Effectiveness of mobile health‐based self‐management application for posttransplant cares: A systematic review

Abstract Background and aims Patients after transplantation need medical management for the rest of their lives, and self‐management seems to lead to greater adherence to medical standards, improve early physical changes, and increase patient empowerment. The main objective of this article is to systematic review of the consideration to mobile health applications (m‐Health apps) used in transplantation. Methods A systematic search was conducted MEDLINE (through PubMed), Web of Science, Scopus, and Science Direct from inception to November 2020. The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) statement was used in this study. Comprehensive research was carried out using a combination of keywords and MeSH terms associated with m‐Health, empowerment, self‐management, and transplantation. Two independent reviewers screened titles and abstracts, assessed full‐text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included posttransplant care and mobile phone‐based applications to support self‐management and self‐care. Also, thesis, book chapters, letters to editors, short briefs, reports, technical reports, book reviews, systematic reviews, or meta‐analysis were excluded. Results We divided all the reviewed articles into four categories, self‐management (medication adherence, adherence to medical regimen, and remote monitoring), evaluation, interaction, and interface; 37.5% of the studies were focused on lung transplantation. In 56.25% of the studies, medication adherence was considered because one of the main reasons for the rejection and graft loss is stated medication nonadherence. Also, 62.5% of the studies demonstrated that the use of m‐health improved medication adherence and self‐management in transplantation. Conclusions The use of m‐Health apps interventions to self‐management after transplantation has shown promising feasibility and acceptability, and there is modest evidence to support the efficacy of these interventions. We found that m‐Health solutions can help the patient in self‐management in many ways after transplantation.

modest evidence to support the efficacy of these interventions. We found that m-Health solutions can help the patient in self-management in many ways after transplantation.

K E Y W O R D S
medication adherence, mobile health, posttransplant cares, self-management

| INTRODUCTION
Chronic illness is a condition that lasts for 1 year or more and requires constant medical attention. 1 According to the World Health Organization (WHO), chronic diseases such as cardiovascular and respiratory diseases, cancer, and diabetes are the leading causes of death worldwide. 2 On the other hand, transplantation, one of the most effective treatments for end-stage organ failure, 3 should also be considered a chronic disease because it requires lifelong follow-up to manage concomitant diseases and prevent transplant loss. 4 In 2018, a total of approximately 146 840 organ transplants were performed worldwide. 5 Patients after transplantation need medical management for the rest of their lives, and they should engage in self-care behaviors such as medication management, follow-up medical appointments, and monitoring symptoms regularly.
Although biological factors are essential for transplant survival, other factors, such as adherence to medication and medical care, are also influential. 6 For example, one of the main reasons for the rejection and graft loss is stated medication nonadherence. 7 Patients need daily care for daily life, communication with the treatment staff, scheduling an appointment with a doctor and going to the clinic, and adhering to medication. Furthermore, some of the conditions that may cause transplant rejection include infection, neoplasms, recurrence of significant diseases, nephropathy, metabolic syndrome, and surgical complications. Patients may also experience social psychological consequences such as social isolation, job disruption, financial crisis, and emotional burden. 8 Most of the time, transplant recipients encounter many problems that they have to deal with on their own. It is necessary to change the routine of medical practices towards patients centered mode in this particular patient population. Therefore, self-management is one way to manage or prevent potential health conditions after transplantation and has become increasingly critical for long-term transplant survivors, which is believed to play a vital role in the improvement of quality of life and health status. 9 Self-management is the behaviors and activities that a person uses to practically manage the disease and manage the patient's physical or functional effects. 10 Self-management seems to lead to greater adherence to medical standards and improve early physical changes and increase patients' ability. 11 Advances in information and communication technologies (ICTs) in health care have led to the development of m-health, and it has revolutionized the provision of health services. 12,13 m-Health to support patients with chronic diseases in self-management has been widely considered in the last decade. 14,15 WHO defines m-Health as a medical and public health approach supported by mobile devices, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices. 2 Statista website shows that the m-Health market is growing and projected to exceed US$ 300 billion by 2025. Based on this information, it can be concluded that m-Health has great potential in medical and public health approaches. 16 Mobile phones have great potential to influence the management of chronic conditions worldwide due to their popularity, availability, portability, and technology capacity. m-Health applications facilitate communication between patients and treatment staff, reduce chronic diseases costs, adhere to medical regimens, and influence patient outcomes. 14,17,18 Due to the increasing popularity of m-Health, some studies have reported the effect of m-Health interventions on chronic diseases; for example, Fan and Zhao examined the effect of m-Health on the outcomes of patients with chronic diseases and its limitations. This study showed a positive trend in m-Health interventions for the management of chronic diseases. 19 Badawy et al examined the evidence for the effectiveness of text messages and m-Health applications to promote medication adherence in adolescents with chronic health conditions and stated that this approach is effective for promoting drug adherence in adolescents with chronic disease. 20 Badawy et al also found that texting and mobile phone app interventions can correct adherence to preventive behavior in adolescents. 21  • To assess the efficacy of m-Health in self-management.
• To review the application quality evaluation scale.

| METHODS
The current systematic review was based on the PRISMA checklist to ensure the inclusion of relevant studies. 25

| Literature search
We searched MEDLINE (through PubMed), Web of Science, Scopus, and Science Direct from inception to November 2020. Comprehensive research was carried out using a combination of keywords and MeSH terms associated with m-Health, empowerment, self-management, and transplantation. Table 1

| Data extraction
After article retrieval, all titles and abstracts of articles were examined based on the main objectives, and reviewers selected relevant studies.
Abasi and Kiani screened all titles and abstracts to find relevant articles.
Articles that met our inclusion criteria were selected for full-text review.
Subsequently, full texts of relevant studies were screened thoroughly by two reviewers (Abasi and Kiani). Any conflicts were resolved by discussion with the senior authors (Yazdani and Mahmoudzadeh-Sagheb).
Lastly, after selected final articles, specific categories were considered to classify and analyze relevant articles. The categories were considered for the qualitative analysis of the articles present in Figure 1. Critical articles were summarized and entered into customized extraction forms based on these categories to diminish bias. Two authors (Abasi and Kiani) independently extracted the study characteristics from each article based on the classification. The information extracted by the researchers was reexamined to reach an agreement. The next reviewer (Yazdani and Mahmoudzadeh-Sagheb) assessed and verified the extracted information. EndNote software was used for resource management. All synthesis and analysis were performed using SPSS v25.

| Description of studies
The distribution of studies by publication year is represented in Transplantation, mobile health, m-Health, telemedicine, self-management, self-care Search strategy • Transplantation AND ("mobile health" OR "m-Health" OR "telemedicine") AND ("selfmanagement" OR "self care") • "Organ transplantation" AND ("mobile health" OR "m-Health ") The classification of reviewed articles studies involved heart transplant recipients, and 18.75% of studies involving recipients of multiple transplants.

| Self-management
The posttransplant care starts immediately after transplantation surgery. Continuous follow-up care should be provided for transplant patients to improve survival and outcomes. This critical care must continue after the patient is discharged from the hospital. All reviewed articles were categorized into three groups based on their objectives. These three topics include medication adherence, adherence to the medical regimen, and remote monitoring. In the following, the reviewed articles are described based on these three categories.

| Medication adherence
Medication adherence means nonobservance and deviation of the drug regimen and adverse effects on the prescribed regimen. 26

| Evaluation
An important part of software development is quality evaluation. For example, user satisfaction is one of the evaluations that can be measured by examining the usability of the system 42 ; 37/5% of the studies did not have an application quality evaluation scale, 27

| Interaction
According to Table 2, most research studies had interaction features, and we considered the interactive nature of m-Health application feedback, alert, and reminder.

| Interface
In most studies, design criteria (use appropriate font sizes, use meaningful colors, use graphs, the contrast between text, and background, etc.) were not considered, but a few studies followed the principles of user-centered design, and some used design criteria. 7,28,[35][36][37]40 Therefore, m-Health can be used to reduce psychosocial consequences and improve self-management skills. [46][47][48] Telemedicine is defined as "remote delivery of healthcare services over the telecommunication infrastructure." Concepts of telemedicine with web-based platforms, mobile applications, video conferencing, chat, remote vital sign monitoring, or a variety of those combinations are suitable for transplantation follow-up. However, the additional advantage of new telemedicine concepts over standard posttransplant care must be demonstrated to justify the use of additional costs. 49 The development and implementation of these systems entail several different costs such as the cost of equipment, personnel, and communications. 50 Two of the most common methods of economic evaluation are cost-utility analysis (CUA) and cost-effectiveness analysis (CEA). CUA is especially used in the evaluation of health technology.
The main purpose of the CUA is to estimate the cost ratio of a healthrelated intervention and its benefits in terms of the number of years that users live in perfect health. 50,51 Today, the introduction of new e-Health technologies significantly increases the cost-effectiveness of the healthcare system. 52 Although m-Health is a cost-effective one of telemedicine technology with a low-cost and efficient strategy, the evidence is limited, and most studies have not reported it and lacked a comprehensive analysis. 53,54 In addition, a study found the development and successful implementation of a m-Health application costly and time-consuming. 32 According to previous studies, the main limitations of the economic evaluation of telemedicine are the lack of randomized controlled trials, the size of small samples, and the lack of quality data and appropriate measures. 50 To develop effective m-Health applications to support self-management, end-user participation is essential, and previous research has shown that end-user engagement leads to higher levels of user acceptance and satisfaction. User satisfaction when using m-Health applications as a tool to support self-management is of particular importance. Because satisfaction reduces the barriers to successful implementation. 7 Lack of usability can be a major barrier to the rapid adoption of mobile services. 55 Most of the studies reviewed in this study did not use standard usability tools to evaluate the program, and most applications reach consumers with little to no empirical evaluation, but Pocket PATH is one of a limited number of m-Health interventions to have undergone user-centered development and testing. 35 The unavailability of the studied mobile health applications in the application market is considered a limitation in our study because their installation could be useful in order to more closely examine the capabilities of applications and evaluation.

| CONCLUSION
We conducted a comprehensive review of m-Health applications in posttransplant care. We found that m-Health solutions can help the patient in self-management in many ways after transplantation.
Medication management is important after solid organ transplantation, and according to the evidence, this study shows that m-Health in this field strengthens medication adherence and may help empower patients. For more exploitation and better results, it is suggested that more attention be paid to understanding the end-user's expectations and participation in developing an m-Health application; also more attention should be paid to user design and usability factors.

ACKNOWLEDGMENT
We express our gratitude to the Shiraz University of Medical Sciences.

CONFLICT OF INTEREST
The authors declare no conflicts of interest.

AUTHOR CONTRIBUTIONS
Conceptualization: Sanaz Abasi, Azita Yazdani. Zahra Mahmoudzadeh-Sagheb had full access to all of the data in this study and take complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
Zahra Mahmoudzadeh-Sagheb and Azita Yazdani affirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
All data analyzed for and presented in this article are from the 16 studies we reviewed. The data are accessible via referenced articles.