Smartphone Apps for Health and Wellness

By John Higgins

Smartphone Apps for Health and Wellness helps readers navigate the world of smartphone apps to direct them to those which have had the best medical evidence in obtaining the users’ goal. The book covers the history of apps, how they work, and specific apps to improve health and wellness in order to improve patients outcomes. It discusses several types of apps, including apps for medical care, sleeping, relaxation, nutrition, exercise and weight loss. In addition, sections present the features of a good app to empower readers to make their own decision when evaluating which one to use.

This is a valuable resource for clinicians, physicians, researchers and members of biomedical field who are interested in taking advantage of smartphone apps to improve overall health and wellness of patients.

• Summarizes smartphone apps with the best evidence to improve health and wellness
• Discusses the most important features of an app to help readers evaluate which app is appropriate for their specific needs
• Presents the typical results expected when regularly using an app in order to assist healthcare providers in predicting patient outcomes

• Language: English
• Publisher: Academic Press
• Release date: Jan 6, 2023
• ISBN: 9780323992725

Book preview

Chapter 1

Introduction

John Patrick Higgins¹, ², ³ and Shelby Irwin⁴,    ¹McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States,    ²The Division of Cardiovascular Diseases, Lyndon B. Johnson General Hospital, Houston, TX, United States,    ³Memorial Herman Ironman Sports Medicine Institute, Houston, TX, United States,    ⁴McGovern Medical School, Houston, TX, United States

Abstract

Applications represent a burgeoning field of health and wellness technology that span genres including medical monitoring, sleep, productivity, exercise and diet, education, and much more. As use of mobile applications increases across the population, it is important to understand the types of apps available, the makings of a successful application, and the efficacy and impact of these apps on their userbase. This introductory chapter explores the history of apps and the many subtypes of health and wellness applications, as well as their potential benefits and drawbacks.

Keywords

App; good apps; health and wellness app; medical problem apps; use-case; history of apps; app efficacy; mobile apps

1.1 What is an app?

While ubiquitous in the modern era, the term application, or app for short, only originated in the last several decades. An application is essentially a computer program that can be used on a range of different devices. An application can serve a myriad of purposes: it can be used for practical tasks like scheduling or creating spreadsheets, or more casually for playing games or listening to music. Almost any program that can be created in code can be used as a mobile application, meaning the variety and number of apps is nearly limitless. For example, the Google Play App Store alone currently contains over 2.87 million apps available for download on a variety of Google devices.¹

1.2 Some history

Many consider Nokia’s Snake game to be the original smartphone application, debuting in 1997 on the Nokia 6110 phone. This game was relatively unrivaled in its field as the first application on a mobile device, but app use would balloon exponentially with the creation of the Apple App Store by Steve Jobs in 2008.² As Jobs’ App Store became a central location for users to find and download hundreds—eventually millions—of different apps, application development skyrocketed worldwide. Whether functional or recreational in purpose, applications can connect users across the globe, as anyone with a computer or mobile device has access to these programs. Increased consumer usage resulted in an increase in the number and variety of genres of apps, as well as competition between application developers.

One large factor in the competition between app developers and among applications themselves is the distinction between free versus paid applications. Many developers began releasing separate Premium and Lite versions of their applications, with the Premium version costing money to download and having more features than the free, Lite version. Moreover, applications can offer in-app purchases, meaning that certain add-ons or extra features of apps require paid purchasing, even if the download of the app itself is free. Finally, many applications now include advertisements that run throughout usage, meaning developers can also receive ad revenues on their applications. In 2016 the app industry was estimated to be a $143 billion industry, with apps accounting for 80% of mobile internet access time.³ These many avenues for increased income result in an impressive market for the attention of the consumer, as well as monetary incentive for creating and marketing popular applications.

The application industry is not only lucrative monetarily but also powerful in its reach; individuals across a variety of social and economic classes and age ranges participate in the use of mobile applications to varying degrees.⁴ The accessibility of mobile applications (given a device and an internet connection) unites broad demographic groups, unlike many other products specific to certain subsets of the population. For example, smartphone applications have an audience as young as preschool children—ranging from games for kids to educational apps—and a user population as old as many grandparents.⁵ Given their great number, large market power, and pervasiveness throughout society, mobile applications influence diverse populations and affect their purchasing, interaction with others, lifestyle habits, and much more.

1.3 What defines a good app?

With millions of applications on the market, there are certain factors that allow good apps to stand out. A critical aspect of widespread and long-term application usage is their user-friendliness. Applications with interfaces that are easy to access (allow users to seamlessly navigate the app, find settings and account information, etc.) are likely to be preferred over apps with confusing or challenging design. Further, an esthetically pleasing design can allow apps with similar purposes to stand out from their competitors. Another method for retaining application usage involves sending notifications to users. Applications can configure helpful or interesting notifications to remind users of their progress on the app or send updates to increase time spent on the application. A similar user-engagement tactic involves goals or rewards that celebrate increased app usage, ensuring that individuals remain on an app for as much time as possible. As apps become more popular, the ability for interaction with other users can create a sense of community that enhances the app experience. Some apps target family and friends so users engage with individuals they know personally who have downloaded the same application, whereas another strategy is connection to complete strangers who are also interested in the application’s contents or goal. This sense of comradery or competition among users can be very effective in rating an app as good or better than other similar applications. Finally, it is important for applications to contain few bugs or errors built into application code, as well as easy troubleshooting ability. Users will be less likely to use an app, or even rate an app poorly, should it contain many glitches or significant issues with troubleshooting in-app issues. For health- and wellness-related apps in particular, it seems especially important for applications to be video based, as those with video content received 65% more downloads and 40% more daily active users than those without.⁶ Chapter 4 will expand upon these themes, further exploring how certain apps may stand out in this competitive arena.

1.4 Apps for health and wellness

Having established a basic background of applications and laid the groundwork for Chapter 4’s discussion of factors that determine a good app, we will now focus on the genre of health and wellness apps. As with other app genres, there are countless numbers of health applications, both paid and free versions, available on multiple application stores for download. The following overview will include the main subcategories within health and wellness: applications for medical problems, exercise, weight loss and nutrition, mental health, sleep, education, and scheduling. Covered in more detail in subsequent chapters, this overview introduces central application categories for the reader.

1.5 Medical problem apps

Chapter 5 covers applications meant to address specific medical issues. Specialized for various disorders, these applications provide information and even a sense of community for individuals experiencing the same health problems. Diabetics can use applications like NutriSense connected to blood glucose sensors to track glucose levels throughout the day, and even to control insulin pumps. The application Positive Peers was created as a private social support group for individuals positive for HIV, and the app AIDSinfo serves as a glossary for HIV- and AIDS-related terminology. Apps can be used for smoking cessation (e.g., SmokeFree and EasyQuit), for tracking the symptoms of bipolar disorder (Juli, MoodLog), and for uploading progress pictures of user’s skin for monitoring remotely by dermatologists (Aysa). Evidence for the efficacy and future of remote medical monitoring apps was illustrated in a 2020 Nature study, which reported that a form of artificial intelligence was able to diagnose certain common skin conditions at a level on par with dermatologists and superior to that of primary care physicians and nurse practitioners.⁷ Other more niche applications are designed for specific subgroups, like the app that assists wounded service members in rehabilitating into their home communities through active engagement and communication with social workers and case managers.⁸ The options are endless for medical applications and the accessibility of apps allows for individuals with very specialized medical issues to find support and assistance relatively easily. So ubiquitous are these mobile health applications becoming—now termed mHealth apps—that studies in the United Kingdom have contrasted the efficacy of mHealth apps to general practitioners.⁹ Though general practitioners were uniquely capable of performing procedures, coordinating team-based treatment, and other more personal aspects of medicine, a study showed that mHealth apps have the potential to perform medical history taking, make diagnoses, and manage some long-term disease-specific care.⁹ Other medically focused apps are not centered on a particular illness but instead assist users in tracking health parameters like period tracking. Applications like Clue allow individuals to monitor and predict menstrual cycles, track ovulation periods, and more.

1.6 Exercise, weight-loss, and nutrition apps

A prominent market share of the health and wellness app genre includes applications dedicated to exercise and nutrition. Though there exist apps dedicated to just one of these categories, often apps have the capacity to track both. Exercise apps run the gambit of user levels of experience—there are applications marketed toward those new to exercise or to experienced athletes and workout gurus. The application Couch to 5K is geared specifically for individuals who have no experience with running as a form of exercise; the app coaches these users with guided audio and timed workouts to prepare individuals to complete a 5K run in 3 months. Other applications create exercise plans with built-in adjustment for various levels of difficulty; if a user has tried a workout on an easier level, they can adjust this same workout to a higher level of difficulty with ease. Generally, exercise apps either focus on a workout genre (High-Intensity Interval Training, Cardio, Yoga, Weightlifting, etc.) or provide a variety of mixed workout types within the app. Other subcategories include apps that feature exercises requiring equipment or equipment-free exercises that can be performed anywhere.

Another feature that developed the exercise application market is the ability to pair smartphone applications with data from smart watches. Companies like FitBit and Apple sell smart watches which monitor parameters ranging from heart rate to number of steps per day to hours spent standing up. By linking these statistics to workout apps, users can have a more finely tuned idea of their workout efficacy, extrapolating information like calories burned in a single workout session. Many exercise apps have also leaned heavily on the community aspect of their userbase. Applications that allow users to share workout information with one another encourage competition and support between individuals in the same network. This element can also be combined with smart watch usage. A stellar example of the interplay between applications on various forms of technology is Apple’s smart watch and the iPhone Fitness app. Minutes spent exercising, heart rate, hours spent standing, distance walked in a day, and much more can be shared between select friends who also own Apple smart watches, even to the extent of sending supportive or competitive messages to one another via the smart watch. Using a single fitness application, Apple has connected their customers virtually across multiple devices to any other user of these same devices.

The counterparts of the exercise-based weight loss apps are the diet monitoring weight loss apps. These applications focus on food consumption, tracking the health information of foods inputted by users throughout the day. Often, these apps will include serving size suggestions, meal suggestions, and daily calorie limits based on height, weight, and age information provided by the user. As with exercise apps, these applications can also be paired with other devices to be more finely tuned to the specific user; many smart scales can be paired with weight loss applications. These scales can send information on user weight, body fat percentages, and BMI to the smartphone application via Bluetooth, thus automatically updating the user on weight loss progress. Other applications focus less directly on weight loss but more on promoting healthy dietary habits such as appropriate water intake. The application Plant Nanny allows users to track daily water intake and will water a virtual plant according to this amount; the more water consumed per day, the healthier the virtual plant will be. There are even smart water bottles that pair with applications and track water intake automatically without the need for manual input.

1.7 Mental health apps

The above exercise apps tend to focus on physical fitness; there are, however, wellness applications that center on the balance between mental and physical well-being. Standout examples of this more holistic genre of health applications are meditation and yoga apps. These applications vary from yoga workout apps to applications that are purely guided meditations or mantras. Whether they contain the videos of routines for users to try or more self-reflective content, these applications have gained popularity due to their emphasis on serenity and focus. Branches of this genre even include applications promoting journaling, self-reflection, and positive psychology. Mental health is also a focus of this genre of app, and applications like Mood Mission and Catch It are designed to help individuals with depression and/or anxiety redirect negative moods and journal about mental health episodes, respectively. A 2020 study found that most top-ranked apps marketed to assist individuals with depression include evidence-based interventions or clinical input in app design to aid a wide age range of users battling depression.¹⁰

1.8 Sleep apps

Sleep tracking applications are a popular type of wellness app, which use cellphone or wearable technology to track the user’s sleep patterns throughout the night. The app generally records restlessness via movement of the cellphone on the bed, number of times the phone is picked up throughout the night, and other parameters to gage sleep patterns and quality of sleep. Many of the applications instruct users to place their cellphone under their pillow at night as they sleep and use the phone’s built-in accelerometer to estimate individual’s sleep-and-wake cycles. With this and other information, the app can then set alarms for the user at lighter points in the REM cycle in attempts to improve the quality of sleep and increase wakefulness with the alarm.¹¹ Other apps rely on knowledge of the circadian rhythms and the effects of blue light to turn down phone brightness and reduce notifications leading up to the user’s set bedtime, thus promoting easier, more restful sleep. Still other sleep apps use calming white noise sounds or bedtime stories to assist those who struggle to fall asleep. Given this wide range of uses and the increased quality of life that this genre of apps advertises, it is not surprising that sleep apps are becoming more and more prevalent at the top.

1.9 Educational apps

Medical applications are even useful for those in training in healthcare fields to recognize and become more familiar with the signs and symptoms of various diagnoses. For example, a smartphone application created to record and plot sound waves for visualization in real time has been used to assist novice listeners in distinguishing heart sounds and murmurs at the bedside.¹²

Besides their rising use in medical education, apps also exist that claim to sharpen memory, critical thinking (e.g., Cognifit), and other mental acuity. Applications are marketed to the very young—apps for learning to read and honing math and science skills—as well as for the very old—those that claim to aid individuals in battling memory loss or other mental decline. Especially in the era of online learning following the COVID-19 pandemic, educational applications found a foothold for students who were forced to learn remotely. These apps range from pre-prepared educational content in the form of videos or text to more individualized tutoring options. For users not in the market for specific educational content, apps with tips for focus and study may be of assistance. One popular application, Forest, ensures that users have focused study time by planting a tree that grows during a dedicated study period. If the individual uses their phone in a nonproductive way (playing games, watching videos, etc.) during the designated study interval, the tree will fade and die. Thus the app encourages virtual rewards for maintained periods of attention to a task. A similar study app, Pomodoro, will allow users to schedule work and break periods that optimize their focus and attention.

1.10 Scheduling apps

The final category of applications to be covered in this publication includes scheduling apps. In an increasingly online world, it follows that organization of appointments, meetings, and other events would take place virtually as well. Applications have been developed that manage to-do lists or map important appointments with built-in and customizable reminders for the user. Meetings can also be scheduled and organized via these applications, some of which will sync automatically with email accounts and other calendars to provide scheduling assistance across multiple platforms. Whether for personal use—tracking doctor’s office visits or haircuts—or for professional or academic use—scheduling advising meetings, tutoring sessions, or business meetings—scheduling apps aid in organization, long-term schedule tracking, and even goal mapping.

1.11 Efficacy of health/wellness apps

Having briefly discussed several genres of health and wellness applications, it is important to lay out the evidence for the efficacy of apps in general and health apps more specifically. On an individual level, one of the most interesting examples of the positive effect of applications on user fitness and activity levels is that of PokemonGo. A sensation in the summer of 2016, PokemonGo was drawing in upward of 250 million new users per month at its peak in popularity.¹³ The application is an augmented reality game that utilizes a mobile device’s GPS system to allow users to visualize features of the game in real life settings. Given that the app requires a user to search for and find Pokemons that are separated geographically in space and are found on a map of real-life locations near the user, it encouraged users to physically move between locations to play the game. Studies have found that the users of PokemonGo increased their walking duration, distance, and number of steps per day by almost 1500 steps compared to activity levels prior to use of the app.¹⁴ While it is unclear how long the effects of the increased physical activity are statistically significant (some studies have shown the effect of the app to wear off after a 6-week period), it is evident that mobile applications have the ability to alter physical well-being in real and tangible ways.¹⁵ Further, being that PokemonGo was not in any way marketed as a fitness application, one can extrapolate the increased benefits on wellness from apps geared toward that specific purpose. The proceeding chapters delve into more of the research that backs these apps.

1.12 Use-cases

Evidence for the efficacy of health and wellness applications has reached the corporate level; a number of companies have implemented incentive-based policies to encourage increased health in their employees. In efforts to increase productivity, decrease healthcare costs, and increase employee longevity, employers have used a variety of incentive programs to reward employees for positive health outcomes and healthier lifestyle choices. While the benefits of these interventions are disputed (some argue that there are no significant causal effects on medical spending and employee absenteeism), applications have been used by some companies to track and encourage employee health.¹⁶ A study tracking employees at a financial institution found that use of the FitBit app to encourage activity and wellness not only increased average step counts but also improved morale overall. The study attributes some of the success of the health intervention to the group competition feature available in the FitBit app that allowed small groups of employees to compete for step count goals. Even for individuals unable to participate in physical activity, benefits were reported through the app’s sleep tracking and calorie consumption features.¹⁷ In general, companies seem to have taken notice of the utility of health tracking apps and some have chosen to implement use of these applications in hopes of improving employees’ mental and physical well-being. Further, given the existence of monetary incentive programs for employees with certain body fat, cholesterol, and blood pressure levels, health tracking applications may become more and more important in the world of employer-sponsored health promotions.¹⁸

While mobile apps have been on the rise in recent years, the COVID-19 pandemic certainly affected application use, at least in the short term. Between 2010 and 2019, the most downloaded applications worldwide included many social media giants like Facebook, Instagram, Snapchat, Twitter, and YouTube.¹⁹ Downloads in 2020 featured many of the same social media apps, along with the breakout video conferencing application Zoom that skyrocketed in popularity during the COVID-19 pandemic.²⁰ In terms of health apps, top downloads for 2020 include a mixture of workout-based applications and meditation-based apps.²¹

The height of the COVID-19 pandemic brought with it a surge of telehealth and telemedicine options, as patients and clinicians found it more challenging to meet in person for appointments. These healthcare encounters range from virtual consultations to remote patient monitoring to telephone and video visits and more.²² As various health systems were forced to transition to a virtual format, it remains to be seen how healthcare mobile applications may increase in prevalence and/or importance. An example of such an application that is relatively unprecedented is the emergence of several contract tracing applications designed to monitor the spread of the SARS-CoV-2 virus through the population. These mobile apps make use of mobile tracking data and reported COVID-19 cases to track infections and to alert individuals of possible exposures based on users’ locations. The benefits of these applications include both speed and reliability (compared to previous, manual versions of contact tracing), but drawbacks include concerns about efficacy, privacy, and data security.²³ In the future, similar applications could be used to gather information for governments or individuals about potential spread of disease or exposure to pathogens.

1.13 Considerations

With the rise in number, scope, and popularity of mobile applications in the modern era, the fact remains that apps, especially those centered on improvement of health, are a new and relatively unproven entity. There exists a scarcity of data as to the efficacy of various health-centered applications. Though there is significant potential for improvement in health and well-being with use of these applications, progress must be made in the evaluation of applications and their actual effects on user health and wellness. For example, applications that claim to aid in weight management should be rated as to actual results (or lack thereof) for participants. Perhaps more critically, apps that market management of mental health conditions or other chronic medical conditions may be dangerous should individuals forgo proven medical management for mobile application use. In the best-case scenario, successful health applications would not only improve well-being in the areas most important to users but could also be used as a form of preventative healthcare. Mobile applications that include patient health records may improve patient outcomes due to increased ability to monitor decision-making, disease management, lab values, and other parameters between in-person appointments.

Other limitations to consider in the world of health applications include disparity in application usage as well as a lack of integration into healthcare systems.²⁴ An analysis of users of health applications on mobile devices found that individuals using these apps were more likely to be younger, more affluent, more educated, and more fluent in English.²⁴ Given this information, ethical concerns ought to be raised considering which populations are most able to use potentially helpful resources like mobile applications and how other groups can better be reached. Moreover, the gap between collection of individual data and integration of this data in personal health records or other medical systems serves as a barrier to effective usage of these health apps. If the goal of health apps is to assist individuals in managing their care, then the inclusion of updated health information in centralized data sites seems