Bridging the Gap: The Potential of Mobile Apps to Support Shared Medical Appointment Patients Before, During, and After Appointments

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Dec 10, 2013 (3 years and 7 months ago)

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Bridging the Gap: The
Potential of Mobile Apps to Support Shared Medical Appointment
Patients Before, During, and After Appointments

Jessica Toussaint, MS

Competitive
Analysis

Competitive
reviews
take an in
-
depth look at
other sites or apps and analyze

which
approach
es

work

well and which don’t
.
A competitive review allows you to leverage others’
experiences, learn from others’ approaches, and ultimately differentiate your site

or app from
others in the same space.

Six

mobile health
iPhone
applications
were

chosen based upon their similarity to themes
echoed in the observations and literature review.
Two

competitive reviews were conducted for
the reoccurring themes

of

social s
upport, and
health
education
/health literacy
.
The apps in the
latter category also included features in the third theme of goal setting/task setting.
For each
competitive review, three applications were chosen with a focus on the features
supported by th
e
literature review, observations, and client feedback
.
Applications were co
mpared
and
analyzed
for applicability to SMA patients
,

lessons learned, things to avoid, and things that could be done
similarly.

All
apps chosen for this competitive review were
iPhone apps as opposed to Android

apps

because
Android

apps are

developed on several different platforms

and operating systems
,
which
complicate
s

the development process. Additionally, using the iPhone for the initial app
exploration w
ill translate better

should Cambria Health
decide to also design and develop for the
iPad in the future.

Analysis.

Twenty
-
one variables were analyzed, ranging from
the target audience, to expert and user
generated content, to social media and sharing (See appendix A). These
twenty
-
one variables
were compared between three applications and then analyzed for how a SMA application could
and/or should do things similarly and differently.

Social networking and social support apps.

The Eatery, Pinterest, and Diabetic Connect

were s
elected
for the review of social
networking apps
based upon client feedback. The Eatery and Pinterest were well
-
liked for their
use of imagery and user generated content. Diabetic Connect was chosen because it is an app
derived from an existing strong so
cial network and uses storytelling and social support to help
individuals manage a chronic condition
, similar to how SMAs use shared experience and patient
to patient education to help people manage their health
.

Health literacy and health education apps.

Cancer.net, Fooducate, and Diabetes IQ

were selected
for the health education app
review because they contained feature sets that were vocalized by the client as desirable in the
Cambria Health app. Cancer.net has a wealth of expert information and also b
asic tracking tools
for patients, including the ability to log questions for an appointment. Fooducate uses a barcode
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1



scanner to give users immediate and actionable feedback. Diabetes IQ integrates a game with
expert information and tracking tools.

Evalu
ation

P
rocess evaluation

consisted of weekly meetings with the preceptor and monthly
meetings with
Cambria Health
.
Status memos were issued after any important phase to keep the
client abreast of the project and allow for feedback where necessary.

Based o
n the observations, personas and user scenarios were developed as an assessment
of contextual and audience understanding. These were reviewed by the preceptor
,

Cambria
Health, and Harvard Vanguard Medical Associates
.

Wireframes
, which were developed as pa
rt of the recommendations,

were unable to be
tested during this phase of the project

because of time limitations. These were, however,
reviewed by a professional designer and the preceptor.

Results

Observations

The
twenty
-
eight
SMA participants
varied

in age, gender, and race. However, the
majority of participants were white and all were adults with the exception of the children in the
children allergy SMA. However, in that instance, the parents were the target audience being
observed and their child
ren were the secondary audience.

The three major themes
that
consistently
arose from the
five
observations
were goal setting, social support, and education.
Secondary themes that arose were role modeling, experiential learning, and communication or
inter
actions with networks outside of the SMAs that were relevant to patients’ health.

Goal setting.

At
four
out of the
five
observations, a behaviorist
or physician
suggested goals for a
patient. Often, the goals set by the
providers
were action plans
consist
ing of proximal goals
that
would help the patient reach a more general goal. The action plan was stimulated by either
group conversation or a more general goal stated by the patient.

For example:

Patient: “I need to get back in shape”.

Behaviorist: “Ho
w about you try to
exercise
this week with [your friend]?”

Patient: “But I’m so busy with work and [my friend] goes in the afternoons when I’m still
on the job.”

Behaviorist: “Maybe you should just try to go once. You don’t work on Saturdays


could you
go with him then?”

In the above example, the behaviorist did not only help with the action plan, but also helped to
find solutions to the behavior change barriers.

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2




In the physicals for men over 50, there was a
flip board

upon entering the room that
stated
,

Lately, regarding my health, I’ve been:



Wondering…



Feeling good about…



Thinking I’d like to…

When a patient entered the room the behaviorist wrote the patient’s answers to these three
questions on the
flip board
. Throughout the appointment the physicia
n touched on all three
questions, using the third to help the patient create an action plan for things that he may want to
change.

Social support.

Two out of the
five
SMAs consisted of a group that met weekly for social support and
monthly for a SMA.
T
hes
e SMA patients mentioned communicating with each other outside of
the SMA

via text messages, phone conversations, or in
-
person
. When some of the patients set
goals, other patients discussed how they could help them meet those goals.

At all of the SMAs p
atients discussed life circumstances, offering context to their
conditions and inv
iting other patients or the
providers to offer suggestions about how they could
handle different situations. At
four

out of the
five
SMAs patients shared ideas about how the
y
cope with different
health and/or life
situations.
SMA
participants

also offered encouragement
and empathy when a patient expressed
a troublesome situation.


This is a paraphrasing of a conversation ensued during the children allergy SMA that
illustrat
es the type of support patients offer each other:

Parent 1: “
I worry about my son/daughter when they go to daycare. Parents like to bring
in treats for special occasions and [son/daughter] can’t participate.


Parent 2: “I make a bunch of cupcakes that I
know are safe and bring them into the
daycare for them to freeze.

Then, when someone brings in treats, the teacher just has to
defrost a cupcake.


Parent 3: “What a great idea! Then [son/daughter] can feel included.”

Behaviorist: “Let’s write this idea on

the board. What else helps you cope with your
children’s’ allergies?”

Prior to this conversation, the parents in the room were barely interacting. However,
after this one idea was suggested, parents started swapping stories, sharing experiences, and
off
ering each other ideas for how to overcome common barriers that they had faced.

In one of the
Suboxone

SMAs a patient shared that s/he was quitting smoking. The
doctor asked other patients to share their experiences about quitting


what their motivation
was,
Bridging the Gap



3



how they did it, and how they maintained the behavior change. Patients offered ideas, social
support, and health tips to the first patient.

Education.

In
four
out of the
five
SMAs patients were
first seen by the physician or nurse

separate
ly

from

the group. Upon re
-
grouping, the physician conducted a medical recap in which s/he used
different patient issues as teaching points.

In three of the SMAs, patients offered their insight
and educational points about health issues. In one of the SMAs tha
t met monthly, patients made
jokes like, “I feel like I’m in college when I’m here!” and “We don’t joke around, we know our
stuff


you draw diagrams!” These same patients could recall past diagnoses when another
patient was listing symptoms and they were

also able to name generic brands of several
medications.

In the children’s allergy SMA, each child had an allergy skin test performed on the
child’s back. After a period of time, the physician
had to check the children’s backs for the
results. For one o
f the patients, the physician had all the parents gather around the child and he
explained what the results on the child’s back meant. This helped parents more easily
understand their own child’s results

because they were able to emotionally detach from t
he
information
.

In
four
out of the
five
SMAs the physician and/or the behaviorist used a whiteboard to
write down key points, patient ideas, or provide a visual to aid understanding. One of the SMAs
used a PowerPoint slide in an office that did not have a

whiteboard available.

Another SMA
showed charts related to patient health on a big screen television.


Three
out of the
five
SMAs used hands on training. One used models to explain the parts
of an eye while
an
other
used a diagram of the cardiovascular s
ystem to explain how veins and
arteries connect to the heart. The children allergy SMA
used actual food labels to teach patient
caregivers how to interpret the labels
. This same SMA
also
demonstrated how to use an epi
-
pen
with a
fake
epi
-
pen.
Fake
epi
-
p
ens were then given to each of the caregivers, who practiced
using them with the rest of the group.


One of the SMAs used a quiz to determine what patient caregivers did and did not know
about the topic at hand. After each question, the answer was explain
ed regardless of whether or
not the patient caregivers got the answer correct.


Despite being given handouts, paper, and a pen most patients did not write down the
information being communicated. However, during
one

SMA, every patient wrote down the
URL
of a website that contained all of the information that had been given to them that day.
This illustrates that despite all of the important information communicated that day, every
caregiver in the room was interested in obtaining the information online a
fter the SMA was
completed.


Secondary Themes.

A more specific type of learning that occurred in the SMAs was experiential learning. In
four out of the five SMAs patients spoke about how

or what

they had learned from experiences.
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4



On several occasions a
patient would share an experience, which would trigger another patient to
share a similar experience, spurring conversation about what they learned on their own and what
they were learning from the others in the group.

For example:

Patient 1: “I am trying

to quit smoking, but it’s real hard when I’m having a beer with my
buddies.”

Patient 2: “I had to not drink for about a month before I was able to go out and not have a
cigarette.”

Patient 3: “I’m trying to quit


I guess I should do that now before summe
r barbeques and
beers kick in.”

This also is an example of the theme of role modeling, which occurred in
out of the five
SMAs.
Patients spoke about decisions they had made by modeling either others in the group or
others in their network outside of the gr
oup.

The final secondary theme was

communication or interactions

with networks outside of
the SMAs.
In two out of the five SMAs patients spoke specifically about sharing information
with networks outside of the SMA group. In the children with allergy

S
MA, materials were
distributed that were specifically for the patients to share with

other caregivers
. In
one of the
Suboxone

SMAs
, resources outside of the SMA were suggested, though no materials were
distributed.

Competitive Review

Observations,
researc
h
, and client feedback

informed which features were chosen for the
competitive
review. For health education and health literacy
, the competitive review analyzed a
game, note taking tools, expert content, and teaching tools that contained diagrams.
Goal
setting

and health tracking features were
also
reviewed in
these

apps. Three social support applications
were also reviewed, offering insight into user generated content, navigation, and feedback
.

Five out of the six applications were
rated

4+
in the Appl
e store,
but only three were
based on evidence
-
based research. The navigation and design varied between sites and the
usability varied based upon the user interface. The three social networking sites had 5 navigation
items along the bottom of the apps, wh
ile the navigation varied among the three health education
sites.

All of the social networking apps contained user generated content.
Some of the user
generated content was words
, as in DiabeticConnect, while
some was pictures and words

as in
the Eatery or Pinterest
.
All of the health education apps contained expert generated content.
On
Cancer.net
, all of the expert generated content was written, while on
Fooducate
, the app

additionally

used scales
and imagery
.
Cancer.net was the onl
y site that dated its expert content.
Two of the apps provided substantial, immediate feedback or alternative options to support
behavior change.

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5



Several applications integrated with existing phone functionality, Facebook, or other
websites
. O
thers provi
ded features that would enable providers to
tailor

an appointment

to the
patients’ needs

or enable a patient to prepare for an appointment
.

For the full results, s
ee appendices
A
-
H
.


Discussion

Observations


Social support, health literacy/education, and

goal setting emerged in almost all of the
SMAs, which is consistent with what has been found in previous studies. These three themes
differentiate SMAs from
a typical one
-
on
-
one appointment with a physician.

Goal setting

occurred in four out of the five
SMAs

and was typically a major role of the
behaviorist.
Like a number of goal setting articles, the behaviorists or

providers often took a
high level and sometimes ambitious goal and helped create an action plan
consisting of

smaller
objectives
to help th
e patient
more easily
attain the end goal.

T
he goals were often spurred by
conversations with the patient, and therefore based around patient needs

and barriers, which is
consistent with the Social Cognitive Theory.
Although many
goal setting

apps already exist,
creating an app that allows patients to tailor their goals to their needs and create action plans
based on their SMA experience could be a potential niche in the market
, using the
Transtheoretical Model to make the goal setting tailore
d to the patients’ stages
. This
goal setting

approach

is also c
onsistent with several principle
s of adult learning, including needs assessment,
immediacy, and praxis

(Vella, 2002)
.

Praxis, which is action through reflection (Vella,
2002)
, is also eviden
t in the education
part of SMAs, where patients

reflect on experiences that have either helped them cope with a
condition or situation or could potentially help other patients in the SMA do the same.
Social
support transpired

during the SMAs

through story
telling, emotional support, and encouragement.
An app allowing individuals to connect outside of an appointment could
, according to the
research,

increase an individual’s ability to cope with a condition, reach their goals, and improve
their
perceived and

actual
health.

In addition to patient
-
to
-
patient education, the providers used tools throughout the SMA
to help patients or caretakers better understand information

and hopefully increasing their health
literacy, though this is something that could not be

measured through
only
observations
. These
tools could be imitated in a mobile application, continuing the education of the SMAs outside of
the appointment. Communicating information in more than one way
and in an emotionally de
-
escalated environment out
side the
appointment

is
important to increase health literacy and
improve

health outcomes of patients.

There are some major limitations of these observations. First, although the SMAs were
all conducted by different physicians, they were conducted
within

one organization

and

are
therefore
not necessarily representative of SMAs
conducted by

other

organizations. Therefore,
future studies should observe SMAs across different organizations
to determine

similarities and
Bridging the Gap



6



differences. Additionally, only five SM
As were observed, where there are over 50 offered at the
participating organization alone. Finally, the SMA participants were relatively homogenous
within a group. They were either connected by age, condition, or both.
Some SMA groups,
especially those
participating in routine physical appointments, are much more heterogeneous
and may offer a very different experience.

Future research should include a broader spectrum of
SMAs conducted across several different organizations.

The final limitation of thi
s research was
the inability to conduct interviews, which would have provided a stronger basis for
recommendations.
Future research should include interviews with patients

to better understand
the SMA patient’s experience before, du
ring, and after the app
ointment and
also
with providers
to better understand how they would utilize the mobile application in their practice.

Competitive Review

During the competitive review, several benefits and barriers of features were exposed that
should influence the design

of a SMA application.

Social networking and social support apps.

Navigation consistently
appears

at the bottom of all three of these sites, with no more
than five options. For one of the sites, navigation
disappears

to offer more screen real estate,
whic
h decreased the usability. Full screen usage is sometimes essential, but the user should be
aware of how to access the navigation should they enter full screen mode. Because many SMA
participants
are patients managing chronic conditions,
and

can be an
older

population, they
may
not be smart phone savvy

and therefore may
not know how to intuitively find something if it just
disappears

off the screen
.

Pinterest and Diabetic Connect
have

an easy to find privacy policy, which will be very
important for Camb
ria’s health app. In Diabetic Connect, the “Info” button on the welcome
screen offers a link to the privacy policy. In Pinterest, “terms of service” can be found in the
account button once the user is logged in. For Cambria Health’s app, having the priv
acy policy
available to the user before they create an account will be important, as the application will be
collecting personally identifiable information and users, by creating an account, are opting in to
the privacy policy terms. Diabetic Connect iden
tifies in the privacy policy what is considered
personally identifiable information and explains to the user what type of information is collected
,
a standard that Cambria health should follow
.

All three of these sites also have support pages, and
as noted

in the Appendix B
, user
feedback was the major driver for enhancement decisions for Diabetic Connect. Having a
feedback form where users can request new feature sets and feedback on the current ones could
provide Cambria Health with beneficial qualitativ
e information at minimal additional cost once
the support/feedback feature is built.

Both Pinterest and Diabetic Connect
allow

users to br
owse before creating an account so
that users can

explore some of the features before creating an account.

Because
Cambria
Health’s app will be proprietary and will require sign up before being used, this feature could
enable users to explore some of the benefits prior to an account creation and help to
entice
them
to sign up.

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7



Social support
and networking is

the major

goal

of these apps, and two of them integrated
with Facebook, the most popular social site in the world
.
The Eatery

forces users to register
through Facebook, however,

users
were
not pleased that
there is no other way to create an
account

(see Appendix C
). Offering easy sign
-
up through Facebook is becoming a common
option across applications, however, given this feedback it should not be the only option. It is
interesting that Diabetic Connect, the only app concerned with personally identifiable
informa
tion, does not connect with Facebook, and more research should be done with a third
party legal expert to determine if integrating with Facebook should be done.

All three apps
have

user generated content, which is representative of social networking
apps.

However, neither Pinterest nor Diabetic Connect identify in their discussions/boards when
a marketer or expert is the source of information. Like Diabetic Connect, Cambria Health should
not have any advertisements or third party marketing, as this may sk
ew the user’s perception of
the app. However, unlike Diabetic Connect, if there is expert content it should be highlighted as
such, so that users can distinguish
between

their peer’s advice and an expert’s advice.


Some users like the ability to see and
comment on what other users are doing, however,
this is not universal. Connected products can be more persuasive “because they can provide
contingent information


that is, information that takes into account variables that are relevant to
users, their go
als, and their contexts
” (
Fogg, 2003). However, not all users have the desire to
connect to others in a community. One review from The Eatery stated, “It’s addicting to see and
rate what your friends are eating! It actually inspires me to make healthier

choices and track my
eating habits!” (Ellen A, 2011) while another stated “I don’t give a darn about what other people
are eatin
g” (pwm3, 2011). Therefore, Cambria Health should

not have the social networking be
the only feature of the app, nor force thi
ngs to be socially integrated.
This correlates with the
research that showed that users do not often share with their Facebook friends, and in fact may
only want to share with certain people within that network. For this reason it is important to
offer u
sers the option to share or not to share things with the people in

the app community,
with
their Facebook friends
, or with other people in their network through email or text, which
may
help to keep both users who are and who aren’t interested engaged.

Bot
h Pinterest and The Eatery use the phone camera to generate images, which is
advantageous for low literacy adults. Cambria Health may want to integrate the smartphone’s
built in photo and/or video components to enhance their user’s ability to share and re
ceive
information through a channel other than words. Because content is user generated in a social
networking app, if it the content is only written, low literacy adults may be discouraged from
using the feature.

One of the
best

features
in

The Eatery is

the immediacy and type of feedback received.
Having almost instant feedback and rewards for continued use of the application may
, according
to aforementioned research,

increase user engagement. The Eatery
also
offers weekly insights,
but only if you con
tinuously use the app each day throughout the week. This offers an incentive
to users to stay engaged with the application.

Health education and health literacy apps.

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8



Cancer.net
has

similar navigation to the three social networking apps, but
Fooducate

and
DiabetesIQ handle

navigat
ion differently. Fooducate uses
a symbol in the top left corner of all
pages for their navigation. This symbol is intuitive and common for experienced smart phone
users. This feature may not be as intuitive to new smart pho
ne users or those that primarily use
their phone for calls and emails. This feature does, however, offer the application the
opportunity to have more than 5 sections. Diabetes IQ, on the other hand,
does

not have any
other navigation other than the initi
al landing page and a breadcrumb to return to previous pages.
This
makes

the app much more challenging to navigate, as the user cannot jump f
rom section to
section and
must
touch the screen

several times if they are deep within the app to return to the
in
itial landing page.

For expert generated content, Fooducate
does

a good job of using not only words but
also
imagery and scales to increase the users understanding of the information that s/he was
receiving. Cancer.net
contains

a lot of information, but n
o diagrams or images, which could
prove challenging for low health literacy users.
Given the large number of low literacy adults in
the United States, this greatly limits their audience.
However, Cancer.net did include a “last
updated” date on
its
expert generated content, so
that
users
know

how up to date the information
is
. DiabetesIQ presents

their expert content in the form of a presentation, so t
hat users can
not
move around the information freely, which greatly reduced both the usability of th
e app and my
persona
l engagement. Cambria Health needs to tailor all information to low literacy and low e
-
literacy users, making the app accessible to the largest audience possible.

One of the best features in the expert generated content was Fooducate’s

“better options”
section. When facilitating behavior change, it is important to not only educate people on the
severity of their current behavior, but also to offer them cues to action that enable them to change
that behavior
, thereby increasing self
-
ef
ficacy
. With the Fooducate app, a user may discover that
their favorite food has an “F” rating and is quite unhealthy. The user can then immediately click
on “better options” to find substitutes that are healthier. In the customer reviews, David Rachal

(2012)

states, “I love the alternatives presented for my clients who never know what to
substitute”.

Fooducate does not offer extensive user generated content, but it does allow users to
create a shopping list of items and share this list via Twitter, Face
book, or email. It would be
interesting to see if the ability to share product information in the same way would increase
behavior change because of added social support. DiabetesIQ allows users to track exercise,
weigh & BMI, blood pressure, and glucose

and share this via email
.
Unfortunately, this study
did not uncover
if users utilize the option to share this information, and if so, with whom. This
could provide an easy way for patients to track their health and/or goals and share them with a
physici
an prior to an appointment.

Cancer.net has extensive tools for users. One of the tools is the ability to write down
questions for the physician, which allows patients to write down things as they think of them. In
cases where patients may be uncertain t
o ask, the app offers question suggestions. The patient
can then write down answers to these questions during their appointment. This tool builds upon
the established portable and immediate nature of a mobile phone. The question feature of this
app coul
d potentially increase health literacy because it allows patients to recall information
Bridging the Gap



9



when they need it. This tool could be integrated into the SMA app, so that patients are more
prepared when they attend an appointment. The ability to share these ques
tions with the
physician prior to the appointment could also increase the physician’s ability to prepare for
patient questions and have materials that address patients’ concerns on hand
, which research has
shown enables providers to tailor the SMA to the p
atients’ needs
.

Cancer.net, unlike DiabetesIQ, offers users the option to turn off tracking information.
One of the two reviews for DiabetesIQ states, “Another account forced
-
account app

”,
highlighting users concerns with (1) having to create an account

and (2) tracking personal
information. Cancer.net’s approach allows the company to track information, but only if the user
does not choose to opt out
, which should be echoed in Cambria Health’s application
.

Tracking
provides valuable feedback, but shoul
d not be done at the expense of the target audience’s trust.

A competitive review is by nature a limited process, as only six out of hundreds of
thousands of health aps were compared. Health apps need to be continually evaluated, and
research with the tar
get audience should be done in order to better understand impact, efficacy,
and engagement.

Conclusion

Building upon the
three
major themes revealed in the research
, there are several potential
ways that a mobile health application can be used to improve

the health literacy, self
-
management, and overall health of SMA patients.
mHealth is going to continue to evolve, and it
is important that we examine both how it has been used, how it is being used, and how it could
potentially be used moving forward.


A
dditional evidence based research is needed to better understand how feature sets,
design, and user experience impact a mobile health application’s ability to educate or change
behavior.
It is also
needed to better understand user engagement with applica
tions and how it
varies in different audience segmentations.

Appendix
A
.

Competitive Review Template


App Name and Logo

1.

Objective/Problem

What is the objective, problem, or challenge
?

2.

Purpose

/
Goals

/ Objectives

How clear are th
e purpose and goals of the
app

at

a glance from name, tagline, and imagery?


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10



3.

Target audience

Which population(s) does the website serve?

4.

Users

Is there any information about users through
images, stories, or testimonials or about site
usage?


5.

Ratings, reviews & feedback

What are the ratings, reviews, and feedback
(with links)
?

6.

Downloads

How many users and downloads are there?

7.

Research

Was there any research used?

8.

Design

How professional is the design?
Characterize
the design (modern, dated,
simple, crisp…)
and if the design works given the site purpose
and users.

9.

Layout and navigation

What sections does the website have? Are
sections delineated by content type, roles, or
user needs?
How usable
and organized are the
layout and navigation

(including labels and
menus)
? Do they make apparent the options a
user has?

10.

Branding

Does the home page identify the organization
behind the site? Does it make clear their
purpose and goals in general and for the
website in particular?

11.

External affiliat
ions

Is there branding from other organizations,
accreditation (such as HONcode),
sponsorship, Google ads, or advertising?

Bridging the Gap



11



12.

Expert content

What are the expert
-
generated components
(including
text, graphics, audio, video,
blogs,
directions/maps,
ask the
exper
t, glossary, quiz,
chat with an expert)?

If there is content, when
was the content published and reviewed? Is it
dated?

13.

Authors and oversight

Are authors listed and, if so, are their
credentials available? Is there an advisory
board
or clinician inv
olvement
? Is there a
review process?

14.

Readability

Is the content easy to understand? What
reading level is it?

15.

User
-
generated content

What are the user
-
ge
nerated components
(including
discussion forums, blogs, user
-
submitted videos, wikis, social boo
kmarking,
ratings, and reviews)
? Is user
-
generated
content clearly delineated from expert
content?

16.

Policies

Are there explicit privacy policies or ones for
how user
-
generated components managed,
organized, or moderated?

17.

Registration

Do users register and
, if so, what can they do
before and after
registering?


18.

Cost

Is there a cost and if so, what is it?

19.

S
ocial media and content sharing

Which, if any, social media

is used?

Can
content be shared?

20.

Support

Is there a website or support forum for users
?


Bridging the Gap



12



21.

Overall assessment

What are the overall best and worst features of
the
app
?




Appendix B
.

Competitive Review of Social Networking / Social Support Apps



Eatery


Pinterest



Diabetic Connect


1.

Objective /
Problem

According to the press
release, the
purpose of
The Eatery is that it

tracks and analyzes your
overall eating patterns to
give you a big
-
picture
breakdown of your
strengths, weaknesses
and the best places to
make a change
(Rosenthal, 2011)”.

The website states that
the mission of Pinterest
i
s, “
to connect everyone
in the world through the
'things' they find
interesting. We think that
a favorite book, toy, or
recipe can reveal a
common link between
two people. With
millions of new pins
added every week,
Pinterest is connecting
people all over
the world
based on shared tastes
and interests.


https://pinterest.com/abou
t/

The Diabetic Connect
mission is to create social
health networks that
conne
ct people to a
support community of
Diabetics
.

http://www.diabeticconnec
t.com/about

2.

Purpose and
Goals

The purpose is not clear
from the logo, though the
way that the app should
be used is. The tagline is
“A massive health
experiment”, which does
not
offer clarity into how
The name of the app
becomes clear once the
app is used. The play on
words may not be
obvious to lower

literacy
individuals. The
Pinterest website login
screen states, “Pinterest is
The name of this
application makes the
purpose and goals
of the
application very clear,
though the logo does not
offer further clarity.

Bridging the Gap



13



the app benefits the user.

The purpose of the
application becomes
clearer once the user has
logged in and can see the
navigation.

an online pinboard.
Organize and share things
you love”. However, the
mobile login screen has
no such introduction.

3.

Target audience

This app is targeted at
people who want to
monitor their eating
habits in a way that does
not require calorie
counting and time
intensive tracking
methods.

One article stated that
women account for
approximately 60% of the
visitors. There are a
higher percentage of
users in the Midwest,
Northwest, and
Southeast.
(Owens,
2012)

Forbes claims that
women account for 80%
of the base, with twenty
-

and
thirty
-
some
thing
women being the main
target market. (Arthur,
2012)

Diabetic adults

4.

Reviews

See appendix C for
customer reviews.





See appendix D for
customer reviews.

There were no customer
reviews available for this
application.

5.

Ratings

iTunes rating:
Not

enough ratings of current
version. All versions
rating is 4+


http://itunes.apple.com/us
/app/the
-
eatery/id468299990?mt=8

iTunes rating: 4+


http://itunes.apple.com/us
/app/pinterest/id42904799
5?mt=8


iTunes:
Not enough
ratings to display an
ave
rage
for the current
version of this
application.

http://itunes.apple.com/us
/app/diabetic
-
connect/id418076239?mt=
8

Bridging the Gap



14



6.

Downloads

Couldn’t find this data.

Pinterest has become
either the

third
or fourth
most popular social
network in the United
States, behind
Facebook,
Twitter
, and possibly
LinkedIn (depending on
which analytics company
is reporting).


Experian rep Matt
Tatham says Pinterest
beat its next
-
closest
competitor, L
inkedIn, in
total visits in February.
Tatham says the rankings
by total visits for March
is as follows:

1. Facebook: 7 billion

2. Twitter: 182 million

3. Pinterest: 104 million

4. LinkedIn: 86 million


(Wasserman, 2012).

Couldn’t find this data

7.

Research

T
his application does
appear to have been
based on some evidence
based research.

The website states,

Studies show that
simply recording your
meals helps you lose
more weight. It's not
about counting calories


it's about becoming
aware of your habits.


https://eatery.massivehealt
There is no evidence that
shows that research was

used in the development
of this site or app.

There was not much
formative research done
initially on the
application. Alliance
Health knew from the
start that it was a
necessary part of their
strategy to have an app.
There was some
formative research do
ne
with the existing network
to figure out what feature
set should go on mobile.
However, enhancements
were determined based
Bridging the Gap



15



h.com/

One of the blog entries
states,

A study
published by the Kaiser
Permanente Center for
Health Research
discovered that

participants who kept
food journals lost twice
as much weight as those
who did not
.

Documenting what you
eat requires
accountability, can reveal
patterns, and allows you
to

establish realistic
health goals. Whether
you want to eat healthier,
feel better, or lose
weight, recording what
you eat can help you
achieve your objective.


http://blog.massivehealth.
com/post/20376617728/t
aking
-
pictures
-
of
-
your
-
food
-
makes
-
you
-
healthier


on user feedback through
the site.


The UX design for the
Android

version of the
app underwent focus
groups, which resulted in
a

complete redesign of
the Android version so
that it played off of
existing Android phone
features instead of feeling
like an iPhone app.


(Oldroyd, personal
communication, April 12,
2012)

8.

Design

The design is clean, crisp,
and modern. The
features are
(
appropriately) optimized
to work with touch.

The design is simple and
clean. The app uses
iPhone standards and the
features are
(appropriately) optimized
to work with touch. The
app uses screen real
estate very well, using as
much of the limited space

as possible.

The design is simple and
not crowded, though not
as clean or crisp as
Pinterest or The Eatery.
It still has features
optimized to work with
touch. The app does not
use screen real estate as
well as The Eatery or
Pinterest.

Bridging the Gap



16






9.

Layout and
navigation

The navigation persists
on all pages along the
bottom of the screen.
The five sections of the
app are feed, fit or fat,
snap, friends, and me.
Each section has an icon
that clarifies what the
user will be doing if they
touch on that navigation

square.


The navigation is
incredibly clear and easy
to use. The section that
the user is in is in bold,
though not highlighted in
a different color like
Pinterest or Diabetic
Connect.

The navigation persists
on all pages along the
bottom of the
screen.
The five sections of the
app are following,
explore, camera, activity,
and profile. Each section
has an icon that clarifies
what the purpose of that
section is. The images
are not as clear as “The
Eatery” but they are
helpful. Although the
sect
ion that the user is in
is clearly highlighted, the
other sections are hard to
read and could be
challenging for users with
vision impairment.


When scrolling in the
“Following” and
“Activity” sections, the
navigation disappears
from the page until the
The navigation persists
on all pages along the
bottom of the screen.
The five sections of the
app are featured,
discussions, activity,
search, and profile. Each
section has an icon that
clarifies what the purpose
of that section i
s. The
area that the user is
currently in is clearly
highlighted.


Bridging the Gap



17



us
er scrolls back up.



10.

Branding

There is not a lot of
branding throughout the
application. Branding is
consistent in the iTunes
store, in the logo, and on
the website.

The Pinterest logo
appears on every scre
en
of the application, except
for the camera tool.

The Diabetic Connect
logo appears on the
featured and profile
pages, but not on
discussions, activity, or
search.

11.

External
affiliations

There is no branding and
no evident external
affiliation. Being ad
free
helps to keep the design
clean.

The press release states
the funders, “
The
company raised a seed
-
round of venture capital
from Andreessen
Horowitz, Charles River
Ventures, Greylock
Partners, Mohr Davidow
Ventures, Felicis
Ventures, and others.

The co
mpany is based in
San Francisco.”
(Rosenthal, 2011)

There is no branding
from outside
organizations or ads.
However, companies can
post on Pinterest and it is
not always apparent to
users when a pin is being
promoted by a consumer
or a seller.

There is n
o branding
from other organizations,
although other
organizations do partner
with Alliance Health
Networks. There are no
ads either, which helps
ensure the user’s trust in
the app and its purpose.

12.

Expert content

Expert components exist
in the “Me” tab of

the
navigation, where a user
can access graphs to chart
eating habits and insights
about the user’s eating
habits week to week.

There is only user
generated content on
Pinterest.


Diabetic Connect has
partnered with Joslin
Diabetes Center. “
With
this partnership, Diabetic
Connect's 650,000
members can interact
with Joslin's experts,
including diabetes
educators,
endocrinologists and
clinicians, following their
posts, asking questions
and tracking discussions
of interest.
” (Alliance
Bridging the Gap



18




Health Ne
tworks, 2012)
However, if the
professionals are
participating in the
conversations on the app,
it is not clear. Expert
advice is clear on the
corresponding website.

13.

Authors and
oversight

Massive Health, Inc.

Cold Brew Labs

Alliance Health
Networks, Inc.

14.

Readability

The content is easy to
read, however, the
weekly insights may be
more difficult for people
to understand. For
example:

“You ate 83% healthy
this week, 3% better than
last week. Wednesday
was your best day, and
Monday was your worst.”

All in
sights are
complimented
by

visuals,
giving the user a different
way to process the
information.

Content is imagery,
which makes it accessible
to individuals of all
literacy levels. The
descriptions are user
generated and vary in
reading level.


Content

is user generated,
so sometimes it is easy to
understand and other
times not. Users with a
low literacy or health
literacy level may have
trouble participating in
some of the discussions.

Bridging the Gap



19





15.

User
-
generated
content

Users input images and
can label images
with
descriptions. Users can
also comment on other
people’s food.


All content is user
generated, however, (as
stated above) users do not
have a way of knowing if
content has been
generated by consumers
like themselves or
marketers/sellers.



All
content on the app
appears to be user
generated. Expert
content exists on the
Diabetic Connect
website.




Bridging the Gap



20







16.

Policies

No explicit privacy
policies found.

The privacy policy can be
found here:

http://pinterest.com/about
/privacy/

The privacy policy can be
found here:

http://www.diabeticconne
ct.com/privacy
-
policy


17.

Registration

With the newest version
of the app, users must
have a Faceb
ook account
to register. A user needs
to register to use any of
the application features.


Users can register either
through Facebook,
through an invite, or
through using their email.
Users can browse content
without logging in but
cannot create their ow
n
boards, comment on pins,
or follow other users until
they have logged in.

Users can see
discussions, search, and
read the featured
discussion. In order to
participate in the
conversations, a user
must register.

18.

Cost

This is a free app.

This is a free
app.

This is a free app.

19.

S
ocial media
and content
sharing

Users connect through
Facebook and can use
friends to “keep
you
honest and give feedback
on your eating choices.”

Pinterest integrates with
Facebook and use
rs can
choose to share when
they pin or like someone
else’s pin.

This app is a social media
site and does not
integrate with others.
The site is an
amalgamation of
conversations among
Bridging the Gap



21



http://blog.massivehealth.c
om/post/12200155118/no
w
-
available
-
from
-
massive
-
health
-
experiment
-
01
-
the



people with a like
medical condition.


20.

Support

Website:
https://eatery.massiveheal
th.com/

FAQs:
http://eatery.tenderapp.co
m/help/kb

Blog:
http://blog.massivehealth.
com/


http://support.pinterest.co
m/home

http://www.diabeticconne
ct.com/


21.

Overall
assessment

Best features:



Use of the camera



Almost instant
feedback on food
choices



Weekly insights with
visuals

Worst features:



Requires Facebook
Best features:



User generated
content



Use of imagery

Worst features:



No delineation
between user and
expert content

Best features:



Discussions for
social support and
ideas



Discussions
that are
on website show up
on app and vice
versa, so they are
interconnected

Bridging the Gap



22



login


Worst features:



Can’t tell if a
discussion/comment
is coming from an
expert or a user




Bridging the Gap



23



Appendix C
.

Sample of “The Eatery” Customer Reviews

on iTunes





Bridging the Gap



24



Appendix
D
.

Sample of “Pinterest” Customer Reviews

on iTunes




Bridging the Gap



25



Appendix
E
.

Competitive Review of Health Education Apps


Cancer.net


Fooducate


Diabetes IQ


1.

Objective /
Problem

The iTunes

store states
that cancer.net provides

“Accurate oncologist
-
approved cancer
information from
Cancer.Net, with tools to
help plan and manage
your cancer treatment and
care.



The problem is that many
people struggle to read
nutrition labels and/or
determine if the food they
are buying is health
y.
Fooducate is designed to
help people make better
food choices for
themselves and their
family by analyzing
labels and ingredients.

The goal of this app is to
educate and track
Diabetes. According to a
news article, “The app is
intended to explore ho
w
the lifestyle and diet
decisions play out in
terms of blood sugar. Its
end goal is to connect the
theory of managing
diabetes to everyday
reality” (Bardi, 2011).


2.

Purpose and
Goals

The tagline appears at the
top of the home screen,
and clearly states
part of
the purpose of the site

Oncologist
-
approved
cancer information from
the American Society of
Clinical Oncology
”. This
tagline highlights the
expert information,
however, does not
highlight the various
tools available to the
user. The logo does no
t
increase the user’s
understanding of the site
unless the user is familiar
already with the
cancer.net website.
There is no other imagery
The name very clearly
states the purpose of the
site. H
owever, the
imagery, icons, and app
functionality makes the
purpose of the app clear
throughout the
experience.

The name of the title and
the logo both reinforce
the purpose of the app.

Bridging the Gap



26



on the site other than the
logo and user generated
imagery.

3.

Target audience

This app is targeted at
cancer patients.

This app
is targeted at
people who want to make
better food choices, with
a specific focus on
parents.

The app is targeted at
individuals

with Diabetes
over age 13.

4.

Reviews

See appendix F for
customer reviews.





See appendix G for
customer reviews.

See appendix

H for
customer reviews.

5.

Ratings

iTunes rating: 4+


http://itunes.apple.com/us
/app/cancer.net
-
mobile/id433501257?mt=8

iTunes rating: 4+


http://itunes.apple.com/us
/app/fooducate/id3984367
47?mt=8

iTunes rating: 4+


http://itunes.apple.com/us
/app/diabetesiq
-
with
-
ucsf/id464049959?mt=8

6.

Downloads

Couldn’t find this data.

Couldn’t find this data.

This data was
unavailable, but there
were only 11 reviews
which
indicate

either a
low download rate or a
low engagement rate.

7.

Research

The information in this
application is heavily
based on evidence
-
based
research. According to
the cancer.net website,

All content is subject to
a formal peer
-
review
process by
the

Cancer.Net Editorial
Board
, composed of more
than 150 medical,
surgical, radiation, and
pediatric oncologists,
According to the New
York Times, “
Fooducate
said its app used an
algorithm that counted
not just nutrients, but if
the nutrients were added
in processing, which
result
s in a lower score.
Sodium, sugar and
saturated fats count
against a food; fiber and
naturally occurring
nutrients count in a
This app was based on
research done at the
University of California,
San Francisco (UCSF).
According to Bardi
(2011), “
The app
originated with materi
al
developed over the last
few decades at the UCSF
Diabetes Teaching
Center, which has helped
thousands of people with
all types of diabetes
Bridging the Gap



27



oncology nurses, social
wor
kers, and patient
advocates. In addition,
ASCO editorial staff
reviews the content for
easy readability.
Cancer.Net content is
reviewed on an annual
basis or as needed.”

(Cancer.net, 2011)

It is unclear if formative
research was done to
determine the feat
ure set
for the application.
(Note: I have emailed
them to try to get more
information)

food’s favor.


However, no information
could be found to
determine what, if any,
research was used.
Additionally, it is unclear
i
f formative research was
done on the UI/UX of the
site. (Note: I have
emailed them for more
information)

manage their disease.”

It is unclear if formative
research was done to
determine the feature set
for the applicatio
n.
(Note: I have emailed
them to try to get more
information)

8.

Design

The design is simple and
straightforward and has
been scaled for the iPad
without decreasing
usability. However,
increased screen real
estate could be used
better had the iPad design
b
een optimized.


The design is simple,
clean and uncluttered.


The main design is
simple and optimized in
most places.


The overlay in the game
is buggy and confusing
and the icons that need to
be touched for navigation
in the bottom left and
right hand corner are not
44 px. Had the design
and development of the
game been done better, it
Bridging the Gap



28






may be more engaging
and a fun way
of learning
for the user.




9.

Layout and
navigation

The navigation persists
on all pages along the
bottom of the screen.
The five sections are info,
questions, medications,
symptoms, and rss.


The navigation naming is
incredibly clear and easy
to us
e. The section that
the user is in is in
highlighted in blue,
The navigation is
intuitive if the user is
already a
n avid
smartphone user.
However, for a user that
does not use apps much,
the navigation is quite
hidden. The navigation
button is in the top left
hand corner of all
screens.


There is no navigation.
The only way to navigate
to different sections of
the app is from the initial
landing page.

Bridging the Gap



29



making it clear where the
user is. The contrast of
the other sections of the
nav may be difficult to
read for users with vision
impairment.

The advantage of having
such a small navigation is
twofold; (1) it uses less
s
creen real estate and (2)
more than 5 navigation
options can be made
available by creating a
separate screen.






If the user dives deeper
into the app and then
wants to return to the top
Bridging the Gap



30



level or a different
section of the app, s/he
must hit back until at the
homepage. This makes it
hard to go from section to
section within the app.


10.

Branding

The cancer.net name

and
logo is on the landing
page of each section, and
disappears for some
pages that are more clicks
into the application.


Branding is consistent
and evident only through
color usage. Otherwise,
there is no branding once
the user is logged in.

The homep
age has the
app name and a couple of
sections that have the
UCSF logo, including a
section with the UCSF
directory.


Bridging the Gap



31



11.

External
affiliations

A Cancer.net’s

affiliation
with the American
Society of Clinical
Oncology (ASCO) is
stated in the “About Us”
section of the application.
No external affiliations
are evident.

There are advertisements
along the bottom of the
application. An ad free
version is available

for
$3.99.


In the about us section on
the website, Fooducate
states, “
Fooducate is
NOT funded or
influenced by food
manufacturers,
supplement companies,
diets, or any sort of
magic pill.”


http://www.fooduc
ate.com
/about

There is branding from
UCSF and QuantiaMD.

12.

Expert content

Expert content is one of
the major features of this
site. As mentioned
above, all content is
reviewed by experts. A
last updated date is at the
bottom of each
informational page.


Expert content fuels the
major feature of this app,
which is the analyzing of
foods. Product details
include a grade, which
makes it simple for
anyone to, at a glance,
know if the food they are
purchasing is good or
bad.

When you click into the
prod
uct details, it shows
The expert generated
content includes a game,
which currently

is buggy
and only worked about
50% of the time.
However, the concept of
the g
ame is a good one.
Results of users taking
the quiz at the same time
are shared so that a
competitive user can see
how they compare to
others. There are also
several levels to help
keep the user engaged.

Bridging the Gap



32






this grade on a scale,
which will help
individual’s with low
literacy understand the
grade. It also shows the
calories on a scale.

INSERT NEW IMAGE
HERE


DOWNLOAD
WHEN YOU GET
HOME.

The comments offer
additional information
from exp
erts in the
“things to know” section,
which can be seen when
the user scrolls down on
the detail screen.

INSERT COMMENTS
IMAGE HERE.

Another feature of the
app is the “Better
Options” section, which
makes it easy for the user
to find a healthy
alternative
among the
thousands of items on
their grocery store’s
shelf.






There is also a “Did You
Know” section, wh
ich is
information in
presentation format.
Therefore, the user
cannot easily skip the
sections they may be
familiar with or navigate
through the information.
Also, there doesn’t
Bridging the Gap



33



The “Healthy Me”
section of the app shows
which products have been
viewed and their ratings.
It also says how long the
user has been getting
“Fooducated”, offering
another form of feedback.


Finally, daily tips are
offered through the
Fooducate blog both on
the app and on the site.

INSERT BLOG IMAGE
HERE.

appear to be an index of
the Did You Know
sections or a way to
navigate to o
ther
information other than
that which is displayed
on the homepage.



However, at the end of a
Did you Mean
presentation, DiabetesIQ
does offer the user the
option of receiving more
information on a topic,
which is a good cue to
help further improve the

user’s knowledge.


They also offer the user
the opportunity to share
the presentation.

Bridging the Gap



34





13.

Authors and
oversight

ASCO

Fooducate, Ltd.

UCSF & QuatiaMD

14.

Readability

All content is tested for
readability, however, this
is complicated
information and reading

level could be further
decreased. There are
many long sentences with
undefined terms. Low
literacy individuals could
be aided with images or
audio, which is currently
not available.


Images, scales, and
simple ratings make this
app ideal for low health

literacy and low literacy
individuals. Some of the
contents are more
complex and the “things
to know” section could
be optimized for a lower
literacy level.

Much of the information
is easy to read, but use of
diagrams, images, and
lower literacy level
wo
uld improve the app
for low health literacy
users.

Bridging the Gap



35



15.

User
-
generated
content

Users can write questions
for their physician and
then later write answers.



If a user cannot think of a
question, the app
suggests some for
him/her.

Users can generate
content in a variety of
ways. First, they can
create a shopping list
after browsing through
foods. This is especially
nice after using the
“Better Options” feature.


Users can also comment,
like, or “
don’t like” a
product


similar to
Facebook.




Users can track their
exercise, weight & BMI,
blood pressure, and
glucose.



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36




Users can also record
information about their
medications. The user
can take a picture and
then add the drug name,
dosage, frequency, who it
was prescribed by, when
they started taking it, and
any notes.




They can also share this
information with others.


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37






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38




Finally, users can track
their symptoms u
sing the
symptom tracker.



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39





16.

Policies

The privacy policy is
located at the bottom of
the “Info”
screen, which
is the landing screen for
the application. It is very
short, and offers the user
the option to turn off
tracking information.

There is a policy
presented the first time
that the app is
downloaded. This policy
does not appear each time
the

app is opened,
however, so if different
users use the same phone
they may not have read
the information.

The membership
agreement must be
agreed to prior to creating
an
account and is also
available at all times in
the settings section of the
app. Unfortunately, this
app does collect
personally identifiable
information and does not
offer individuals the
opportunity to opt out,
though personal health
information (PHI) is
not
collected.

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40





If using Facebook to
login, the application
states what Facebook has
access to.






17.

Registration

Users do not have to
register to use the app. In
the persistent header at
the top of the page, there
is lock symbol. This
allows the user to enter a
passcode if they want to
protect the information
kept in the app.


Users can use the app as
a guest, sign in through
email, or use Facebook.


Users are taken to the
web to register. They
must create a free
account in order to access
anything in the
application.

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41



18.

Cost

This is a free app.

This is a free app.

This is a free

app.

19.

S
ocial media
and content
sharing

There is no connection to
social media in this app,
nor is the ability to share
the content in the app
with others.


Users can share their
shopping list through
email,
Facebook
, or
twitter. However, users
cannot sha
re product
information.


The user can share that
they have seen a
presentation using the
“refer” button after
viewing. However, it
jumps the user out of the
app to the email client.



The user can also email
health tracking.

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42




20.

Support

There is a page
in the
“Info” section called
“Patient Helpline” from
which the user can email
cancer.net. There was no
obvious support link on
the website for the app,
however.


There is a support page
where users can ask
questions, post ideas, and
read others comments.


https://getsatisfaction.co
m/fooducate


There is also an FAQ
section in the main
navigation of the app and
the ability to email
Fooducate.



In the setting page there
is an option to email or
call
QuantiaCare Support.
If the user click on email,
it takes him/her to his/her
email client on the phone.




If the user clicks on call,
s/he can either add the
phone number to his/her
contacts or copy the
phone number to the
clipboard.


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43





21.

Overall
assessm
ent

Best features:



Ability to take a
picture of medication
and write
information down
about it



Ability to write down
questions (and later
answers) for
physician and
suggested questions
available if patient is
unsure what to ask



Symptom tracker



Expert
content

Worst features:



Links all go to the
website, instead of
linking to other parts
of the application



Not enough visuals
in the expert
information



Cannot share the
information in the
app easily with
others

Best features:



Immediate feedback
on food
choices
through scan



Ability to create and
share shopping list



Use of simple
grading system and
scales for
comparability



Use of alternatives to
help with behavior
change

Worst features:



Can’t share product
info

Best features:



Ability to search for
doctor/
pharmacy in
any area


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44







Ability to track
exercise, weigh/BMI,
blood pressure, and
glucose and share
this tracking with
someone via email

Worst features:



Buggy game



Information is shared
in presentation
format, and user
cannot navigate to
other informati
on or
share information



No navigation to
move from section to
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45



section within the
app




Appendix F
.

Sample of “
Cancer.net
” Customer Reviews

on iTunes





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46



Appendix G.

Sample of “Fooducate” Customer Reviews on iTunes





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47



Appendix H
.

Sample of “Diabetes IQ” Customer Reviews