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APP REVIEWS

Changing Behaviour (Part Two)

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Dr. Andrew Chou
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According to the World Health Organization (WHO), “Health promotion is the process of enabling people to increase control over, and to improve, their health.” Part of this process involves access to credible medical information, but determining what is or is not credible is not straightforward. Part of this process involves access to credible medical information, but determining what is or is not credible is not straightforward. In one British study, researchers simulated patients searching for answers to five common pediatric questions from UK-based sites. The authors found that only 39 per cent of the 500 sites they searched provided correct information [2]. Despite this, web-based resources and digital apps can still be an important asset in health promotion.

Being able to direct patients to reliable apps can also facilitate clinical encounters. Often in clinic, I rely mostly on spoken medical advice with occasional printed handouts. Yet, spoken medical advice is not as easily or accurately remembered as written information [3]. As we move towards using our smartphones for on-the-go information, apps may eventually be used to supplement advice we give during our clinical encounters. Yet, one of the issues at the moment is finding information that is both credible and relevant to Canadians. Fortunately, there is an increasing number of locally developed apps designed to provide Canadians with reliable medical information.

Apps Reviewed

CANImmunize
4 stars4 stars4 stars4 stars4 stars
Prevention in Hand
3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

Prevention in Hand

3.5 stars3.5 stars3.5 stars3.5 stars3.5 stars

Prevention in Hand is a content aggregator that is designed to help both patients and health care providers access credible Canadian information pertaining to health promotion and chronic medical conditions. The app was developed in partnership between the College of Family Physicians of Canada (CFPC) and the Public Health Agency of Canada (PHAC) with the input of health care professionals. The app itself is easy to navigate and reliable. Links to external resources are categorized according to topic. However, all of the featured links open in an external web browsing app, making the process of reading multiple articles quite cumbersome. Furthermore, the app would benefit from having brief descriptors underneath each link to help users identify relevant resources more easily. Overall, Prevention in Hand is a useful resource for helping patients find credible Canadian medical content.

Detailed Review View All

Features

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The app is a content aggregator that aims to provide access to reliable information pertaining to a variety of common medical conditions as well as general health promotion. Upon starting the app, users can choose to access information targeting either patients or health care providers. The information is then further categorized into topics, such as kidney disease and diabetes. Each topic includes a brief description and a list of links to external resources, including websites, PDFs and videos. For health care providers, the content is geared towards guidelines and patient care. For patients, the information is more basic. A search tool is also included to help users quickly find articles. Unfortunately, the app currently lacks any built-in tools for sharing or saving/favouriting articles

Effectiveness

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The app was developed in partnership between CFPC and PHAC. It was created with the input of physicians and the resources linked from the app are credible sources, including government websites, medical societies and non-profit organizations. Furthermore, the app explicitly tries to avoid including resources with commercial interests. However, given the broad range of topics covered, some content is sparse. For instance, the provider-oriented section on pregnancy contains only a single link on pre-natal nutrition.

Usability

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The app is easy to use and features a clean blue-white colour scheme. Icons are used to help users quickly identify topics. While the interface is well done, one issue that hinders the usability of the app is the fact that external links open up in a separate web browsing app. This requires users to go back to the app to select a different article each time, leading to a cumbersome back-and-forth process if users seek to read multiple articles. Furthermore, the app would benefit from adding a brief description underneath each linked resource to help users find relevant resources more quickly. The app also suffered at least one instance of an included article being behind a paywall.

Privacy & Security

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The app does not require any registration and does not collect any personal health or identifiable information. This is outlined in a privacy statement within the app. Information, such as IP addresses and access times are used to improve app functionality.

Reliability

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The app works well and reliably, and did not crash during my use of it. However, it does suffer from mild “linkrot”, as some of the externally linked content has moved or is no longer available. Nevertheless, the majority of content is still accessible. The software was last updated in November 2015, although the actual content within the app has been updated more recently. There is a contact form for feedback within the app indicating a two-day turnaround time for a response.

Accessibility

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The app is free and available for both Apple and Android devices. The app is available in both English and French and does not require any in-app purchases to access its content. Most of the external links that were visited through the app did not require any registration or payment.

CANImmunize

4 stars4 stars4 stars4 stars4 stars

CANImmunize is a feature-rich vaccination app developed with Canadian physicians and funded by the Government of Canada. It is designed as a digital alternative to traditional paper immunization records. It allows users to track vaccines that have either been previously administered or are due according to the vaccine schedule within their province or territory. The app also provides educational content to help users learn more about vaccines and vaccine safety. The app is well designed, fairly easy to use and provides accurate information. However, a few bugs did appear that are described in more detail in the review below. Overall, CANImmunize has a lot of potential and could foreseeably be used to replace paper records in the future.

Detailed Review View All

Features

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CANImmunize is an app designed as a digital alternative to traditional paper immunization records. Users can create profiles for themselves or family members to track both vaccines that have been administered or are overdue according to the schedule for their province or territory. However, it does not take into account situations where an individual may need to deviate from the standard schedule. Options to add additional vaccines, such as those for travel, are included as well. In addition to tracking vaccines, the app has an educational component; users can learn about vaccines in the context of traveling, pregnancy, and pain management. The app also has a section for children – featuring videos, games, and comics – and an “Outbreaks Map” that allows users to search for nearby disease outbreaks according to geographic location. Finally, users may also export and/or print their records. In fact, the app currently features a pilot project that allows residents in Ottawa to push their child’s vaccine records to Ottawa Public Health, which may signal the future direction of this app.

Effectiveness

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The app is an effective tool for helping individuals track immunizations that are in line with the provincial or territorial vaccination schedule. While there are no specific references listed for some of the educational components of the app, its contents are consistent with information from government organizations such as the National Advisory Committee on Immunization (NACI).

CANImmunize was developed with physician input by researchers from the Ottawa Hospital with support by the Children’s Hospital of Eastern Ontario (CHEO) and the Better Outcomes Registry & Network (BORN). Funding was provided by the Government of Canada.

Unfortunately, there are no peer-reviewed studies assessing the app’s effectiveness.

Usability

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Despite being dense in features, the app is fairly easy to use, although I had to rely on the help menu a number of times in order to, for example, learn how to turn off notifications.

While the substantive information was often correct, the app’s ability to proactively offer accurate vaccine advice to patients broke down somewhat under closer scrutiny. To test this, I created a hypothetical adult patient in Ontario who was starting immunizations for the first time. Upon doing this, the app correctly informed me that the oral rotavirus vaccine was no longer needed, but still advised me that I was overdue for the pneumococcal conjugate 13-valent vaccine. Contradictorily, within the description of that vaccine, it correctly indicated that adults do not need it except under certain circumstances. I then moved this hypothetical adult to Nova Scotia, where despite having received two doses of the MMR vaccine, it recommended three additional doses of the MMRV vaccine. There was also no way to indicate that my hypothetical patient has had prior exposure to varicella, thus obviating the need for that vaccine. Finally, when I reported that this individual received a vaccine for HPV, it incorrectly recommended a booster in three months’ time, rather than two. These types of issues obviously make fully relying on the app’s proactive vaccine advice problematic.

As of this writing, immunization records can be backed up to iCloud or Google Drive. However, transferring records between Android and Apple devices is not currently possible. This will be remedied with a future planned update.

Finally, I found the password protection to be tedious. There is no way to remain logged in to the app, meaning every time you leave it – say, to send a text message – you will have to re-enter your password. Furthermore, if you forget your password, you will need to send in an e-mail to reset it.

Privacy & Security

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There is a privacy and security statement within the app. Information is stored locally unless users choose to sync their information with iCloud or Google Drive for backup. As per the CANImmunize privacy policy on its website, the app complies with Ontario’s Personal Health Information Protection Act, 2004. The app also allows users to create their own password within the app to prevent unintended access to personal health information.

Reliability

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The app works well and reliably and did not crash. The app was last updated on June 6, 2017; plans for future updates are listed on its website. The app itself allows user feedback and bug reports. Also reassuring is the fact that the app developers respond to online reviews in the Google Play Store. There seems to be a clear intention to keep developing and improving this app in the future.

Accessibility

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The app is free and available for both Apple and Android devices. It is available in both English and French and does not require any in-app purchases to access its content. It can be used by Canadians in any province and territory.

Patient Experiences

Way back in 2013, when there were only 40,000 health-related apps compared to the current count of more than 165,000, BJ Fogg, PhD, expressed concern that behaviour change apps didn’t often work.

According to the June 27, 2013 Medscape , Fogg says it isn’t technology that’s holding back the design of apps that could help patients – particularly those with chronic conditions – adopt healthy behaviours. “The capability is here. Evidence-based data on how behaviour change works is also here. What’s needed”, he says, “is for the possessors of these two disparate fields of knowledge – software engineers and cognitive scientists, whose paths don’t normally cross – to seek each other out and collaborate.”

Fogg, director of the Stanford University Persuasive Technology Lab, went on to say “The real key to changing behaviour, not just in healthcare but in any consumer experience, is to help people do what they already want to do. That’s motivation. There’s no way you can browbeat someone to do something they don’t want to do. …. To help them to do what they want to do, you have to make it really easy to do that thing. That’s ability. And then you need a trigger, a reminder, to prompt behaviour. That’s the overall recipe. If you don’t have any one of those things — motivation, ability, and trigger – I guarantee the app will fail. You have to do them all.”

This edition of Practical Apps – like the previous edition – brings family physicians and patients apps that have been developed within or in partnership with Canadian healthcare organizations. These reviews look at all-Canadian efforts to harness technology to promote healthy behaviours with the added benefit of having been developed with clinical oversight and evaluation.

References

  1. Health promotion. Health Topics 2017 [cited 2017 Aug 12]; Available from: http://www.who.int/topics/health_promotion/en/.
  2. Scullard, P., C. Peacock, and P. Davies, Googling children’s health: reliability of medical advice on the internet. Archives of Disease in Childhood, 2010. 95(8): p. 580-582.
  3. Kessels, R.P.C., Patients’ memory for medical information. Journal of the Royal Society of Medicine, 2003. 96(5): p. 219-222.
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