Views on Mobile Health Apps for Skin Cancer Screening in the General Population

An In-depth Qualitative Exploration of Perceived Barriers and Facilitators

T.E. Sangers; M. Wakkee; E.C. Kramer-Noels; T. Nijsten; M. Lugtenberg

The British Journal of Dermatology. 2021;185(5):961-969.

Abstract and Introduction

Abstract

Background: Mobile health (mHealth) applications (apps) incorporating artificial intelligence for skin cancer screening are increasingly reimbursed by health insurers. However, an in-depth exploration of the general public's views towards these apps is lacking.

Objectives: To explore the perceived barriers and facilitators towards mHealth apps for skin cancer screening among the Dutch general population.

Methods: A qualitative study consisting of four focus groups with 27 participants was conducted. A two-stage purposive sampling method was used to include information-rich participants from the Dutch general population with varying experience of mHealth. A topic guide was used to structure the sessions. All focus group meetings were transcribed verbatim and analysed in thematic content analysis by two researchers using several coding phases, resulting in an overview of themes and subthemes, categorized as (sub-)barriers and (sub)facilitators.

Results:Main barriers to using mHealth apps included a perceived lack of value, perception of untrustworthiness, preference for a doctor, privacy concerns, a complex user interface, and high costs. The main factors facilitating the use of mHealth among the general population were a high perceived value, a transparent and trustworthy identity of app developers, endorsement by healthcare providers and government regulating bodies, and ease and low costs of use.

Table 1. Participants' characteristics
	Participants, n	Median age, years (IQR)	Female	Previous experience with mHealth	History of skin cancer
Focus group 1 (CZ)^a	5	50 (44–62)	4 (80)	0 (0)	2 (40)
Focus group 2 (CZ)^a	6	70 (62–71)	3 (50)	2 (33)	2 (33)
Focus group 3 (Social media)^b	8	23 (20–26)	6 (75)	6 (75)	0 (0)
Focus group 4 (Social media)^b	8	22 (19–25)	5 (63)	3 (38)	0 (0)
Total	27	25 (21–56)	18 (68)	11 (41)	4 (15)

Values are n (%) unless otherwise stated. IQR, interquartile range; mHealth, mobile health apps (in general). ^aCustomer panel of health insurer CZ. ^bPanel recruited though social media.

Table 2. Identified main barriers to and facilitators of using mobile health (mHealth) apps for skin cancer screening, with respective sub-barriers and subfacilitators in italics
Barriers	Facilitators
Perceived lack of value of mHealth apps for skin cancer screening Limited knowledge about the usefulness and functionality Lack of concern towards skin cancer Lack of integration with healthcare system Perception of untrustworthiness Perceived lack of accuracy Doubts about the reliability of the app developer Preference for a doctor instead of an app Privacy concerns Unsolicited personal data sharing by trackers and spyware Complex and distracting user interface Difficult in-app navigation In-app commercial advertising Perceived high costs associated with using mHealth Cost in relation to GP visit	Perceived high value of mHealth apps for skin cancer screening Performing a skin cancer risk assessment from home Monitoring suspicious skin lesions over time Integration with skin cancer care Transparent and trustworthy identity of the app developer Endorsement from healthcare providers (GPs, dermatologists) and government regulating bodies. Endorsement from healthcare providers Government regulation Ease of use Simple user interface Easy to perform a risk assessment Usable by all ages Added value of an app over website Low (or no) cost of use The possibility of reimbursement by health insurers

GP, general practitioner.

Table 3. Illustrative participant quotations on barriers to using mobile health (mHealth) apps for skin cancer screening
Barrier	Participant quotation
Perceived lack of value of mHealth apps for skin cancer screening	'I don't have an app, because I don't see the need for it anyway.' Participant Focus Group 2
Perception of untrustworthiness	'Yeah, sort of, I'd do a little research myself into how well that algorithm would work, but it sounds like an algorithm that says whether a picture is good or not. That sounds a bit like it's doubtful whether it works at all.' Participant Focus Group 4
Preference for a doctor instead of an app	'It's not a resistance to an app. It's not. But it's me as a person who'd rather have someone live in front of me. […] That just seems a lot more truthful and believable as you have someone to talk to.' Participant Focus Group 2
Privacy concerns	'It's more about what you look for, because when you download an app like that, it's really quite personal data that you send. Sometimes you take a photo and so on, you just don't want it to be linked to you, in general. So, in that respect, I really wouldn't want to create an account.' Participant Focus Group 4
Complex and distracting user interface	'I have no idea. I just couldn't figure it out. So I thought it was very user-unfriendly.' Participant Focus Group 2
Perceived high costs associated with using mHealth	'… [I]f you go to the doctor it's free and if you have an app, so yes less reliable in your opinion and then you have to pay, and if you go to the doctor it is included in your health insurance. That's weird, isn't it?' Participant Focus Group 2

Table 4. Illustrative participant quotations on facilitators of using mobile health (mHealth) apps for skin cancer screening
Facilitator	Participant quotation
Perceived high value of mHealth apps for skin cancer screening	'I always feel a little burden to go to the GP, with the idea that it is actually not necessary to go to the GP.' Participant Focus Group 4
Transparent and trustworthy identity of the app developer	'Is there a team behind this or is it clear that an algorithm determines what's going on? Or does it involve a real doctor or whatever?' Participant Focus Group 1
Endorsement by healthcare providers (GPs, dermatologists) and government regulating bodies	'… [I]f you would also give it approval because of a ministry or because of a legal regulation or something like that, this guarantee should be legal. The responsibility lies with the government with regard to its quality.' Participant Focus Group 2
Ease of use	'User-friendliness is an important precondition if you want to entice people to use it.' Participant Focus Group 2
Low (or no) cost of use	'If my insurance company says I can use that app for free, I'm quite willing to try it.' Participant Focus Group 2