at 6 and 12 months and were, therefore, not further examined. User data showed that 335 users opened the app (250/335, 74.6%, were returning visitors), with an average session time of 1 minute, and SABA registration was most often used (7506/13,081, 57.38%). Qualitative data (from a total of 4 participants; n=2, 50% female) showed that the participants found the app acceptable and clear. Three participants stated that gaining insight into asthma and its triggers was helpful. Two participants no longer used the app because they perceived their asthma as controlled and, therefore, did not use SABA often or only used it regularly based on the advice of the pulmonologist. Conclusions: The initial findings regarding the app’s feasibility and usability are encouraging. However, the notable dropout rate underscores the need for a cautious interpretation of the results. Subsequent studies, particularly those focusing on implementation, should explore the potential integration of the app into standard treatment practices.

BACKGROUND Approximately 262 million people worldwide are affected by asthma, and the overuse of reliever medication—specifically, short-acting beta2-agonist (SABA) overuse—is common. This can lead to adverse health effects. A smartphone app, the Asthma app, was developed via a participatory design to help patients gain more insight into their SABA use through monitoring and psychoeducation. OBJECTIVE This pilot study aims to evaluate the feasibility and usability of the app. The preliminary effects of using the app after 3 months on decreasing asthma symptoms and improving quality of life were examined. METHODS A mixed methods study design was used. Quantitative data were collected using the app. Asthma symptoms (measured using the Control of Allergic Rhinitis and Asthma Test) and the triggers of these symptoms were collected weekly. Quality of life (36-Item Short-Form Health Survey) was assessed at baseline and after 3, 6, and 12 months. User experience (System Usability Scale) was measured at all time points, except for baseline. Furthermore, objective user data were collected, and qualitative interviews, focusing on feasibility and usability, were organized. The interview protocol was based on the Unified Theory of Acceptance and Use of Technology framework. Qualitative data were analyzed using the Framework Method. RESULTS The baseline questionnaire was completed by 373 participants. The majority were female (309/373, 82.8%), with a mean age of 46 (SD 15) years, and used, on average, 10 SABA inhalations per week. App usability was rated as good: 82.3 (SD 13.2; N=44) at 3 months. The Control of Allergic Rhinitis and Asthma Test score significantly improved at 3 months (18.5) compared with baseline (14.8; β=.189; SE 0.048; P<.001); however, the obtained score still indicated uncontrolled asthma. At 3 months, there was no significant difference in the quality of life. Owing to the high dropout rate, insufficient data were collected at 6 and 12 months and were, therefore, not further examined. User data showed that 335 users opened the app (250/335, 74.6%, were returning visitors), with an average session time of 1 minute, and SABA registration was most often used (7506/13,081, 57.38%). Qualitative data (from a total of 4 participants; n=2, 50% female) showed that the participants found the app acceptable and clear. Three participants stated that gaining insight into asthma and its triggers was helpful. Two participants no longer used the app because they perceived their asthma as controlled and, therefore, did not use SABA often or only used it regularly based on the advice of the pulmonologist. CONCLUSIONS The initial findings regarding the app’s feasibility and usability are encouraging. However, the notable dropout rate underscores the need for a cautious interpretation of the results. Subsequent studies, particularly those focusing on implementation, should explore the potential integration of the app into standard treatment practices.

BACKGROUND Chronic lung disease (CLD) is one of the most prevalent noncommunicable diseases globally, significantly burdening patients and increasing health care expenditures. Digital health education (DHE) is increasingly important in chronic disease prevention and management. However, DHE characteristics and impacts in CLD are rarely reported. OBJECTIVE This study aimed to provide an overview of the existing literature on DHE for CLD, with a focus on exploring the DHE mediums, content, mechanisms, and reported outcomes in patients with CLD. METHODS We searched PubMed, Web of Science, Embase, PsycINFO, and The Cochrane Library with the assistance of a librarian specialist. Articles were screened by the reviewer team with ASReview (Utrecht University) and EndNote X9 (Clarivate Analytics) based on predefined inclusion and exclusion criteria and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Quality assessment was conducted with the Critical Appraisal Skills Program tool. A descriptive analysis was used to summarize the study characteristics, DHE characteristics, and outcomes. RESULTS A total of 22 studies were included in this review with medium or high quality. They were published between 2000 and 2022, showing an increasing publication trend with the year, mostly in developed countries (16/22, 73%). Websites and mobile apps (10/22, 45%) were the most widely used DHE medium. Education on self-management skills of CLD was the primary topic (21/22, 95%), 4/22 (18%) of which mentioned DHE mechanisms. The majority of studies reported positive changes in CLD awareness (14/16, 88%), clinical outcomes (3/6, 50%), DHE feasibility, acceptability, and satisfaction (6/8, 75%), lifestyle outcomes (3/3, 100%), and psychosocial outcomes (7/8, 88%). Only 2 studies reported cost-effectiveness (2/22, 9%). CONCLUSIONS Despite the heterogeneity of the study situation, some aspects can be concluded. DHE can improve disease awareness and clinical outcomes in patients with chronic lung disease, with good feasibility, acceptability, and satisfaction through different mediums and learning content. There is still relatively little research among people in low- and middle-income countries. Future research should consider the impact on cost-effectiveness, duration, frequency, and theoretical mechanisms of the DHE to maximize the potential impact. It should also be conducted in the context of health services research to better reflect the real world. CLINICALTRIAL

EHealth offers opportunities to improve health and healthcare systems and overcome primary care challenges in low-resource settings (LRS). LRS has been typically associated with low- and middle-income countries (LMIC), but they can be found in high-income countries (HIC) when human, physical or financial resources are constrained. Adopting a concept of LRS that applies to LMIC and HIC can facilitate knowledge interchange between eHealth initiatives while improving healthcare provision for socioeconomically disadvantaged groups across the globe. To outline the contributions and challenges of eHealth in low-resource primary care settings. We adopt a socio-ecological understanding of LRS, making LRS relevant to LMIC and HIC. To assess the potential of eHealth in primary care settings, we discuss four case studies according to the WHO 'building blocks for strengthening healthcare systems'. The case studies illustrate eHealth's potential to improve the provision of healthcare by i) improving the delivery of healthcare (using AI-generated chats); ii) supporting the workforce (using telemedicine platforms); iii) strengthening the healthcare information system (through patient-centred healthcare information systems), and iv) improving system-related elements of healthcare (through a mobile health financing platform). Nevertheless, we found that development and implementation are hindered by user-related, technical, financial, regulatory and evaluation challenges. We formulated six recommendations to help anticipate or overcome these challenges: 1) evaluate eHealth's appropriateness, 2) know the end users, 3) establish evaluation methods, 4) prioritise the human component, 5) profit from collaborations, ensure sustainable financing and local ownership, 6) and contextualise and evaluate the implementation strategies.

Background: The lack of an international standard for assessing and communicating health app quality and the lack of consensus about what makes a high-quality health app negatively affect the uptake of such apps. At the request of the European Commission, the international Standard Development Organizations (SDOs), European Committee for Standardization, International Organization for Standardization, and International Electrotechnical Commission have joined forces to develop a technical specification (TS) for assessing the quality and reliability of health and wellness apps. Objective: This study aimed to create a useful, globally applicable, trustworthy, and usable framework to assess health app quality. Methods: A 2-round Delphi technique with 83 experts from 6 continents (predominantly Europe) participating in one (n=42, 51%) or both (n=41, 49%) rounds was used to achieve consensus on a framework for assessing health app quality. Aims included identifying the maximum 100 requirement questions for the uptake of apps that do or do not qualify as medical devices. The draft assessment framework was built on 26 existing frameworks, the principles of stringent legislation, and input from 20 core experts. A follow-up survey with 28 respondents informed a scoring mechanism for the questions. After subsequent alignment with related standards, the quality assessment framework was tested and fine-tuned with manufacturers of 11 COVID-19 symptom apps. National mirror committees from the 52 countries that participated in the SDO technical committees were invited to comment on 4 working drafts and subsequently vote on the TS. Results: The final quality assessment framework includes 81 questions, 67 (83%) of which impact the scores of 4 overarching quality aspects. After testing with people with low health literacy, these aspects were phrased as “Healthy and safe,” “Easy to use,” “Secure data,” and “Robust build.” The scoring mechanism enables communication of the quality assessment results in a health app quality score and label, alongside a detailed report. Unstructured interviews with stakeholders revealed that evidence and third-party assessment are needed for health app uptake. The manufacturers considered the time needed to complete the assessment and gather evidence (2-4 days) acceptable. Publication of CEN-ISO/TS 82304-2:2021 Health software – Part 2: Health and wellness apps – Quality and reliability was approved in May 2021 in a nearly unanimous vote by 34 national SDOs, including 6 of the 10 most populous countries worldwide. Conclusions: A useful and usable international standard for health app quality assessment was developed. Its quality, approval rate, and early use provide proof of its potential to become the trusted, commonly used global framework. The framework will help manufacturers enhance and efficiently demonstrate the quality of health apps, consumers, and health care professionals to make informed decisions on health apps. It will also help insurers to make reimbursement decisions on health apps.

Self-management interventions (SMIs) may fail if they misalign with the local context. To optimize the implementation of SMIs in Chinese people with chronic lung disease (CLD), the local context was identified in Chinese primary care (PC) and secondary care (SC). A mixed-method study using semi-structured interviews and quantitative surveys was conducted on people with CLD and healthcare professionals (HCPs). The qualitative data was collected until data saturation was reached, and participants were invited to complete the survey after the interview. The qualitative data—analyzed with the framework approach—was triangulated with the quantitative data. A total of 52 participants completed the interviews, and 48 also finished the survey. Four themes were identified; (a) illness perceptions (e.g., patients had poor CLD knowledge and SM, inadequate resources lead to suboptimal disease control in PC); (b) self-management skills (e.g., most patients delayed exacerbation recognition and action, and some were admitted at the crisis point); (c) factors influencing self-management skills (e.g., (in)adequate disease knowledge and medical expenditure affordability); and (d) needs for self-management (e.g., increased disease knowledge, individualized self-management plan, eHealth, (healthcare insurance) policy support). Identified themes were dependent on each other and should be leveraged when implementing SMIs. Ultimately, such SMIs can optimize patient health outcomes.