Determinants of the Use of Health and Fitness Mobile Apps by Patients With Asthma: Secondary Analysis of Observational Studies

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 J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 1h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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, J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 2h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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 J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 3h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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. J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 4h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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). J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 5h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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. J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 6h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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 J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 7h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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. J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 8h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X 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 J Med In e ne Res 2021 | ol. 23 | iss. 9 | e25472 | p. 9h ps://www.jmi .o g/2021/9/e25472 (page numbe no o ci a ion pu poses) Ne es e alJOURNAL OF MEDICAL INTERNET RESEARCH XSL • FO Rende X