INTRODUCTION
Mobile applications and the computing ability of smartphones have changed mobile health (mHealth). More than 3 billion mHealth apps are estimated to have been downloaded in 20151. Mobile applications can be easily downloaded, and many users can receive tailored text messages and information at low cost. The use of smartphone technology is increasing rapidly globally. Between 2014 and 2015, the global use of smartphones grew by 566 million. There is rapid adoption of the smartphone as demonstrated by its estimated broadband penetration of 47% and that 3G coverage has nearly reached 70% of the world population2. In the same period, the Asia-Pacific region has experienced an 83% increase in internet mobile data traffic2.
The national Information Communication and Technology (ICT) data show that the mobile penetration rate in Brunei has kept above 100% since 20083, and the mobile internet penetration as of 2016 has reached 100 per cent, leading to increased use of mobile applications and social media4, 5. Public App Stores such as iTunes or Google Play serve many consumer needs that include government mobile apps and limited private or enterprise apps. Open standards such as HTML5 for app development is widely used by the Brunei ICT industry. One-third of the mobile applications in Brunei have started using cross-platforms, thus extending local and international links6.
The use of mHealth interventions for smoking cessation represent the WHO (World Health Oganisation) recommended best buys to curb the global public health threat by the tobacco epidemic7. Additionally, a study suggests that a high prevalence of smokers in the US and UK use a smartphone, send and receive texts, download, and use apps, use Facebook and browse health-related internet sites8. Most importantly, smoking cessation by 40 to 60 year-olds reduces the risk of premature death by 90% to 40%, respectively9. Based on this evidence, the Tobacco Free for Life Program of the Health Promotion Center, Ministry of Health , launched the smoking cessation mobile application STaR (Sihat Tanpa Rokok - Healthy Without Smoking) in conjunction with the World No-Tobacco day, 3 June 201510.
The health apps can improve with user-friendly app content, design and interactive features. Content analysis from the sample of smoking cessation application suggests quality and content are interrelated11, 12. Therefore, this study was conducted to outline features and design of the STaR app, and estimate its quality based on the Mobile Application Rating Scale (MARS). Furthermore, we evaluated the compliance of the app content with smoking cessation clinical practice guidelines developed by the Ministry of Health.
METHODS
App development, design and technical features
The smartphone application was developed using in-house expertise within the Ministry of Health, including an ICT expert, a behaviour-change psychologist, and a public health and health promotion expert. Table 1 summarises the information on the app classification design and technical features. The STaR mobile application uses the Malay language. The app is free in Brunei’s app store and published by the Ministry of Health. The primary purpose of the application is to encourage smoking cessation. STaR uses HTML5 with adaptive cross-platform design. The technical features include sharing of Facebook content, possessing an app community of users, and space for dedicated profiles. The theoretical basis of the content was derived from cognitive behaviour change theories, assessment and motivation. The app targets adolescent, young adults and current adult smokers. The app contains 7 sections and 9 sub-sections.
Table 1
App classification, design and technical features
| Characteristics | Description |
|---|---|
| App name | STaR (Sihat Tanpa Rokok - Healthy Without Smoking) |
| Language | Malay |
| Available platform | Apple Store and Play Store |
| Developer | In-house development (smoking cessation counsellor and ICT trained health personnel within MoH) |
| Version | 1.6 |
| Last update date | 17 May 2015 |
| Development cost | 2937 USD* |
| Type | Free, Native, HTML 5, adaptive design |
| Security policy | Yes ( compliance with Google and Apple security policy) |
| User rating | 3.8** |
| Affiliation | Government |
| Purpose | App that gives smokers in Brunei a supportive group and a channel to find help to stop smoking |
| Technical features | Allows sharing with Facebook, has an app community, requires login, does not require web access to function, no password protection features |
| Strategies applied | Assessment, information and awareness, cognitive changes (thought challenging ), advice/ tips/ motivation, cognitive behaviour change (positive events), behaviour change, motivational theories and health promotion |
| Targeted population | Adolescent age 13-17, young adult 18-25, adults using smartphone |
| Total section in the app and their type | Users profile , latest updates, about smoking cessation, smoking cessation clinic , contact us, users, chat Total : 7 sections and 9 sub-sections |
Study design and duration
We report on records of the mobile app activity over the app development website, Android and Apple smartphones. The study was conducted from July to August 2016.
Tools and technique
Data extraction was conducted using the pre-validated tools (MARS scale) and a checklist of criteria with themes derived from the smoking cessation clinical practice guidelines13 and past studies11, 14. The compliance of content with clinical practice guidelines was accessed to extract and classify: the app content as a basic intervention; the ABC approach (Ask, Brief Advice, Cessation Referral) as an intensive intervention; and the 5A approach (Ask, Advice, Assess, Assist, Arrange) and 5R motivational interventions (Relevance, Risks, Rewards, Roadblocks, Repetition) for people motivated to quit, as described in clinical practice guidelines13. The mobile application quality rating scale (MARS) was applied to rate the quality of the content used in the application. The Ms-Excel proforma was prepared as suggested by Stoyanov et al14. The leader of the app development team was consulted to access the background information during the quality and compliance assessment process. The MARS quality scale measured app quality on five domains; engagement, functionality, aesthetic, informative and subjective. Quality was measured using 19 quality indicators each on a 5-point scale (from 1=inadequate to 5=excellent). The compliance of the app information with the national smoking cessation guidelines was assessed by scanning the content of the app. The authors individually rated the level of conformity for each section with a yes, no or not enough information to determine the criteria. The rating exercise was performed independently and the discrepancies were settled with discussions among experts. Inter-rater reliability of 85% was achieved using Ms-Excel proforma.
Ethical consideration
The Ethical approval was obtained from the research ethics committee of the Institute of Health Science, University Brunei Darussalam. The privacy and confidentiality of the application users were preserved with security features such as password protection, as outlined in the application terms of use.
RESULTS
App utilisation
There were 145 downloads from the Google Play Store and 52 from the Apple Store. Apple Store downloads represent almost one-fourth (26%) of the total. An app rating of 3.8 for the Google Play Store was observed. There were 39 current users. The number of people accessing the app on Facebook was 155. In the past six months, the majority (56%) of the messages uploaded were pictures. More than three quarters (78%) of the messages provide information on the benefits of Smoking Cessation (Table 2).
Table 2
App utilization and quality
Quality analysis
The mean MARS score was 3.31. The average score on each of the four components of quality ranged from 2.50 to 3.57. The functionality feature had the lowest mean score of 2.50 and the information component had the highest mean score of 3.57. The app mean subjective quality was 2.50.
Compliance with clinical practice guidelines
The content of the app compliance with the national smoking cessation guidelines shows low compliance to the Level 1 intervention, i.e. the ABC approach. The intensive Level 2 interventions, i.e. the 5A approach and the motivational intervention, i.e. the 5R approach, exhibit high to moderate level compliance, respectively. For the Level 3, i.e. the pharmacy-based intervention, the app contains minimal information to judge the criteria. Overall, the app content showed compliance with 50% of the criteria of the Smoking Cessation guidelines. Detail criteria and their assessment are presented in Table 3.
Table 3
Compliance with clinical practice guidelines on smoking cessation
DISCUSSION
The study presents content and quality analysis of the STaR mobile app for smoking cessation. The goal was to compare the content of the STaR mobile application with predefined standards, outlined in clinical practice guidelines, and to estimate its quality on the Mobile App Rating Scale (MARS). The results indicate that the STaR app has average quality and compliance scores followed by low app use.
Given that a large proportion of the population uses smartphone applications15, the country has the highest mobile internet coverage among South-East Asian (ASEAN) countries16, and that it has a high prevalence of smoking17, the STaR mobile application should adopt the highest spectrum of technological features in order to engage with the smokers and track their cessation process, as outlined in the smoking cessation clinical practice guidelines. Accordingly, a cross-sectional mHealth study among Brunei and Indonesian populations found that promoting support mechanisms, quality of service, and quality of information are prominent factors identified by health-care staff for an effective mHealth program18. The high prevalence of mHealth opportunity justifies the development of STaR apps that target smokers.
Despite the high prevalence of cigarette smoking, the app utilisation statistics were low based on downloads, current users and persons assessing social media content. There are supply and demand side factors at play. Especially for the government health system, mobile apps have low inter-operability19. A patchwork of legal and liability issues, such as privacy and security, and human resources to control, monitor and update mobile applications in the health sector are yet to be addressed globally20, 21. In addition, our study app was largely developed by health care professionals with minimal expertise in ICT. Few interventional studies on Smoking Cessation apps suggest that targeting social groups, such as working women, university students, and industrial workers, with tailored messages based on push notification increases app utilisation22. In our study app, push notification on tailored targeted populations was rare.
Quality scores from the MARS scale are widely used to rate mHealth apps involving physical activity, smoking cessation and disease management11, 14, 23. Our study analyses on quality using the MARS score are concurrent with analyses of popular smartphone mobile apps for smoking cessation23. Quality scores are heavily decreased by feedback features, tailored user content and client preference, while our app is in its infancy to regulate and monitor these features12. This app is a non-intended informative app without those aforementioned tailoring and tracking features. Moreover, a recent analysis of smartphone apps suggests low availability and usability of informative apps12.
The compliance of the app content was measured with 33-point criteria derived from the verbatim outlined in the smoking cessation guidelines. The majority of these criteria are in accordance with US public health clinical practices to treat tobacco dependence. The mean adherence index of 12.9 (SD=6.8) on a 42-point scale was found in an analysis of 98 smartphone smoking cessation applications12. In our study, the compliance was low for the ABC approach, 5R approach and pharmacotherapy component, but the best adherence was found with the 5A approach.
This study builds on progress and provides foresight on the use of the mHealth application for smoking cessation. Limitations include failure to document the user’s perspective on app utilisation and the quality assessment process. Perspectives on a smoker’s ease of use and need would be future research priorities. Additionally, the compliance criteria of the app are built around the assumption that the recommendations in the Clinical Practice Guidelines adopted by health care personnel of Brunei in a clinical setting are applicable to a mobile app setting. It has been shown that further studies are needed to test this argument11, 24. Finally, the personnel rating the app are not experts and receive no training, despite their time and effort in learning from online videos. This may have generated additional quality and adherence scores. Other sources of systematic bias that is accounted for, but not very likely, include observer bias and reference standard bias, as we found no evidence on critical appraisal of smoking cessation clinical practice guidelines. Unlike other similar studies11,12, 24-26, our study is unique in its analyses of a single mobile application for smoking cessation.
CONCLUSIONS
The results of our study indicate that the STaR app could be improved through the better adoption of every component and strategy outlined in the smoking cessation clinical practice guidelines. Improving aesthetic and functional features to integrate smokers by continuous engagement and follow-up activities with the application is recommended.
