Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru

Abstract

Background Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

“…The primary barrier to engagement noted in 25 studies was users’ experience of technical issues [ 44 , 50 , 80 , 92 , 100 , 103 , 118 , 129 , 138 , 155 , 172 , 179 , 185 , 195 , 205 , 208 , 212 - 220 ], such as a mobile app crashing and shutting down unexpectedly; in 3 studies, participants did not have the resources required to use an intervention [ 171 , 221 , 222 ]. In 7 studies, participants expressed concerns over the eventual costs associated with using an intervention [ 85 , 93 , 104 , 123 , 165 , 223 , 224 ]. Costs could be related to the need for a smartphone, having internet access, or making purchases through the app.…”

“…Costs could be related to the need for a smartphone, having internet access, or making purchases through the app. Usability issues formed a barrier to engaging with an intervention [ 46 , 50 , 78 , 84 , 148 - 150 , 157 , 159 , 170 , 224 - 228 ]. Examples of usability issues were difficulty finding information in an intervention [ 78 ], a time-consuming process to log in to an intervention [ 159 ], and difficulty navigating within an intervention [ 150 , 157 ].…”

“…If an intervention was used as part of ongoing in-person therapy, the way that therapists used or were willing to use an intervention influenced participants’ engagement with an intervention [ 84 , 103 , 127 , 150 , 169 , 212 , 243 ]. The adoption of an intervention as part of therapy depended on the therapist’s digital literacy skills [ 244 , 245 ], their past experience with mental health technology [ 120 ], and the ability to easily integrate its use into their practice as a provider [ 132 , 195 , 205 , 211 , 224 , 226 , 246 ].…”

A smartphone-assisted brief online cognitive-behavioral intervention for pregnant women with depression: a study protocol of a randomized controlled trial

“…The potential of digital technology to deliver mental health interventions has been increasingly recognized worldwide [120]. There is a growing literature on interventions using smartphone applications to promote mental health, both with [121,122] or without the intermediation of a mental health professional [31]. Our study adds to the literature by testing whether an app providing an intervention package, including CBT, psychoeducation, nutrition, physical activity, and social support, can promote maternal and child health and well-being.…”

Recruitment, training and supervision of nurses and nurse assistants for a task-shifting depression intervention in two RCTs in Brazil and Peru

“…In Lima, the study was conducted in primary health care centers from the social security network and outpatient services from three hospitals from the Ministry of Health network. A pilot study found nurses in Peru were overwhelmed with the number of tasks assigned to them, and, with a few exceptions, were not motivated to invest time in additional responsibilities [17]. This was a likely barrier to implementation so the research team decided to hire full-time nurses to conduct the intervention.…”