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Background: There is a lack of hearing health care globally, and tele-audiology and mobile technologies have been proposed as important strategies to reduce the shortfall. Objectives: To investigate the accuracy and reliability of smartphone self-test audiometry in adults, in community clinics in low-income settings.

Methods: A prospective, intra-individual, repeated measurements design was used. Sixty-three adult participants (mean age 52 years, range 20-88 years) were recruited from ENT and primary health care clinics in a low-income community in Tshwane, South Africa. Air conduction hearing thresholds for octave frequencies 0.5 to 8 kHz collected with the smartphone self-test in non-sound treated environments were compared to those obtained by reference audiometry.

Results: The overall mean difference between threshold seeking methods (ie, smartphone thresholds subtracted from reference) was -2.2 dB HL (n = 467 thresholds, P = 0.00). Agreement was within 10 dB HL for 80.1% (n = 467 thresholds) of all threshold comparisons. Sensitivity for detection hearing loss >40 dB HL in one ear was 90.6% (n = 84 ears), and specificity 94.2% (n = 84 ears).

Conclusion: Smartphone self-test audiometry can provide accurate and reliable air conduction hearing thresholds for adults in community clinics in low-income settings.

Background: Stress urinary incontinence (SUI) affects 10%-39% of women. Its first-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed supervised or unsupervised. Health apps are increasing in number and can be used to improve adherence to treatments. We developed the Tät app, which provides a 3-month treatment program with a focus on PFMT for women with SUI. The app treatment was evaluated in a randomized controlled trial, which demonstrated efficacy for improving incontinence symptoms and quality of life. In this qualitative interview study, we investigated participant experiences of the app-based treatment.

Objective: This study aimed to explore women’s experiences of using an app-based treatment program for SUI.

Methods: This qualitative study is based on telephone interviews with 15 selected women, with a mean age of 47 years, who had used the app in the previous randomized controlled trial. A semistructured interview guide with open-ended questions was used, and the interviews were transcribed verbatim. Data were analyzed according to the grounded theory.

Results: The results were grouped into three categories: “Something new!” “Keeping motivation up!” and “Good enough?” A core category, “Enabling my independence,” was identified. The participants appreciated having a new and modern way to access a treatment program for SUI. The use of new technology seemed to make incontinence treatment feel more prioritized and less embarrassing for the subjects. The closeness to their mobile phone and app features like reminders and visual graphs helped support and motivate the women to carry through the PFMT. The participants felt confident that they could perform the treatment program on their own, even though they expressed some uncertainty about whether they were doing the pelvic floor muscle contractions correctly. They felt that the app-based treatment increased their self-confidence and enabled them to take responsibility for their treatment.

Conclusions: Use of the app-based treatment program for SUI empowered the women in this study and helped them self-manage their incontinence treatment. They appreciated the app as a new tool for supporting their motivation to carry through a slightly challenging PFMT program.

Trial Registration: ClinicalTrials.gov NCT01848938; https://clinicaltrials.gov/ct2/show/NCT01848938 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01848938)

Introduction: Both the demands and the options for patients to communicate with health care providers utilizing eHealth solutions are increasing. Some patients, or relatives to patients, want to consult another health care provider than the regular one, merely in text.

Objective: To improve text-based medical consultation by learning from long-term experiences.

Materials and methods: Physicians with comprehensive experience of answering free-text medical inquiries at an official health portal in Sweden were interviewed. The interviews were analyzed using a grounded theory approach.

Results: Over time, the interviewed physicians developed strategies on how to formulate the answer to a medical inquiry from a previously unknown inquirer. The answering physicians experienced their primary role as providers of medical information and as mediators between an inquirer and the regular health care provider. Many of the answering physicians experienced a personal development with improved communication skills, also in face-to-face meetings with patients.

Conclusion: Text-based medical consultation is part of an expanding area in eHealth. The development of strategies, guidelines, ethical considerations as well as educational efforts are needed to optimize the skills of asynchronous text-based health consultation.

AIMS: To evaluate the effect of a mobile app treatment for stress urinary incontinence (SUI) in women.

METHODS: Randomized controlled trial, conducted 2013-2014 in Sweden. Community-dwelling adult women with ≥1 SUI episode/week recruited through our website and randomized to app treatment (n = 62) or control group (postponed treatment, n = 61). One participant from each group was lost to follow-up. Intervention was the mobile app Tät(®) with a treatment program focused on pelvic floor muscle training (PFMT), and information about SUI and lifestyle factors. Primary outcomes, 3 months after randomization: symptom severity (International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form [ICIQ-UI SF]); and condition-specific quality of life (ICIQ Lower Urinary Tract Symptoms Quality of Life [ICIQ-LUTSqol]).

RESULTS: One hundred and twenty-three women were included (mean age 44.7), with moderate/severe SUI (97.5%, 120/123), mean ICIQ-UI SF score 11.1 (SD 2.8) and mean ICIQ-LUTSqol score 34.4 (SD 6.1) at baseline. At follow-up, the app group reported improvements in symptom severity (mean ICIQ-UI SF score reduction: 3.9, 95% confidence interval 3.0-4.7) and condition-specific quality of life (mean ICIQ-LUTSqol score reduction: 4.8, 3.4-6.2) and the groups were significantly different (mean ICIQ-UI SF score difference: -3.2, -4.3to -2.1; mean ICIQ-LUTSqol score difference: -4.6, -7.8 to -1.4). In the app group, 98.4% (60/61) performed PFMT at follow-up, and 41.0% (25/61) performed it daily.

CONCLUSIONS: The mobile app treatment was effective for women with SUI and yielded clinically relevant improvements. This app may increase access to first-line treatment and adherence to PFMT.

AIMS: To perform a deterministic cost-utility analysis, from a 1-year societal perspective, of two treatment programs for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post. The treatments were compared with each other and with no treatment.

METHODS: We performed this economic evaluation alongside a randomized controlled trial. The study included 250 women aged 18-70, with SUI ≥ 1 time/week, who were randomized to 3 months of pelvic floor muscle training via either an Internet-based program including e-mail support from an urotherapist (n = 124) or a program sent by post (n = 126). Recruitment was web-based, and participants were self-assessed with validated questionnaires and 2-day bladder diaries, supplemented by a telephone interview with a urotherapist. Treatment costs were continuously registered. Data on participants' time for training, incontinence aids, and laundry were collected at baseline, 4 months, and 1 year. We also measured quality of life with the condition-specific questionnaire ICIQ-LUTSqol, and calculated the quality-adjusted life-years (QALYs) gained. Baseline data remained unchanged for the no treatment option. Sensitivity analysis was performed.

RESULTS: Compared to the postal program, the extra cost per QALY for the Internet-based program ranged from 200€ to 7,253€, indicating greater QALY-gains at similar or slightly higher costs. Compared to no treatment, the extra cost per QALY for the Internet-based program ranged from 10,022€ to 38,921€, indicating greater QALY-gains at higher, but probably acceptable costs.

CONCLUSION: An Internet-based treatment for SUI is a new, cost-effective treatment alternative.

OBJECTIVES: To evaluate the long-term effects of two non-face-to-face treatment programmes for stress urinary incontinence (SUI) based on pelvic floor muscle training (PFMT).

SUBJECTS AND METHODS: The present study was a randomized controlled trial with online recruitment of 250 community-dwelling women aged 18-70 years with SUI ≥ one time/week. Diagnosis was based on validated self-assessed questionnaires, 2-day bladder diary and telephone interview with a urotherapist. Consecutive computer-generated block randomization was carried out with allocation by an independent administrator to 3 months of treatment with either an internet-based treatment programme (n = 124) or a programme sent by post (n = 126). Both interventions focused mainly on PFMT. The internet group received continuous e-mail support from a urotherapist, whereas the postal group trained on their own. Follow-up was performed after 1 and 2 years via self-assessed postal questionnaires. The primary outcomes were symptom severity (International Consultation on Incontinence Questionnaire Short Form [ICIQ-UI SF]) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life [ICIQ-LUTSqol]). Secondary outcomes were the Patient Global Impression of Improvement, health-specific quality of life (EQ-visual analogue scale [EQ-VAS]), use of incontinence aids, and satisfaction with treatment. There was no face-to-face contact with the participants at any time. Analysis was based on intention-to-treat.

RESULTS: We lost 32.4% (81/250) of participants to follow-up after 1 year and 38.0% (95/250) after 2 years. With both interventions, we observed highly significant (P < 0.001) improvements with large effect sizes (>0.8) for symptoms and condition-specific quality of life (QoL) after 1 and 2 years, respectively. No significant differences were found between the groups. The mean (sd) changes in symptom score were 3.7 (3.3) for the internet group and 3.2 (3.4) for the postal group (P = 0.47) after 1 year, and 3.6 (3.5) for the internet group and 3.4 (3.3) for the postal group (P = 0.79) after 2 years. The mean changes (sd) in condition-specific QoL were 5.5 (6.5) for the internet group and 4.7 the for postal group (6.5) (P = 0.55) after 1 year, and 6.4 (6.0) for the internet group and 4.8 (7.6) for the postal group (P = 0.28) after 2 years. The proportions of participants perceiving they were much or very much improved were similar in both intervention groups after 1 year (internet, 31.9% [28/88]; postal, 33.8% [27/80], P = 0.82), but after 2 years significantly more participants in the internet group reported this degree of improvement (39.2% [29/74] vs 23.8% [19/80], P = 0.03). Health-specific QoL improved significantly in the internet group after 2 years (mean change in EQ-VAS, 3.8 [11.4], P = 0.005). We found no other significant improvements in this measure. At 1 year after treatment, 69.8% (60/86) of participants in the internet group and 60.5% (46/76) of participants in the postal group reported that they were still satisfied with the treatment result. After 2 years, the proportions were 64.9% (48/74) and 58.2% (46/79), respectively.

CONCLUSION: Non-face-to-face treatment of SUI with PFMT provides significant and clinically relevant improvements in symptoms and condition-specific QoL at 1 and 2 years after treatment.

Stress urinary incontinence is common and sometimes embarrassing. New, simple, and easily accessible treatments are needed. We telephone interviewed 21 women who participated in a randomized controlled study comparing two treatment programs based on instructions for pelvic floor muscle training. One program was Internet-based and included email support by a urotherapist; the other was sent by post. There was no face-to-face contact in either program. Our main aim was to explore the women's experiences of the Internet-based treatment. Grounded theory analysis revealed three categories: hidden but present, at a distance but close, and by myself but not alone. These were incorporated in a core category: acknowledged but not exposed. The leakage was often a well-hidden secret, but the study treatments lowered the barrier for seeking care. In the Internet group, a supportive patient-provider relationship developed despite the lack of face-to-face contact. Internet-based treatment programs can increase access to care and empower women.

Objective To compare two treatment programmes for stress urinary incontinence (SUI) without face-to-face contact: one Internet-based and one sent by post.

Patients and Methods Randomised, controlled trial conducted in Sweden 2009-2011. Computer-generated block-randomisation, allocation by independent administrator. No 'blinding'. The study included 250 community-dwelling women aged 18-70 years, with SUI >= 1 time/week. Consecutive online recruitment. The women had 3 months of either; (i) An Internet-based treatment programme (124 women), including e-mail support and cognitive behavioural therapy assignments or (ii) A treatment programme sent by post (126). Both programmes focused mainly on pelvic floor muscle training.

Primary outcomes symptom-score (International Consultation on Incontinence Questionnaire Short Form, ICIQ-UI SF) and condition-specific quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life, ICIQ-LUTSQoL).

Secondary outcomes (i) Patient Global Impression of Improvement, (ii) Incontinence aids, (iii) Patient satisfaction, (iv) Health-specific QoL (EQ5D-Visual Analogue Scale), and (v) Incontinence episode frequency. Follow-up after 4 months via self-assessed postal questionnaires.

Results In all, 12% (30 women) were lost to follow-up. Intention-to-treat analysis showed highly significant improvements (P < 0.001) with large effect sizes (>0.8) with both interventions, but there were no significant differences between groups in primary outcomes. The mean (SD) changes in symptom-score were: Internet 3.4 (3.4), Postal 2.9 (3.1) (P = 0.27). The mean (SD) changes in condition-specific QoL were: Internet 4.8 (6.1), Postal 4.6 (6.7) (P = 0.52). Compared with the postal-group, more participants in the Internet-group perceived they were much or very much improved (40.9% (43/105) vs 26.5% (30/113), P = 0.01), reported reduced usage of incontinence aids (59.5% (47/79) vs 41.4% (34/82), P = 0.02) and were satisfied with the treatment programme (84.8% (89/105) vs 62.9% (71/113), P < 0.001). Health-specific QoL improved in the Internet-group (mean change 3.7 (10.9), P = 0.001), but not in the postal-group (1.9 (13.0), P = 0.13). Overall, 69.8% (120/172) of participants reported complete lack of leakage or reduced number of leakage episodes by >50%.

Conclusions Concerning primary outcomes, treatment effects were similar between groups whereas for secondary outcomes the Internet-based treatment was more effective. Internet-based treatment for SUI is a new, promising treatment alternative.

Objective. The main hypothesis, and the objective of the study, was to test if the participants allocated to the treatment group would show a larger reduction in depressive symptoms than those in the control group. Methods. This study was a randomized nine week trial of an Internet-administered treatment based on guided physical exercise for Major Depressive Disorder (MDD). A total of 48 participants with mild to moderate depression, diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders, were randomized either to a treatment intervention or to a waiting-list control group. The main outcome measure for depression was the Beck Depression Inventory-II (BDI-II), and physical activity level was measured using the International Physical Activity Questionnaire (IPAQ). The treatment program consisted of nine text modules, and included therapist guidance on a weekly basis. Results. The results showed significant reductions of depressive symptoms in the treatment group compared to the control group, with a moderate between-group effect size (Cohen's d = 0.67; 95% confidence interval: 0.09-1.25). No difference was found between the groups with regards to increase of physical activity level. For the treatment group, the reduction in depressive symptoms persisted at six months follow-up. Conclusions. Physical activity as a treatment for depression can be delivered in the form of guided Internet-based self-help.