O iginal Pape
De e minan s o he Use o Heal h and Fi ness Mobile Apps by
Pa ien s Wi h As hma: Seconda y Analysis o Obse a ional
S udies
Ana Luísa Ne es1,2,3*, MD, MSc, PhD; C is ina Jácome1,2*, PT, MSc, PhD; Tiago Ta ei a-Gomes1,2,4,5, MD, PhD;
Ana Ma ga ida Pe ei a1,2,6, MD; Ru e Almeida1,2, PhD; Ri a Ama al1,2,7,8, PhD; Magna Al es-Co eia6, MD; Sand a
Mendes2, MSc; Cláudia Cha es-Lou ei o9, MD, PhD; Ma ga ida Valé io9, MD; C is ina Lopes10,11, MD, PhD; Joana
Ca alho12, MD; Ana Mendes13, MD; Ca meli a Ribei o14, MD; Sa a P a es15, MD; José Albe o Fe ei a16, MD;
Ma ia Fe nanda Teixei a17, MD; Joana B anco18, MD; Ma a San alha19, MD; Ma ia João Vasconcelos20, MD; Ca los
Lozoya21, MD, PhD; Na acha San os22, MD; F ancisca Ca dia23, MD; Ana So ia Mo ei a24, MD; Luís
Tabo da-Ba a a25,26, MD, PhD; Cláudia So ia Pin o27, MD; Rosá io Fe ei a28, MD; Ped o Mo ais Sil a29, MD; Tania
Mon ei o Fe ei a30, MD; Raquel Câma a31, MD; Rui Lobo32, MD; Diana Bo dalo33, MD; C is ina Guima ães34, MD;
Ma ia Espí i o San o35, MD; José Fe az de Oli ei a36, MD; Ma ia José Cálix Augus o37, MD; Rica do Gomes38, MD;
Inês Viei a39, MD; So ia da Sil a40, MD; Ma ia Ma ques41, MD; João Ca doso42, MD, PhD; Ana Mo e e6,43, MD;
Ma ga ida A oso44, MD; Ana Ma ga ida C uz45, MD; Ca los Nunes46, MD; Ri a Câma a47, MD; Na alina Rod igues48,
MD; Ca mo Ab eu49, MD; Ana Luísa Albuque que50, MD; Claúdia Viei a51, MD; Ca los San os52, MD; Rosália
Páscoa1,2,53, MD; Ca la Cha es-Lou ei o54, MD, MSc; Adelaide Al es55, MD; Ângela Ne es56, MD; José Va anda
Ma ques57, MD; B uno Reis58, MD; Manuel Fe ei a-Magalhães2,17, MD, PhD; João Almeida Fonseca1, MD, PhD
1Depa men o Communi y Medicine, In o ma ion and Heal h Decision Sciences (MEDCIDS), Facul y o Medicine, Uni e si y o Po o, Po o, Po ugal
2Cen e o Heal h Technology and Se ices Resea ch (CINTESIS), Facul y o Medicine, Uni e si y o Po o, Po o, Po ugal
3Impe ial NIHR Pa ien Sa e y T ansla ional Resea ch Cen e, Ins i u e o Global Heal h Inno a ion, Impe ial College London, London, Uni ed Kingdom
4Ins i u o de In es igação e Fo mação A ançada em Ciências e Tecnologias da Saúde, Ins i u e o Resea ch and Ad anced T aining in Heal h Sciences
and Technologies, Uni e si y Ins i u e o Heal h Sciences, Coope a i a de Ensino Supe io Poli écnico e Uni e si á io, CRL, Gand a, Po ugal
5Faculdade de Ciências da Saúde, Uni e sidade Fe nando Pessoa, Po o, Po ugal
6Alle gy Uni , Ins i u o and Hospi al CUF, Po o, Po ugal
7Depa men o Ca dio ascula and Respi a o y Sciences, Po o Heal h School, Poly echnic Ins i u e o Po o, Po o, Po ugal
8Depa men o Women’s and Child en’s Heal h, Paedia ic Resea ch, Uppsala Uni e si y, Uppsala, Sweden
9Se iço Pneumologia, Hospi ais da Uni e sidade de Coimb a, Coimb a, Po ugal
10Unidade de Imunoale gologia, Hospi al Ped o Hispano, Unidade Local de Saúde de Ma osinhos, Ma osinhos, Po ugal
11Imunologia Básica e Clínica, Faculdade de Medicina, Uni e sidade do Po o, Po o, Po ugal
12Se iço de Pedia ia, Hospi al Ped o Hispano, Unidade Local de Saúde de Ma osinhos, Ma osinhos, Po ugal
13Se iço de Imunoale gologia, Hospi al de San a Ma ia, Cen o Hospi ala Lisboa No e, Lisboa, Po ugal
14Se iço de Imunoale gologia, Cen o Hospi ala e Uni e si á io de Coimb a, Coimb a, Po ugal
15Se iço de Imunoale gologia, Hospi al de Dona Es e ânia, Cen o Hospi ala Uni e si á io de Lisboa Cen al, Lisboa, Po ugal
16Se iço de Imunoale gologia, Unidade I, Cen o Hospi ala Vila No a de Gaia/Espinho, Vila No a de Gaia, Po ugal
17Se iço de Pedia ia, Cen o Ma e no In an il do No e, Cen o Hospi ala Uni e si á io do Po o, Po o, Po ugal
18Se iço de Pneumologia, Hospi al Bea iz Ângelo, Lou es, Po ugal
19Se iço de Pedia ia, Hospi al da Senho a da Oli ei a, Guima ães, Po ugal
20Se iço de Imunoale gologia, Cen o Hospi ala Uni e si á io de São João, Po o, Po ugal
21Se iço de Imunoale gologia, Hospi al Ama o Lusi ano, Unidade Local de Saúde de Cas elo B anco, Cas elo B anco, Po ugal
22Se iço de Imunoale gologia, Cen o Hospi ala Uni e si á io do Alga e, Po imão, Po ugal
23Unidade de Saúde Familia Te as de Azu a a, Ag upamen o de Cen os de Saúde Dão La ões, Mangualde, Po ugal
24Unidade de Imunoale gologia, Hospi al do Di ino Espi i o San o, Pon a Delgada, Po ugal
25Depa men o Alle gy & Clinical Immunology, Co a da Bei a Uni e si y Hospi al Cen e, Co ilhã, Po ugal
26Cen o de In es igação em Ciências da Saúde - Heal h Sciences Resea ch Cen e & NuESA –En i onmen & Heal h S udy G oup, Facul y o Heal h
Sciences, Uni e si y o Bei a In e io , Co ilhã, Po ugal
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27Se iço de Pneumologia, Hospi al São Ped o de Vila Real, Cen o Hospi ala de T ás-os-Mon es e Al o Dou o, Vila Real, Po ugal
28Depa amen o de Pedia ia, Hospi al de San a Ma ia, Cen o Hospi ala de Lisboa No e, Lisboa, Po ugal
29Imunoale gologia, G upo HPA Saúde, Po imão, Po ugal
30Unidade de Saúde Familia P og esso e Saúde, Ag upamen o de Cen os de Saúde Baixo Mondego, Tocha, Po ugal
31Se iço de Pneumologia, Hospi al Nossa Senho a do Rosá io, Cen o Hospi ala Ba ei o Mon ijo, Ba ei o, Po ugal
32Unidade de Saúde Familia João Semana, Ag upamen o de Cen os de Saúde Baixo Vouga, O a , Po ugal
33Se iço de Pedia ia, Unidade Hospi ala de Famalicão, Cen o Hospi ala do Médio A e, Vila No a de Famalicão, Po ugal
34Unidade de Saúde Familia Caminhos do Cé oma, Ag upamen o de Cen os de Saúde Baixo Mondego, Pampilhosa, Po ugal
35Unidade de Saúde Familia A e No a, Ag upamen o de Cen os de Saúde Baixo Vouga, Oli ei inha, Po ugal
36Imunoale gologia, Hospi al P i ado de Al ena, T o a Saúde, Al ena, Po ugal
37Se iço de Pedia ia, Hospi al de São Teo ónio, Cen o Hospi ala Tondela–Viseu, Viseu, Po ugal
38Se iço de Pneumologia, Hospi al Ga cia de O a, Almada, Po ugal
39Unidade de Cuidados Saúde Pe sonalizados A naldo Sampaio, Ag upamen o de Cen os de Saúde Pinhal Li o al, Lei ia, Po ugal
40Unidade de Saúde Familia Cuida e, Unidade Local de Saúde do Al o Minho, Po uzelo, Po ugal
41Se iço de Imunoale gologia, Cen o Hospi ala Uni e si á io do Po o, Po o, Po ugal
42Se iço de Pneumologia, Hospi al San a Ma a, Cen o Hospi ala Uni e si á io de Lisboa Cen al, Lisboa, Po ugal
43Se iço de Imunoale gologia, Hospi al In an e D Ped o, Cen o Hospi ala Baixo Vouga, A ei o, Po ugal
44Unidade de Saúde Familia Ped as Rub as, Ag upamen o de Cen os de Saúde do G ande Po o III - Maia/Valongo, Maia, Po ugal
45Unidade de Saúde Familia Bom Po o, Ag upamen o de Cen os de Saúde do G ande Po o V - Po o Ociden al, Po o, Po ugal
46Imunoale gologia, Cen o de Imunoale gologia do Alga e, Po imão, Po ugal
47Se iço de Imunoale gologia, Se iço de Saúde da Região Au ónoma da Madei a, Funchal, Po ugal
48Unidade de Saúde Familia Mondego, Ag upamen o de Cen os de Saúde Baixo Mondego, Coimb a, Po ugal
49Se iço de Imunoale gologia, Hospi al São Ped o de Vila Real, Cen o Hospi ala De T ás-Os-Mon es E Al o Dou o, Vila Real, Po ugal
50Unidade de Saúde Familia Coimb a Cen o, Ag upamen o de Cen os de Saúde Baixo Mondego, Coimb a, Po ugal
51Unidade de Saúde Familia Co go, Ag upamen os de Cen os de Saúde Dou o I - Ma ão e Dou o No e, Vila Real, Po ugal
52Unidade de Saúde Familia San o An ónio, Ag upamen o de Cen os de Saúde do Cá ado III - Ba celos/Esposende, Ba celos, Po ugal
53Unidade de Saúde Familia Abel Salaza , Ag upamen o de Cen os de Saúde do Gaia, Vila No a de Gaia, Po ugal
54Se iço Pedia ia Ambula ó ia, Cen o Hospi ala e Uni e si á io de Coimb a, Coimb a, Po ugal
55Se iço de Pneumologia, Unidade I, Cen o Hospi ala Vila No a de Gaia/Espinho, Vila No a de Gaia, Po ugal
56Unidade de Saúde Familia A ace i, Ag upamen o de Cen os de Saúde Baixo Mondego, A azede, Po ugal
57Unidade de Saúde Familia Viseu-Cidade, Ag upamen o de Cen os de Saúde do Dão La ões, Viseu, Po ugal
58Unidade de Cuidados Saúde Pe sonalizados Sicó, Ag upamen o de Cen os de Saúde Pinhal Li o al, Lei ia, Po ugal
* hese au ho s con ibu ed equally
Co esponding Au ho :
C is ina Jácome, PT, MSc, PhD
Depa men o Communi y Medicine, In o ma ion and Heal h Decision Sciences (MEDCIDS)
Facul y o Medicine
Uni e si y o Po o
P aça de Gomes Teixei a
Po o, 4099-002
Po ugal
Phone: 351 225513622
Email: [email p o ec ed]
Abs ac
Backg ound: Heal h and i ness apps ha e po en ial bene i s o imp o e sel -managemen and disease con ol among pa ien s
wi h as hma. Howe e , inconsis en use a es ha e been epo ed ac oss s udies, egions, and heal h sys ems. A be e unde s anding
o he cha ac e is ics o use s and nonuse s is c i ical o design solu ions ha a e e ec i ely in eg a ed in pa ien s’ daily li es,
and o ensu e ha hese equi ably each ou o di e en g oups o pa ien s, hus imp o ing a he han en enching heal h inequi ies.
Objec i e: This s udy aimed o e alua e he use o gene al heal h and i ness apps by pa ien s wi h as hma and o iden i y
de e minan s o usage.
Me hods: A seconda y analysis o he INSPIRERS obse a ional s udies was conduc ed using da a om ace- o- ace isi s.
Pa ien s wi h a diagnosis o as hma we e included be ween No embe 2017 and Augus 2020. Indi idual-le el da a we e collec ed,
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including age, gende , ma i al s a us, educa ional le el, heal h s a us, p esence o anxie y and dep ession, pos code, socioeconomic
le el, digi al li e acy, use o heal h se ices, and use o heal h and i ness apps. Mul i a ia e logis ic eg ession was used o model
he p obabili y o being a heal h and i ness app use . S a is ical analysis was pe o med in R.
Resul s: A o al o 526 pa ien s a ended a ace- o- ace isi in he 49 ec ui ing cen e s and 514 had comple e da a. Mos
pa icipan s we e ≤40 yea s old (66.4%), had a leas 10 yea s o educa ion (57.4%), and we e in he 3 highe quin iles o he
socioeconomic dep i a ion index (70.1%). The majo i y epo ed an o e all good heal h s a us ( isual analogue scale [VAS]
sco e>70 in 93.1%) and he p e alence o anxie y and dep ession was 34.3% and 11.9%, espec i ely. The p opo ion o pa icipan s
who epo ed using heal h and i ness mobile apps was 41.1% (n=211). Mul i a ia e models e ealed ha single indi iduals and
hose wi h mo e han 10 yea s o educa ion a e mo e likely o use heal h and i ness mobile apps (adjus ed odds a io [aOR] 2.22,
95%CI 1.05-4.75 and aOR 1.95, 95%CI 1.12-3.45, espec i ely). Highe digi al li e acy sco es we e also associa ed wi h highe
odds o being a use o heal h and i ness apps, wi h pa icipan s in he second, hi d, and ou h qua iles epo ing aORs o 6.74
(95%CI 2.90-17.40), 10.30 (95%CI 4.28-27.56), and 11.52 (95%CI 4.78-30.87), espec i ely. Pa icipan s wi h dep ession
symp oms had lowe odds o using heal h and i ness apps (aOR 0.32, 95%CI 0.12-0.83).
Conclusions: A be e unde s anding o he ba ie s and enhance s o app use among pa ien s wi h lowe educa ion, lowe digi al
li e acy, o dep essi e symp oms is key o design ailo ed in e en ions o ensu e a sus ained and equi able use o hese echnologies.
Fu u e s udies should also assess use s’gene al heal h-seeking beha io and hei in e es and conce ns speci ically abou digi al
ools. These ac o s may impac bo h ini ial engagemen and sus ained use.
(J Med In e ne Res 2021;23(9):e25472) doi: 10.2196/25472
KEYWORDS
mobile apps; sma phone; pa ien pa icipa ion; sel -managemen ; as hma
In oduc ion
Sma mobile echnology has e olu ionized how we
communica e, sha e, and consume con en , seeping in o many
di e en sec o s o socie y, including heal h ca e [1]. Wi h he
democ a iza ion o sma phone use, wi h 3.8 billion sma phone
use s wo ldwide [2], he ma ke o speci ic apps has expe ienced
a boom. O en ee, easy o download, and easy o use, mobile
apps ha e an ex ensi e applica ion in social, educa ional, and
en e ainmen ields and na u ally in he ields o
sel -managemen and heal h beha io change [3]. Acco ding o
he so wa e applica ion indus y, a ound 500 million
sma phone use s wo ldwide we e using a heal h and i ness
app in 2015; and by 2018, an es ima ed 50% o he 3.4 billion
sma phone and able use s, including heal h ca e p o essionals,
consume s, and pa ien s, would ha e downloaded one [4]. The
o al global mHeal h ma ke is p edic ed o each he US $100
billion ma k in 2021, which cons i u es a 5- old inc ease om
2016 [5]. In his con ex , i is hypo hesized ha apps may
become ubiqui ous solu ions impac ing a la ge numbe o
pa ien s, o en capi alizing on gami ica ion s a egies and social
in e ac ion [6]. In pa icula , heal h and i ness apps a e a
p omising app oach o imp o ing sel -managemen beha io s
in pa ien s wi h as hma, a p e alen long- e m condi ion wi h
po en ial social and economic impac s [7,8], which equi es a
ange o sel -managemen skills in e e yday li e [9]. Indeed,
a ound 1500 mobile apps a e a ge ing pa ien s wi h as hma in
bo h he Apple App S o e and he Google Play S o e [10]. A
sys ema ic e iew published by Unni e al [11] sugges s ha
he use o mobile apps by pa ien s wi h as hma may ha e
bene i s ac oss a ange o ou comes, including medica ion
adhe ence and as hma con ol.
Howe e , he cu en use o sma de ices and apps among
pa ien s wi h as hma emains unexplo ed, as emphasized by a
posi ion pape o he Eu opean Academy o Alle gy and Clinical
Immunology, highligh ing he lack o published s udies on he
use o mHeal h in alle gic diseases [12]. While he e a e mo e
han 100 pape s published o e he las 5 yea s, hey ei he
e alua e he cha ac e is ics o speci ic apps ( a he han hei
use) o ocus on he impac o as hma-speci ic apps.
A ecen s udy epo ed ha sma de ice owne ship le els in
pa ien s wi h as hma a e simila o hose o he gene al
popula ion, ha h ee-qua e s o pa ien s had downloaded/used
a gene al app, ye only one- hi d had e e used a heal h and
i ness app [13]. A signi ican a iabili y exis s in usage among
di e en acial/e hnic and sociodemog aphic g oups.
None heless, his e idence comes mainly om s udies conduc ed
in he Uni ed S a es and does no add ess speci ic disease
con ex s [14-18]. The use o heal h and i ness apps in he
as hma con ex can be explo ed h ough he lens o he
concep ual model de eloped by Ande sen e al [19], which
p oposes ha he use o heal h se ices is d i en by h ee
dynamics: p edisposing ac o s (eg, age and gende ), enabling
ac o s (eg, socioeconomic le el, educa ion, and li e acy), and
need (eg, clinical cha ac e is ics and se e i y o disease).
The pu pose o his s udy is o e alua e he use o heal h and
i ness apps by pa ien s wi h as hma and o iden i y de e minan s
o usage. Speci ically, we will in es iga e he ollowing: (1) he
p opo ion o pa ien s wi h as hma using heal h and i ness apps
and (2) he ela ionships among p edisposing, enabling and need
ac o s, and using mHeal h apps.
Me hods
S udy Design
A seconda y analysis o INSPIRERS obse a ional s udies
in ol ing 32 seconda y ca e cen e s (alle gy, pulmonology, and
pedia ics depa men s) and 17 p ima y ca e cen e s in Po ugal
was pe o med (Figu e 1), as pa o he INSPIRERS p ojec .
The design o he INSPIRERS obse a ional s udies was
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dissemina ed h ough email con ac s, social ne wo ks, and o al
communica ions a na ional mee ings/con e ences, and
physicians/cen e s in e es ed in being pa o he s udy con ac ed
he esea ch eam. A con enience sample o adolescen s and
adul s wi h pe sis en as hma was ec ui ed o he INSPIRERS
s udies be ween No embe 2017 and Augus 2020. Depending
on he s udy, each cen e was asked o ec ui a minimum o
2-10 pa ien s. The 3 INSPIRERS obse a ional s udies add ess
he opic o adhe ence o as hma inhale s among adolescen s
and adul s wi h pe sis en as hma (Figu e 1). Fu he de ails on
he p ojec se ing and me hods ha e been p e iously published
[20,21]. This s udy is epo ed in acco dance wi h he STROBE
(S eng hening he Repo ing o Obse a ional S udies in
Epidemiology) guidelines [22].
Figu e 1. INSPIRERS s udies lowcha .
Pa icipan s and Da a Collec ion
Da a we e collec ed using a ques ionnai e du ing a ace- o- ace
isi . The ques ionnai e had a sec ion o be comple ed by he
physician add essing pa ien s’ as hma cha ac e is ics and a se
o ques ions o be sel -comple ed by he pa ien , as de ailed
below. Pa ien s we e included i hey had a p e ious medical
diagnosis o pe sis en as hma, we e a leas 13 yea s old, and
had an ac i e p esc ip ion o an inhaled con olle medica ion
o as hma. Pa ien s we e excluded i hey had a diagnosis o a
ch onic lung disease o he han as hma o a diagnosis o ano he
signi ican ch onic condi ion wi h possible in e e ence wi h
he s udy aims.
Use s and nonuse s we e de ined as indi iduals who answe ed
“yes” o “no,” espec i ely, o he ques ion “Ha e you e e
downloaded and used a heal h and i ness app?” Heal h and
i ness apps we e de ined as a ange o apps ela ed o pe sonal
i ness, wo kou acking, die and nu i ional ips, heal h and
sa e y, e c. In acco dance wi h he concep ual model p oposed
by Ande sen e al [19], a iables collec ed included p edisposing
ac o s, enabling ac o s, and need (Figu e 2). P edisposing
ac o s included demog aphic da a (ie, age, gende , ma i al
s a us, pa ish, and pos code), and enabling ac o s included
educa ion le el, use o sma de ices, and digi al li e acy, bo h
collec ed om pa ien s. Digi al li e acy was de ined as he
median o 5 i ems o he Media and Technology Usage and
A i udes Scale (MTUAS, ie, use o he GPS, b owsing he web,
aking pic u es, gaming, and checking social ne wo ks) a ed
by equency o use in a 10-poin Like scale (1=ne e o 10=all
he ime) [23]. Addi ionally, socioeconomic le el was explo ed
as an enabling ac o , which was de ined as he Po uguese
ecological dep i a ion index, ex ac ed om he pa ien
esidence in o ma ion (ci il pa ish/pos code), and ca ego ized
in o 5 quin iles (Q1=leas dep i ed o Q5=mos dep i ed) [24].
Need a iables included smoking s a us, pa ien s’ pe cei ed
o e all heal h s a us ( om EQ-5D Visual Analog Scale [VAS],
anging om 0 [wo s imaginable heal h s a e] o 100 [bes
imaginable heal h s a e]) [25], he p esence o anxie y o
dep ession (cu -o ≥8 in he Hospi al Anxie y and Dep ession
Subscales) [26], and physicians’inpu , including as hma con ol
le el (uncon olled, pa ially con olled, o well con olled
acco ding o he classi ica ion o he Global Ini ia i e o As hma
[27]), numbe o exace ba ions (episodes o p og essi e inc ease
in sho ness o b ea h, cough, wheezing, o ches igh ness,
equi ing a change in main enance he apy) in he pas yea [28],
and he numbe o unplanned appoin men s in he pas yea .
Age was ca ego ized in o age bands (13-18,18-30, 30-40, 40-50,
50-65, and ≥65 yea s). O he con inuous a iables
(socioeconomic le el, median digi al li e acy, and o e all heal h
s a us) we e ca ego ized in o qua iles.
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Figu e 2. Va iables collec ed included p edisposing ac o s, enabling ac o s, and need acco ding o he Ande sen e al [19]. MTUAS: Media and
Technology Usage and A i udes Scale; VAS: Visual Analog Scale.
Da a Analysis
Coun s and p opo ions we e calcula ed o each a iable.
Mul i a ia e logis ic eg ession wi h he En e me hod was used
o asce ain he de e minan s o being a use o a heal h and
i ness mobile app (dependen a iable) in acco dance wi h
Ande sen e al’s [19] concep ual model. Ca ego ical a iables,
such as gende , age, ma i al s a us, educa ional le el,
socioeconomic le el, use o sma de ices, digi al li e acy,
o e all heal h s a us, smoking s a us, p esence o anxie y o
dep ession, and as hma s a us we e explo ed as independen
a iables, i espec i e o signi icance in p elimina y uni a ia e
logis ic eg essions. We assessed model i using he pseudo-R2
Nagelke ke me hod and es ed o e idence o poo model i
using he Hosme –Lemeshow es . In addi ion, o assess he
inc easing con ibu ion o each co a ia e o he model, we
adop ed a s epwise app oach o build models s a ing om 1
co a ia e un il including all co a ia es in he ull models. Fo
each model, we compu ed he desc ibed goodness o i s a is ics.
The quali y o he inal model was also assessed using he
Aikake In o ma ion C i e ion. Adjus ed odds a ios and 95%
CIs we e calcula ed. S a is ical analyses we e conduc ed using
R and he “glm” package. The map o Po ugal was c ea ed
using Pain maps [29].
E hics App o al
The s udies we e app o ed by he e hics commi ees o all
pa icipa ing cen e s. The s udies we e conduc ed in acco dance
wi h he e hical s anda ds es ablished in he Decla a ion o
Helsinki. Eligible pa ien s we e app oached by physicians du ing
medical isi s and in i ed o pa icipa e. W i en in o med
consen was ob ained be o e en ollmen . Adul pa ien s signed
a consen o m; adolescen s signed an assen o m and a pa en al
consen o m was also ob ained.
Resul s
A o al o 526 pa ien s a ended a ace- o- ace isi be ween
No embe 2017 and Augus 2020 a he 49 ec ui ing cen e s.
O hose, 12 did no answe he ques ion “Ha e you e e
downloaded and used a heal h and i ness app?” and we e
excluded (Figu e 1). The ec ui ing cen e s included 12 o he
18 Po uguese dis ic s, which ep esen ed 9,189,723 inhabi an s
(89% o he o al na ional popula ion) [30]. A de ailed o e iew
o he dis ibu ion o he pa icipa ing cen e s by dis ic is
p o ided in Figu e 3.
The majo i y o he subjec s we e ≤40 yea s old (66.4%, n=341)
and 63.4% (n=326) we e emale. Mos pa icipan s we e single
(58.0%, n=298) and had a leas 10 yea s o educa ion (57.4%,
n=295). App oxima ely one- hi d we e in he 2 lowe quin iles
o he socioeconomic dep i a ion index (29.9%, n=154).
Rega ding gene al heal h s a us, as assessed by EQ-5D VAS,
69.8% (n=359) o he pa icipan s epo ed a sco e o ≥70. Mos
o he subjec s we e ne e smoke s (75.5%, n=388). The
p e alence o anxie y and dep ession symp oms in he sample
was, espec i ely, 34.4% (n=177) and 11.9% (n=61).
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Figu e 3. Numbe o pa icipa ing cen es pe dis ic .
As hma was well con olled among 51.0% (n=262) o
pa icipan s. While 50.8% (n=261) o pa icipan s had 1 o mo e
as hma exace ba ions du ing he las yea , mos o he
pa icipan s did no ha e any unplanned appoin men s (66.1%,
n=340) o inpa ien admissions (94.2%, n=484). The p opo ion
o pa icipan s who epo ed using heal h and i ness mobile
apps was 41.1% (n=211). A ull desc ip ion o he sample, as
well as he cha ac e is ics o he nonuse and use g oups, is
p o ided in Table 1.
Cha ac e is ics o bo h use s and nonuse s we e explo ed using
mul i a ia e logis ic eg ession. The aORs show ha single
indi iduals and hose wi h mo e han 10 yea s o educa ion a e
mo e likely o use heal h and i ness mobile apps (aOR 2.22,
95%CI 1.05-4.75, and aOR 1.95 95%CI 1.12-3.45, espec i ely).
Highe digi al li e acy sco es we e also associa ed wi h highe
odds o being a use o heal h and i ness apps, wi h pa icipan s
in he second, hi d, and ou h qua iles showing, espec i ely,
aORs o 6.74 (95%CI 2.90-17.40), 10.30 (95%CI 4.28-27.56),
and 11.52 (95%CI 4.78-30.87). Pa icipan s wi h dep ession
symp oms had lowe odds o using heal h and i ness apps (aOR
0.32, 95%CI 0.12-0.83). No signi ican associa ions we e ound
wi h gende , age, socioeconomic le el, gene al heal h s a us,
smoking s a us, anxie y, and as hma con ol (including le el o
con ol, numbe o inpa ien admissions, o numbe o
exace ba ions). A de ailed o e iew o he mul i a ia e analysis
is p o ided in Table 2.
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Table 1. Cha ac e is ics o he pa icipan s acco ding o hei use o heal h and i ness mobile apps (N=514).
To al, n (%)Use s (n=211), n (%)Nonuse s (n=303), n (%)Cha ac e is ics
Sociodemog aphic
Gende
326 (63.4)137 (64.9)189 (62.4)Female
188 (36.6)74 (35.1)114 (37.6)Male
Age band (yea s)a
154 (30.0)62 (29.4)92 (30.4)13-18
115 (22.4)74 (35.1)41 (13.5)18-30
72 (14.0)32 (15.2)40 (13.2)30-40
82 (16.0)31 (14.7)51 (16.8)40-50
58 (11.3)7 (3.3)51 (16.8)50-65
26 (5.1)3 (1.4)23 (7.6)≥65
Ma i al s a usb
177 (34.4)49 (23.2)128 (42.2)Ma ied
30 (5.8)11 (5.2)19 (6.3)Sepa a ed
298 (58.0)149 (70.6)149 (49.2)Single
8 (1.6)2 (1.0)6 (2.0)Widow
Educa ion le el (yea s)
219 (42.6)60 (28.4)159 (52.5)0-10
295 (57.4)151 (71.6)144 (47.5)>10
Socioeconomic le elc
51 (9.9)19 (9.0)32 (10.6)Q1 (leas dep i ed)
103 (20.0)48 (22.7)55 (18.2)Q2
109 (21.2)37 (17.5)72 (23.8)Q3
133 (25.9)61 (28.9)72 (23.8)Q4
104 (20.2)40 (19.0)64 (21.1)Q5 (mos dep i ed)
Digi al use and li e acy
473 (92.0)211 (100)262 (86.5)Use o sma de ices
Mean digi al li e acyd
92 (17.9)10 (4.7)82 (27.1)Q1 (0-4.17)
142 (28.6)66 (31.3)76 (25.1)Q2 (4.17-5.67)
117 (22.8)66 (31.3)51 (16.8)Q3 (5.67-6.83)
123 (23.9)69 (32.7)54 (17.8)Q4 (6.83-10.00)
Gene al heal h s a us
O e all heal he
146 (28.4)54 (25.6)92 (30.4)Q1 (0-70)
121 (23.5)53 (25.1)68 (22.4)Q2 (70-80)
151 (29.4)64 (30.3)87 (28.7)Q3 (80-90)
87 (16.9)38 (18.0)49 (16.2)Q4 (90-100)
Smoking s a usb
388 (75.5)151 (71.6)237 (78.2)Ne e smoke s
86 (16.7)46 (21.8)40 (13.2)Fo me smoke s
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To al, n (%)Use s (n=211), n (%)Nonuse s (n=303), n (%)Cha ac e is ics
39 (7.6)14 (6.6)25 (8.3)Cu en smoke s
177 (34.4)67 (31.8)110 (36.3)
Anxie y symp oms
61 (11.9)9 (4.3)52 (17.2)
Dep ession symp oms
As hma s a us
As hma con olg
262 (51.0)110 (52.1)152 (50.2)Well-con olled
248 (48.2)98 (46.4)150 (49.5)Pa ially/uncon olled
261 (50.8)101 (47.9)160 (52.8)
≥1 as hma exace ba ion in he pas yea h
160 (31.1)55 (26.1)105 (34.7)
≥1 unplanned appoin men in he pas yea c
16 (3.1)5 (2.4)11 (3.6)
≥1 inpa ien admission in he pas yea c
a7 pa ien s wi h missing da a.
b1 pa ien wi h missing da a.
c14 pa ien s wi h missing da a.
d40 pa ien s wi h missing da a.
e9 pa ien s wi h missing da a.
2 pa ien s wi h missing da a.
g4 pa ien s wi h missing da a.
h15 pa ien s wi h missing da a.
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Table 2. Mul i a ia e analysis o explain he use o heal h and i ness apps.
P alueOdds a io (5%-95% CI)P edic o
Gende
Re e encea
Male
.191.37 (0.86-2.20)Female
Age band (yea s)
Re e ence13-18
.061.93 (0.97-3.89)18-30
.381.53 (0.59-4.05)30-40
.491.41 (0.53-3.77)40-50
.570.63 (0.12-2.86)50-65
.621.68 (0.19-11.47)≥65
Ma i al s a us
Re e enceMa ied
.371.64 (0.55-4.96)Sepa a ed
.04b
2.22 (1.05-4.75)Single
.931.17 (0.03-33.55)Widow
Educa ion le el (yea s)
Re e ence0-10
.021.95 (1.12-3.45)>10
Socioeconomic le el
Re e enceQ1 (leas dep i ed)
.122.02 (0.84-4.92)Q2
.861.08 (0.45-2.64)Q3
.411.42 (0.61-3.33)Q4
.521.34 (0.56-3.24)Q5 (mos dep i ed)
Mean digi al li e acy
Re e enceQ1 (0-4.17)
<.0016.74 (2.90-17.40)Q2 (4.17-5.67)
<.00110.30 (4.28-27.56)Q3 (5.67-6.83)
<.00111.52 (4.78-30.87)Q4 (6.83-10)
O e all heal h
Re e enceQ1 (0-70)
.871.05 (0.56-1.99)Q2 (70-80)
.670.87 (0.46-1.63)Q3 (80-90)
.690.86 (0.42-1.76)Q4 (90-100)
Smoking s a us
Re e enceNe e smoke s
.071.83 (0.97-3.53)Fo me smoke s
.700.84 (0.34-2.05)Cu en smoke s
Anxie y symp oms
Re e enceNo
.691.12 (0.64-1.95)Yes
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