This cross-sectional survey study found that mobile phone ownership and access is high among medical ward patients; with less access in older patients and among women, but often offset by sharing phone access with proxies. In general, mobile phone owners also had cellular plans with the ability to call and to text. Although many participants reported using their mobile phones regularly, few indicated texting an HCP in the past. Furthermore, we found cellphone-owners and non-cellphone owners alike would like the opportunity to use their mobile phones to communicate with an HCP during their care process. mHealth initiatives have the potential to bridge this gap in care by providing transitional services to all patients discharged from the hospital regardless of their RRAS. Accordingly, most participants with a ‘high’ and ‘low’ risk of readmission assessment score (RRAS) had access to a mobile phone which has important clinical implications in planning for mHealth services aimed at reducing hospital readmissions. The ‘moderate’ group had some variability, with about a quarter not having phone access at all.
In recent years, many medical technology developers focus on smart phone apps as a mode of service delivery. However, our data show that not all medical participants have access to internet on their mobile devices, nor may know how to use ‘apps’. In fact, 25% (12/51) of participants could not access the internet through their phone, either through Wi-Fi or Data, limiting access to app/internet-dependent mHealth services. However, almost all participants can access a basic mobile device that can send and receive phone calls and text messages. Moreover, when asked about their preference of one-way versus two-way communication links with their HCP, there was a higher inclination for two-way communication with a participant stating that “one-way doesn’t make sense. It must be two-way.” In our short discussions with respondents, they indicated that the personalized responses of two-way communication provided more value. To elucidate, more patients indicated that they would prefer to text their HCP with medication-related concerns (which includes discussing side-effects, need for a refill, etc.), in comparison to receiving a medication reminder. One of the survey respondents expressed that the ability to schedule appointments virtually (‘two-way; via text) in addition to appointment reminders (‘one-way’) is ideal. Although two-way communication was preferred, participants still would like the opportunity to receive one-way texts. This suggests that mHealth initiatives that aim to provide care through smart mobile apps, often requiring internet connection and depending on automatic-response or generic medical information, may be less effective in reaching certain patient populations. Indeed, in a meta-analysis, 2-way texting interventions were more effective than 1-way interventions at improvement medication treatment adherence [21]. Lastly, given the predominant participant preference for voice calls, it is plausible to presume that the uptake of complicated phone apps would be significantly low, particularly in the elderly population.
Another implication of this study is minimizing access barriers to innovative health care technology as our findings highlight possible inequities in access to care [22] considering that a higher percentage of male participants had access to mobile phones as compared to women and a younger median age attributed to phone owners in the study. These findings are in line with other studies that found women to be disadvantaged in terms of mobile internet use and less likely to own a mobile phone [23, 24]. Gordon and Hornbrook [25] point to a digital divide between older populations regarding device ownership and health information preferences. However, in a study we conducted in Kenya among HIV participants, women actually had equal or more mHealth participation than their male counterparts [26]. This may point to a potential preference for mHealth that involves text messages among certain demographics, and perhaps other modalities for others. Furthermore, cellphone penetration rates were lower in our participant group in comparison to the rest of Canada [2]. Reasons contributing to this discrepancy may be that our participants were older, or may be from marginalized communities.
The preference for female participants to text is consistent with other literature, which reports that more female than male participants are “mediated communicators” who more habitually communicate using their mobile phones, and have a higher preference for direct two-way communication with their health care team [27]. When asked about the opportunity to text their HCPs, only 17% of women declined, compared to 33% of men who did. Notably, a male respondent enthusiastically reported that mobile phone use in healthcare “is the future” and that although he is unable to text, his family/female spouse would utilize an mHealth intervention on his behalf. This sentiment was shared by other participants. These data provide initial indication that gender may affect the inclination to using mHealth interventions, where a subgroup (e.g., males or low RRAs) are less inclined to using an mHealth intervention. This is useful information for researchers and clinical teams to know in terms of uptake strategies and engaging different subgroups as needed.
Our study has an above average survey response rate, of 59%, which is a strength of this study [28]. The high response rate was likely due to the distribution method, where surveys were researcher administered direct to patients on a ward. We aimed to ensure the highest inclusion of patients-in-ward as possible, including patients who may have had limitations in reading or answering the survey, understanding the survey questions, using the tablet/phone, and other potential hindrances to completing the survey on their own. Another strength of our study is that the survey was audited by a consortium of health professionals, including an mHealth professional, an HCP working on the ward, and a member from the hospitals initiatives team to ensure relevancy to study objectives and the hospital’s priorities for patient care.
This study has several limitations that may introduce bias and reduce generalizability. First, our sample size was limited due to research activity cessation in response to the COVID-19 pandemic. That said, given the boom in digital health and virtual care, the results of these at-risk hospitalized medical patients may be even more relevant. Second, we did not screen patients with language barriers as it prevented them from understanding survey questions or providing informed consent. In future iterations of this study, we aim to utilize interpretation services to better understand the access and phone preferences of this population. Third, although initial demographic comparisons show no significant differences between participant responders and non-responders in terms of gender and age, with a 59% response rate, we expect some nonresponse bias (See Table 1). Finally, we surveyed patients in the IM CTUs where the results may not be generalizable to other urban hospital inpatients, such as surgical patients. This study population was conveniently sampled which may have introduced biases through patient selection. This specific population was selected as they are part of an active and already funded project by the UBC mHealth Research Group. Future iterations of this survey should include a variety of inpatient hospital wards in an urban clinical setting.