mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

Anna Garnett; Melissa Northwood; Justine Ting; Ruheena Sangrar

doi:10.2196/33085

mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

Garnett, Anna; Northwood, Melissa; Ting, Justine; Sangrar, Ruheena 2022-07-08 00:00:00 Background: Informal caregivers, hereafter referred to as caregivers, provide support to older adults so that they can age safely at home. The decision to become a caregiver can be influenced by individual factors, such as personal choice, or societal factors such as social determinants of health, including household income, employment status, and culture-specific gender roles. Over time, caregivers’ health can be negatively affected by their caregiving roles. Although programs exist to support caregivers, the availability and appropriateness of services do not match caregivers’ expressed needs. Research suggests that supportive interventions offered through mobile health (mHealth) technologies have the potential to increase caregivers’ access to supportive services. However, a knowledge gap remains regarding the extent to which social determinants of health are considered in the design, implementation, and evaluation of mHealth interventions intended to support the caregivers of older adults. Objective: This study aimed to conduct a systematic review to determine how health equity is considered in the design, implementation, and evaluation of mHealth interventions for caregivers of older adults using Cochrane Equity’s PROGRESS-Plus (place of residence, race, ethnicity, culture, language, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation) framework and synthesize evidence of the impacts of the identified caregiver-focused mHealth interventions. Methods: A systematic review was conducted using 5 databases. Articles published between January 2010 and June 2021 were included if they evaluated or explored the impact of mHealth interventions on the health and well-being of informal caregivers of older adults. mHealth interventions were defined as supportive services, for example, education, that caregivers of older adults accessed via mobile or wireless devices. Results: In total, 28 articles met the inclusion criteria and were included in the review. The interventions evaluated sought to connect caregivers with services, facilitate caregiving, and promote caregivers’ health and well-being. The PROGRESS-Plus framework factors were mainly considered in the results, discussion, and limitations sections of the included studies. Some PROGRESS-Plus factors such as sexual orientation, religion, and occupation, received little to no consideration across any phase of the intervention design, implementation, or evaluation. Overall, the findings of this review suggest that mHealth interventions were positively received by study participants. Such interventions have the potential to reduce caregiver burden and positively affect caregivers’ physical and mental health while supporting them as caregivers. The study findings highlight the importance of making support available to help facilitate caregivers’ use of mHealth interventions, as well as in the use of appropriate language and text. Conclusions: The successful uptake and spread of mHealth interventions to support caregivers of older adults will depend on creating opportunities for the inclusive involvement of a broad range of stakeholders at all stages of design, implementation, and evaluation. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al (JMIR Aging 2022;5(3):e33085) doi: 10.2196/33085 KEYWORDS caregivers; older adults; mobile health; social determinants of health; intervention; mobile phone mobile apps have the potential to have a greater positive impact Introduction on caregivers by providing support, communication, and facilitation of care, thereby reducing the burden and positively Background affecting caregiver health outcomes [24]. However, to the best Globally, it is estimated that 101 million older adults require of our knowledge, a systematic review of the impact of mHealth care from a friend or family caregiver (informal caregiver; support on caregivers of older adults does not currently exist. hereafter referred to as caregiver), with women providing most Furthermore, to date, reviews on standard caregiver interventions of the support [1]. The support provided by these informal suggest that limited work has been conducted to determine the caregivers is often crucial for enabling older adults to safely suitability of these interventions for caregivers from remain in their home environment [2-4]. Caregiving support, backgrounds representing diverse social determinants of health such as assistance with activities of daily living, attending characteristics [25]. Individual characteristics, such as appointments, and health management, is associated with sociodemographic characteristics and the ability to engage with positive outcomes for both caregivers [5,6] and care recipients technology, should be considered in the design of mHealth [7]. Although caregivers often willingly engage in caring, their interventions [26]. role can negatively affect their psychological well-being, Therefore, the objectives of this systematic review were to (1) particularly when care is provided over a prolonged period determine how health equity is considered in the design, [8-10]. implementation, and evaluation of mHealth interventions aimed The Social Determinants of Health and Inequities at caregivers of older adults using the Cochrane Equity Among Caregivers PROGRESS-Plus (place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus The social determinants of health can influence entry into the age, disability, and sexual orientation) framework [27] and (2) caregiving role and the subsequent experience of being a synthesize the evidence on the impacts of caregiver-focused caregiver. For example, factors such as being a woman, lower mHealth interventions, subsequently discussed through a health educational attainment, and living in a rural setting can bias equity lens. caregiving toward individuals who may perceive that they have little agency in their choice to become a caregiver [11]. Furthermore, a greater intensity of caregiving has been identified Methods among caregivers who are female, people of color, and of lower A systematic review was conducted in accordance with the socioeconomic status [12]. These inequities highlight the need PRISMA (Preferred Reporting Items for Systematic Reviews for interventions with both scope and accessibility to support and Meta-Analyses) statement guidelines [28]. The protocol caregivers with varied demographic characteristics. for this systematic review was registered on PROSPERO Although some programs and community initiatives are (International Prospective Register of Systematic Reviews; available to support caregivers, the literature suggests that CRD42021239584) and is available for electronic access [29]. caregivers struggle to access these supportive services [13-15]. Research Questions Challenges in system navigation, accessing support, geographic location, and scheduling factors can impede the successful use The research questions guiding this systematic review were as of services [16,17]. Recent research indicates that supportive follows: services provided or augmented through mobile health • To what extent is health and social equity considered in the (mHealth) technologies have the potential to make services design, implementation, and evaluation of mHealth more accessible to caregivers [18-20]. interventions for caregivers of older adults? mHealth Interventions as a Potential Solution for • What are the impacts of the examined mHealth interventions on caregivers of older adults based on the following Caregiver Support outcomes: caregiver mental and physical health, caregivers’ The term mobile health (mHealth) was first coined in 2003 in ability to provide care, usability or feasibility of the mHealth response to the rapid development and expansion of mobile intervention for caregivers, and caregivers’ experiences and communication technologies being used within the health care perspectives of engaging in an mHealth intervention industry [21]. The World Health Organization defines mHealth intended to support them? as a “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, Eligibility Criteria personal digital assistants, and other wireless devices” [22]. The Eligible articles were available in full text in the English use of health information technology (computer, internet, and language and were published from 2010 onward to reflect the email) to access health records or locate health information on recent surge in mHealth interventions, concurrent with the rapid the web has become commonplace among caregivers as a means increase in mobile device ownership within the past decade of informing their caregiving role [23]. Research suggests that [30,31]. This review included both quantitative (experimental, https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al quasi-experimental, and observational studies with or without strategy development. Database searches combined a control or comparison groups) and qualitative study designs, comprehensive suite of similar and related terms for the key which evaluated or explored the impacts of mHealth domains of caregivers, older adults, and mHealth interventions. interventions aimed at improving the health of, or providing Detailed search strategies for each database are provided in support to, informal caregivers of older adults. Mixed methods Multimedia Appendix 1. The search results were limited by the studies were also included. mHealth interventions were defined year of publication from 2010 to February 2021, when the search as those that the caregivers of older adults accessed via mobile was initially conducted. The search strategy was repeated in or wireless devices (including mobile phones, tablets, handheld June 2021 to capture newly published articles. Ancestry searches computers, and PDAs). Interventions not accessed by mobile were also conducted using the reference lists of eligible studies, or wireless devices (eg, interventions applied or accessed by as well as related reviews [19,32-34], to search for additional landline telephone as opposed to mobile phone) were excluded, potential articles for inclusion. as were mHealth interventions that targeted the recipient of care Eligible studies identified from the database and ancestry only or only assessed outcomes focused on the recipient of care. searches were independently assessed by a group of 4 reviewers Studies that exclusively included formal caregivers of older (AG, MN, RS, and JT). Each document was reviewed by 2 adults (eg, nurses and personal support workers) or caregivers reviewers (AG, MN, RS, or JT) based on the title and abstract. of individuals who were not identified as older adults (eg, The full texts of relevant studies were then obtained, and 2 children, adolescents, young and middle-aged adults, or adults reviewers (AG, MN, RS, or JT) independently examined the aged <65 years) were also excluded. full texts of the selected studies to determine the final included Eligible studies were also required to report at least one articles in accordance with the eligibility criteria outlined caregiver-specific outcome or finding, including those relating previously. Covidence systematic review software (Veritas to (1) caregiver mental and physical health, (2) caregivers’ Health Innovation) was used to organize the search results and ability to provide care, (3) usability or feasibility of the mHealth facilitate communication between the reviewers. Disagreements intervention by caregivers, and (4) caregivers’ experiences and were resolved by consensus. In cases where consensus could perspectives of engaging in mHealth interventions intended to not be reached, a third reviewer resolved the disagreement. support them. Research protocols, dissertations, reviews, The search strategy yielded an initial 1629 articles for screening commentaries, and abstracts were also excluded. of titles and abstracts. On the basis of the initial screening, the full texts of the 3.31% (54/1629) of articles were assessed. Of Search Strategy and Study Selection the 54 articles, 26 (48%) were subsequently excluded after a A systematic search was conducted on five databases: PubMed, full-text review. The literature search and study selection PsycINFO (ProQuest), CINAHL, Scopus, and Cochrane Library. processes are shown in Figure 1. A total of 28 articles met the An academic librarian was consulted during database search inclusion criteria and were included in the review. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 1. Literature search and study selection process. mHealth: mobile health. sections: (1) mHealth intervention design, (2) study participant Data Extraction recruitment, (3) study results or findings, and (4) discussion or The data were extracted using reviewer-designed data extraction limitations of the investigation. forms in Covidence. A total of 2 reviewers independently Risk of Bias Assessment performed the data extraction. Disagreements were resolved by consensus. In cases where consensus could not be achieved, a Risk of bias (quality) assessments were performed for each third reviewer was consulted. study using standardized critical appraisal tools from the Joanna Briggs Institute Manual for Evidence Synthesis [36]. The Joanna Data extracted from full-text articles included (1) country of Briggs Institute provides distinct critical appraisal checklists investigation; (2) study design and methods; (3) participant for experimental, quasi-experimental, observational, and recruitment, demographics, and baseline characteristics; (4) qualitative study design. One of the reviewers performed the description of the mHealth intervention; and (5) risk of bias assessments for each study, which was then checked caregiver-specific outcomes or findings. In addition, the review by a second reviewer. Disagreements were resolved by team identified which (if any) social determinants of health and discussion and consensus. No studies were excluded from the factors contributing to health inequities were addressed by study review based on quality assessments to achieve a comprehensive investigators, as described by the PROGRESS-Plus framework understanding of the quality of the available literature exploring [27,35]. the impacts of mHealth interventions for caregivers of older PROGRESS-Plus is a framework developed with evidence from adults. The findings of the quality assessments and the working groups from the Campbell and Cochrane limitations of the included articles are summarized in the results, Collaborations, which can be applied to determine whether an and the summary scores of the quality assessments are presented equity lens has been used throughout the stages of study design, in the Results section. implementation, and reporting of research [27]. The framework Data Synthesis includes the following equity factors: place of residence, race, A narrative synthesis of findings was pursued because of the ethnicity, language, culture, occupation (eg, full-time range of included mHealth interventions, caregiver employment or retirement), gender or sex, religion, education, characteristics, and caregiver-related outcome measures, as well socioeconomic status, and social capital, as well as age, as the inclusion of both quantitative and qualitative study disability, sexual orientation, features of relationships, and designs. The narrative synthesis was organized under the time-dependent relationships (Plus factors) [27]. The manner following categories: (1) study characteristics; (2) mHealth in which investigators addressed these factors within the intervention characteristics; (3) consideration of social intervention itself and the study of the intervention was determinants and factors contributing to health inequities in considered in their report of these factors within the following https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al mHealth intervention design, participant recruitment, study [41,56]. Most of the included quantitative studies recruited small results or findings, and discussion or limitations; (4) quantitative convenience samples of caregivers or caregiver–care recipient caregiver-related outcomes; and (5) qualitative caregiver-related dyads; for example, recruiting from single clinics [38,39] or findings. from attendees of an Alzheimer’s Association chapter event [50]. Included qualitative studies were most often limited by a Results lack of clear alignment between philosophical underpinnings, methodology, and research questions or objectives A total of 28 articles were included in this review. A summary [49-53,55-58,60,62]. Although most studies provided sufficient of the included articles is presented in Multimedia Appendix 2 information to demonstrate a logical flow from the analysis and [37-62]. interpretation of data to the overall conclusions, few studies addressed the potential influence of the researcher on the Characteristics of Included Studies research (eg, positionality, trustworthiness, and rigor) [54,62]. Among the 28 included studies, 14 (50%) were quantitative In addition, only 7% (2/28) of qualitative studies provided [37-48,63,64], 7 (25%) were qualitative [49-55], and 7 (25%) information on the location of the researcher’s theoretical used mixed methods [56-62]. Studies were most frequently approach [53,54]. Although other studies may also have used conducted in the United States [38,41,45-48,50,53,58,60], the a theoretical lens or framework to guide their intervention and Netherlands [37,55,57,59], the United Kingdom [54,62], and analysis, they did not report this information. Australia [52,56]. Most studies targeted nonspecific informal mHealth Intervention Characteristics caregivers of older adults; however, 25% (7/28) targeted family or spousal caregivers specifically [38,44,51,52,54,60,64]. The included studies’ interventions were web-based or Approximately 7% (2/28) of studies targeted caregivers who non–web-based applications, interventions, or videoconferencing reported being isolated [56] or experiencing caregiving strain software, which were delivered via mobile phones, tablets, and [38]. Caregivers most commonly provided care to older adults handheld computers. The intervention details, including with dementia or other forms of cognitive impairment intervention description, hardware, stakeholder input, and [37-39,41-44,46,47,50-56,58-60,62,64]. Other studies recruited comparison groups, are outlined in Table 1. caregivers who provided care to older adults with urinary The aims of these interventions fell under three interrelated incontinence [63], older veterans who were medically complex categories: making connections, facilitating caregiving, and [45], and older adults with functional loss or struggling to remain promoting caregiver health and well-being (Figure 2). The independent at home [49,57,61]. included mHealth interventions facilitated various linkages and Risk of Bias Within Included Studies connections between caregivers and supportive services, such as (1) connecting the care recipient’s circle of care, including The full risk of bias assessments for the 28 included studies are caregivers and health professionals [44,45,48,51,53,55, presented in Multimedia Appendix 3 [37-62]. The potential for 57,58,61]; (2) connecting the caregiver to existing social support bias within the 11% (3/28) included randomized controlled trials or facilitating new connections to peer support [40,43,46,56,59]; [37,45,46] most commonly stemmed from a lack of blinding of and (3) connecting the caregiver to services and resources for participants and outcome assessors. Potential sources of bias both themselves and the recipient of care [37,43,47,50,51,53,58]. within other quantitative studies include a lack of control groups [60,62,63] and limited consideration of potential confounders https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Table 1. Details of mobile health interventions of included studies. Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Quantitative studies—randomized controlled trials Beentjes et al [37] FindMyApps, a web-based selection tool Yes; tablet No Caregiver controls re- 8/13 and learning training program to help ceived a tablet but no caregivers find user-friendly apps FindMyApps training or access; received a list of links to websites with apps for people with dementia or mild cognitive impairment Hastings et al [45] Video-enhanced care management: a 14- Yes; tablet No One group received the 5/13 week care management intervention that intervention (video); the included 3 monthly video calls with nurses comparator group re- via a secure internet-based web-based ceived telephone-based meeting room care management Kales et al [46] WeCareAdvisor, a web-based tool for Yes; tablet No Waitlist for the tool; 8/13 family caregivers, which guided them this group received the through a clinical reasoning process to tool 1 month later identify, monitor, and manage behaviors while addressing their motivation, self-ef- ficacy, and problem-solving skills Quantitative studies—quasi-experimental Davis et al [63] TelePrompt, a tablet-based, prompted Yes; tablet No No comparison group; 6/9 voiding and educational intervention to the study was described support caregivers of older adults with by authors as a quasi- urinary incontinence experimental, single- group pre-post design Lai et al [44] Telehealth delivered via videoconferenc- No No Received a weekly care 7/9 ing platforms (apps) aimed at minimizing service via telephone the possible negative impact of social dis- covering information tancing measures made necessary by the relevant to caregiving; COVID-19 pandemic did not receive the inter- vention of weekly health services deliv- ered through video communication apps Park et al [64] Comprehensive Mobile Application Pro- No No Comparator interven- 5/9 gram, a tool providing real-time support tion was a handbook to families caring for patients with demen- that contained the same tia by helping family caregivers manage information as the mo- behavior and psychological symptoms bile app Watcharasarnsap et al A mobile app system based on the reminis- No No Control group did not 9/9 [42] cence therapy framework; the app was use the intervention (no developed to promote the relationship be- intervention) tween caregivers and people with demen- tia and better the mental well-being of both parties Quantitative s tudies — other (ie, noncomparative) Callan et al [38] A self-administered cognitive training in- Yes; hand- No 6/10 N/A tervention using an adaptive, paced serial held comput- attention task, targeting the dorsolateral er prefrontal cortex, which is implicated in regulating emotions, anxiety, and stress https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Davis et al [43] An e-mobile multimedia app for commu- Yes; mobile No N/A 1/10 nity-based dementia caregiver support, phone designed to offer reassurance, information, and services to caregivers and facilitate the implementation of other interventions by nurses and therapists Ptomey et al [47] A remotely delivered exercise intervention Yes; tablet No N/A 4/10 to increase moderate physical activity in caregivers Quinn et al [48] A mobile app designed to improve engage- No No N/A 4/10 ment of the patient-informal caregiver team; the mobile web-based app allowed older adult users to record social and health information and share this informa- tion with their caregivers Lai et al [39] A simple smartphone app for people with Yes; mobile No N/A 6/10 mild cognitive impairment and their fami- phone ly caregivers living in the community; the app supported communication with friends and family, navigation, and serving as a memory prompt and emergency alert sys- tem Salin and Laaksonen A multicomponent intervention, including Yes; tablet Yes N/A 2/10 [40] live broadcasts related to caregiver self- care exercises, informational videos, and videoconferencing web-based meetings to connect informal caregivers Sourbeer et al [41] A preliminary tablet app developed for the Yes; tablet No N/A 2/11 Behavioral and Environmental Sensing and Intervention for Dementia Caregiver Empowerment; the goal of this app is to support the early detection of signs of agi- tation, allowing caregivers to intervene early Mixed methods studies Banbury et al [56] A telehealth peer-support program for Yes; not No N/A 3/8 and 3/10 isolated caregivers of people with demen- specified tia via group videoconferencing Breebaart and van A groupware app for digital network Yes; not No N/A 1/10 and 3/10 Groenou [57] communication to promote collaboration specified among informal and formal caregivers in a mixed care network of home-dwelling older adults Brown et al [58] CareHeroes, an app providing caregivers No Yes N/A 4/10 and 3/10 with a platform for bidirectional sharing of observations and knowledge with providers about care recipients and, in so doing, provide them with information and support for caregiving activities Dam et al [59] Inlife, a web-based social support platform No No Control group did not 4/10 and 7/10 for caregivers of individuals with dementia receive the intervention aiming to enhance positive interaction, (waiting list) involvement, and social support Sikder et al [60] A mobile app intervention delivering No No N/A 5/9 and 3/10 mentalizing imagery therapy (a guided imagery and mindfulness intervention) for family caregivers https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Stutzel et al [61] A mobile phone app, The Mobile System Yes; mobile Yes N/A 5/10 and 7/10 for Elderly Monitoring, which aimed to phone support caregivers in monitoring care re- cipients with functional loss and to im- prove support for caregivers’ communica- tion with the health team Tyack et al [62] An art-based app intervention delivered Yes; tablet Yes N/A 6/9 and 8/10 via a touch screen tablet displaying art images aiming to stimulate and benefit the well-being of caregivers and care recipi- ents with dementia Qualitative studies Garvelink et al [49] A decision support website to inform No No N/A 3/10 caregivers about ways of staying indepen- dent at home for as long as possible, called Supporting Seniors and Caregivers to Stay Mobile at Home Hughes et al [50] A tablet app with multiple components, No Yes N/A 5/10 including games and a stress questionnaire for caregivers Killin et al [51] The Digital Support Platform, an internet- Yes; tablet No N/A 6/10 based, postdiagnostic support tool for families of individuals who had recently received a diagnosis of dementia Rathnayake et al [52] Mobile health apps used for health infor- No No N/A 7/10 mation seeking Ruggiano et al [53] CareIT, a multifunctional smartphone and Yes; mobile Yes N/A 5/10 web-based app designed to meet the edu- phone cation and support needs of caregivers; the app allowed caregivers to self-assess for depression and burden and linked caregivers to resources Ryan et al [54] InspireD—Individual Specific Reminis- Yes; tablet Yes N/A 10/10 cence in Dementia, a personalized reminis- cence program for family carers and peo- ple living with dementia Span et al [55] The DecideGuide, an interactive web tool Yes; tablet Yes N/A 5/10 that helps informal caregivers, people with dementia, and case managers make shared decisions Complete quality appraisal tools and scores are presented in Multimedia Appendix 3. N/A: not applicable. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 2. Mobile health (mHealth) interventions for caregivers of older adults. mHealth interventions included in the review also facilitated [41,50,53,58,61]; (2) promoting self-care and healthy coping caregiving by (1) assisting with daily caregiving activities (eg, behaviors (eg, encouraging physical activity or suggesting digital calendars to organize appointments, providing reminders evidence-based coping strategies for care recipient behaviors) for medication administration, helping caregivers manage care [40,43,47,63,64]; and (3) providing therapeutic interventions recipient behaviors, and tracking information related to the care (eg, art-based interventions [62], reminiscence therapy [42,54], recipient) [39,41,46,48,51,53,57,59,61,63,64], (2) providing cognitive training therapy [38], and mentalizing imagery therapy support for decisions related to care [46,49,55,58], (3) providing [60]). information or education (eg, regarding the care recipient’s Consideration of Factors That Influence Health condition) [40,43-46,48,49,51-53,56,58,63,64], and (4) sending Inequities emergency alerts to the caregiver or to the care team if needed Figure 3 provides a visual summary of the number of studies [39,61]. that included or considered the factors listed in the Finally, the mHealth interventions represented in the review PROGRESS-Plus framework in their report on (1) the design promoted caregiver health and well-being by (1) monitoring or of their mHealth intervention, (2) participant recruitment, (3) assessing caregiver stress, depression, and burden to facilitate study results or findings, and (4) study discussion or limitations. early detection and intervention before reaching crisis levels https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 3. Consideration of place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation (PROGRESS-Plus) factors in included studies. inexpensive mobile apps and devices [61]. Features of Reporting of PROGRESS-Plus Factors in Intervention relationships between caregivers and care recipients were Design considered in the study design such that the mHealth When describing the design of their interventions, 36% (10/28) intervention was a collaborative tool whereby older adults and of studies provided considerations for ≥1 PROGRESS-Plus their caregivers worked together on their health management factor [37,40,41,46,48,49,56,59,61,63]. Approximately 11% [48]. None of the studies mentioned considering participants’ (3/28) of studies considered the place of residence in their occupation, religion, education, disability, sexual orientation, recruitment approaches as their interventions were designed or time-dependent relationships when describing the design of specifically for geographically isolated caregivers [40,56,61]. their mHealth interventions. Approximately 11% (3/28) considered languages through the Reporting of PROGRESS-Plus Factors in Participant provision of alternative language options in the mobile app, Recruitment readability (ie, lay language), and accessibility options such as larger font or less text [37,46,49]. Approximately 11% (3/28) At the participant recruitment stage, 57% (16/28) of studies described social capital as an element of the intervention itself considered ≥ 1 PROGRESS-Plus factor (eg, intervention aimed at providing a platform to organize and [38,40,42,44-46,49,51-53,56-60,64]. Approximately 32% (9/28) access social support) [56,59,63]. Approximately 7% (2/28) considered features of relationships (eg, living situation) described considerations for caregivers’ age in the design of [38,40,44,46,51,52,58,60,64]. Approximately 18% (5/28) of their interventions by improving readability, comprehensibility, studies considered place of residence in participant recruitment and clarity of the language used in the intervention; providing (eg, recruiting participants dwelling in rural areas) caregivers with assistance in completing web-based forms; and [40,42,53,56,57]. Approximately 14% (4/28) of studies reported integrating opportunities for regular check-ins to support that they used specific recruitment strategies to help ensure that mHealth tool use [41,46]. One of the studies considered gender various races, ethnicities, cultures, and languages were or sex, as the intervention was tailored to address the unique represented in their study samples (eg, recruiting from minority needs of caregivers of different genders [46]. Another study populations) [46,49,53,58]. Approximately 11% (3/28) of studies considered socioeconomic status by deliberately selecting considered age (eg, recruiting older caregivers) [38,45,60]. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Approximately 7% (2/28) of studies considered social capital characteristics of the caregivers in the included studies are (eg, recruiting caregivers with an existing social support presented in Table 2. The most commonly reported network) [56,59] and 7% (2/28) considered disability (eg, PROGRESS-Plus factors within the included articles’ results excluding caregivers with sensory impairment) [38,46]. One of or findings were age and gender or sex [37-50,52,53,55-64]; the studies considered time-dependent relationships (eg, features of relationships [37,39,40,42,43,45,46,48,49,51-53, excluding dyads where the care recipient was awaiting imminent 55-59,61,63]; education [37-39,44,46-50,52,55,56,58,61,63,64]; institutional placement) [46], and another considered gender or and race, ethnicity, culture, and language sex [59] at the stage of participant recruitment. No studies [38,41,43,45-49,53,58,60,62,63]. Other factors reported in the mentioned occupation, religion, education, socioeconomic status, results or findings included socioeconomic status or sexual orientation during participant recruitment. [38,44,48,53,61,63,64], social capital [48,55-57,59,61,64], place of residence [40,49,53,56,62,64], and occupation Reporting of PROGRESS-Plus Factors in Results or [50,52,56,61,63,64]. A small number of studies reported on Findings caregivers’ disabilities [49,61,63], time-dependent relationships All but 1 study [54] described ≥1 PROGRESS-Plus factor within (eg, participants’ housing situation) [49,58], and religion [64]. their results or findings. These factors were typically reported No studies reported on sexual orientation in their results or as part of the sample demographics. The key demographic findings. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Table 2. Demographic characteristics of caregiver participants of included studies. Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Banbury et al [56], Aus- 69 Mean 62.6 (SD 13.54) 50 (72.5) female 6 (8.7) did not complete high Not reported • • • tralia 19 (27.5) male school 6 (8.7) completed high school 17 (24.6) had technical and further education or trade 24 (34.8) attended university 16 (23.2) had postgraduate qualifications Beentjes et al [37], 59 Experimental group 38 (64.4) female 12 (20.3) had secondary edu- Not reported • • • Netherlands mean 65.61 (SD 21 (35.6) male cation (vocational) 10.196); control group 8 (13.6) had secondary educa- mean 68.03 (SD tion (academic) 11.675) 11 (18.6) had further educa- tion (vocational) 20 (33.9) had higher educa- tion (vocational) 8 (13.6) had higher education (academic) Breebaart and van Groe- 7 1 (14.3%) middle-aged, 3 (42.9) female 4 (57.1) had low education Not reported • • • nou [57], Netherlands 1 (14.3%) aged between 3 (42.9) male 2 (28.6) had average educa- • • 60 and 65, and 5 1 (14.3) not tion (71.4%) aged ≥70 specified 1 (14.3) did not specify Brown et al [58], United 11 Mean 56.6 (SD 13.6) 9 (81.8) female Not reported 3 (27.3%) White • • • States 2 (18.2) male 7 (63.6%) African • • American 1 (9.1%) Hispanic 1 (9.1) other Callan et al [38], United 27 Mean 74.61 (SD 6.52) 22 (81.5) female 11 (40.7) had middle school 26 (96.3) White • • • States 5 (18.5) male to technical school education 14 (51.9) had some college to college graduate education 2 (7.4) had some postgradu- ate to postgraduate degree Dam et al [59], Nether- 10 Range 49-71 6 (60) female Not reported Not reported • • • lands 4 (40 male) Davis et al [43], United 4 Mean 52 4 (100) female Not reported Not reported • • • States Davis et al [63], United 3 Range 54-85 3 (100) female 2 (66.7) attended college 3 (100) White • • • States 1 (33.3) had a master’s de- gree Garvelink et al [49], 10 Mean 56.9 (SD 14) 6 (60) female 10 (100) had a university de- Not reported • • • Canada and France 4 (40) male gree Hastings et al [45], Unit- 40 Mean 64.7 (SD 10.8) 40 (100) female Not reported 11 (27.5) Black • • • ed States Hughes et al [50], United 10 Mean 60 (range 48-76) 10 (100) female 10 (100) had high school edu- Not reported • • • States cation 9 (90) had higher education Kales et al [46], United 57 Mean 65.9 (SD 14.0) 43 (75.4) female 48 (84.2) had greater than 36 (63.2) White • • • States 14 (24.6) male high school education 18 (31.6) African • • 9 (15.8) had high school or American GEDa 3 (5.3) other https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Killin et al [51] [51], 10 Not reported Not reported Not reported Not reported • • • Scotland Lai et al [44], Hong 60 Experimental group 35 (58.3) female Experimental group: 7.90 Not reported • • • Kong, China mean 72.43 (SD 0.80, 25 (41.7) male (SD 0.25, range 5-11) years range 66-82); control of education group mean 71.83 (SD Control group: 7.04 (SD 0.31, 0.80, range 66-82) range 5-9) years of education Lai et al [39], Germany 24 Mean 62.4 y (SD 16.0, 9 (37.5) female 11 (45.8) had >12 years of Not reported • • • range 31-83) 15 (62.5) male education Park et al [64], South 24 Experimental group 14 (58.3) female 15 (62.5) were high school Not reported • • • Korea mean 54.50 (SD 3.71); 10 (41.7) male graduates or below control group mean 9 (37.5) were college gradu- 61.00 (SD 6.42) ates or above Ptomey et al [47], United 9 Mean 67 3 (33.3) female 3 (33.3) had high school 8 (88.9) White • • • States 6 (66.7) male diploma or GED 1 (11.1) Black • • 6 (67.6) attended postgradu- ate classes Quinn et al [48], United 12 Mean 54.8 (SD 13.3) 11 (91.7) female 6 (50) had a business or some 6 (50) Black • • • States 1 (8.3) male college degree or graduate 6 (50) White • • degree 6 (50) graduated school Rathnayake et al [52], 10 8 (80%) aged <65; 2 9 (90) female 5 (50) had high school educa- Not reported • • • Australia (20%) aged ≥65 1 (10) male tion and below 5 (50) had above high school education Ruggiano et al [53], 36 Mean 65.7 (range 42- 26 (72.2) female Not reported 13 (36.1) non-His- • • • United States 89) 10 (27.8) male panic White 23 (63.9) African American Ryan et al [54], United 17 Mean 69.1 (SD 15.1, 13 (76.5) female Not reported Not reported • • • Kingdom range 31-91) 4 (23.5) male Salin and Laaksonen 20 Range 61-88 15 (75) female Not reported Not reported • • • [40], Finland 5 (25) male Sikder et al [60], United 17 Mean 66.52 (SD 9.61) 12 (70.6) female Not reported 17 (100) White • • • States 5 (29.4) male Sourbeer et al [41], Unit- 46 42 (91.3%) aged >60; 4 38 (82.6) female Not reported 39 (84.8) White • • • ed States (8.7%) aged <60 8 (17.4) male 6 (13.0) African • • American 1 (2.2) Hispanic Span et al [55], Nether- 12 Mean 54.3 (range 19- 7 (58.3) female 1 (8.3) had low education Not reported • • • lands 86) 5 (41.7) male 4 (33.3) had medium educa- • • tion 6 (50) had high education 1 (8.2) did not specify Stutzel et al [61], Brazil 38 Mean 61 (SD 10.75) 32 (84.2) female 21 (55.3) had ≤12 years of Not reported • • • 6 (15.8) male education 17 (44.7) had >12 years of education Tyack et al [62], United 12 Mean 66 (range 48-77) 10 (83.3) female Not reported 12 (100) White • • • Kingdom 2 (16.7) male https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Watcharasarnsap et al 60 8 (13.3%) aged between 31 (51.7) female Not reported Not reported • • • [42], Thailand 18 and 27, 19 (31.7%) 29 (48.3) male aged between 28 and 37, 15 (25%) aged be- tween 38 and 47, 10 (16.7%) aged between 48 and 57, and 8 (13.3%) aged ≥58 GED: General Educational Development. [63]; however, study investigators noted that the intervention Reporting of PROGRESS-Plus Factors in Discussion did not worsen caregiver burden [63]. or Limitations Outcomes Relating to Caregivers’ Health and Well-being Approximately 79% (22/28) of studies considered ≥1 Approximately 39% (11/28) of studies assessed the impact of PROGRESS-Plus factor in the discussion or limitations sections mHealth interventions on various aspects of caregivers’ health of their studies [37,38,40,41,43,44,47-56,58-63]. The most and well-being [37,40,42-44,46,47,60-62,64]. Impacts on frequently discussed PROGRESS-Plus factors in the included caregivers’ mental and psychological health status were assessed articles’ discussion or limitations were age in 25% (7/28) of studies [42,44,46,60-62,64], with generally [37,38,40,41,43,48,50,51,53,54,60,62,63], such as challenges positive results. Specifically, mental health status [44], faced by older caregivers in using mobile devices; race, psychological well-being [42], depression [46,60], mood [60], ethnicity, culture, and language [40,41,43,47,49,52,53,55,58,60], distress [46], and fatigue [64] were each noted to have improved such as a lack of diversity of the study sample; and place of after the implementation of an mHealth intervention. For residence [40,44,47,49,51,53,55,56,61], such as challenges example, the implementation of the WeCareAdvisor tool, related to the lack of access to stable internet in rural locations. designed to provide caregivers with peer navigation, Other PROGRESS-Plus factors described in the study information, and daily messaging, led to significant discussions or limitations were gender or sex improvement in self-reported distress (−6.08, SD 6.31 points; [38,41,52,54,55,63], education [37,38,49,52,56,63], and P<.001) [46]. In this study, those in the control group socioeconomic status [44,47,48,52,53,63]. To a lesser extent, demonstrated a significant decrease in their confidence in caregivers’ social capital [48,56,59], disabilities [38,49], features caregiving (−6.40, SD 10.30; P=.002) [46]. Conversely, a study of relationships (eg, nature of relationship between caregiver that assessed caregiver stress by testing cortisol levels in saliva and care recipient) [54,55], and time-dependent relationships in a pretest-posttest design found no differences after the use (eg, the impact of COVID-19 on the amount of time caregivers of an mHealth intervention designed to manage the behavioral could spend visiting the care recipient) [37,49] were also and psychological symptoms of dementia [64]. Caregivers’ discussed. No studies considered occupation, religion, or sexual self-appraised happiness was also unchanged after the orientation in their discussion or limitations sections. intervention in one of the studies [62]. Quantitative Caregiver Outcomes Approximately 11% (3/28) of studies assessed outcomes related Outcomes Relating to Caregiving to caregivers’ physical health and well-being [44,47,64]. Caregivers self-reported improvements in their general physical Approximately 21% (6/28) of studies assessed the impact of health status following the use of an mHealth intervention to mHealth interventions on outcomes related to caregivers’ support the well-being and community living of older adults capabilities or experiences in providing care. These outcomes and their spousal caregiver dyads [44]. Ptomey et al [47], who included caregivers’ self-efficacy [44,63], sense of competence implemented an mHealth app to encourage exercise, observed [37] and confidence [46] in their caregiving role, knowledge that caregivers’ weekly moderate physical activity increased by related to the care recipient’s condition [63], positive care 49 minutes (30% increase) per week over the 12-week experience [37], and caregiver burden [43,44,46,63,64]. intervention period, whereas light physical activity increased Although some studies found that caregiving self-efficacy and by 11.6 minutes (3% increase) per week. However, Park et al knowledge improved after the implementation of an mHealth [64] found no difference in caregivers’ sleep quality after the intervention [44,63], other studies observed no difference after implementation of a supportive mHealth app. the intervention in caregivers’ sense of competence [37], confidence [46], or positive caregiving experience [37]. Approximately 14% (4/28) of studies used caregivers’ quality of life as an outcome measure for their respective interventions, Approximately 14% (4/28) of studies using the Zarit Burden with mixed findings. Ptomey et al [47] found nonsignificant Inventory [65] found that mHealth interventions led to trends toward improvement in quality of life after the improvements in caregiver burden [43,44,46,64]. However, one implementation of an mHealth intervention. Beentjes et al [37] of the studies, which specifically assessed caregiver burden and Tyack et al [62] found no significant changes in quality of related to the management of urinary incontinence, found that life following their interventions aimed at supporting caregivers burden was similar before and after the mHealth intervention in finding user-friendly apps and viewing art to encourage https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al therapeutic reminiscence, respectively. Salin and Laaksonen and worry reported the highest levels of mHealth intervention [40] observed that some aspects of quality of life, in fact, use [38]. Sikder et al [60] reported that over half of their 17 worsened, albeit mildly (breathing, sexual activity, vitality, study participants accessed ≥75% of the informational depression, and usual activities). One of the studies assessed documents in their mHealth app. The remaining 11% (3/28) of the impact of an mHealth intervention on caregivers’ social studies reported varying frequencies or hours of use per week engagement and found high positive responses using the Kaye during the intervention period [57-59]; however, these studies Gain Through Involvement Scale [66], suggesting that the gains did not comment on whether these frequencies constituted low, in well-being experienced while using the mHealth intervention medium, or high use of their mHealth interventions. may be applicable when tested in a larger sample [43]. However, Approximately 11% (3/28) of studies assessed feasibility by the study investigators noted that their sample was meant only measuring the intervention attendance and retention of for determining intervention efficacy and warranted testing with caregivers during the intervention period [40,45,47]. The a larger sample [43]. attendance rates for caregivers varied from 72% (13.7/19) [40] to 97.1% (34/35) [45]. Ptomey et al [47] and Hastings et al [45] Outcomes Related to Usability, Feasibility, and reported similar figures (7/9, 78% dyads, and 31/40, 78% dyads, Acceptability of mHealth Interventions respectively) for the caregiver–care recipient dyads completing Half of the reviewed studies assessed outcomes related to the their interventions. usability, acceptability, or feasibility of mHealth interventions for caregivers of older adults [38-41,45,47,48,57-63]. Other feasibility measures used by the reviewed studies included the extent to which caregivers followed or adhered to the Approximately 32% (9/28) of studies measured the usability or mHealth intervention [38,63]. Callan et al [38] reported that ease of use of mHealth interventions by caregivers caregivers’ continued engagement in a cognitive training [40,41,45,47,48,58,59,61,63]. Approximately 14% (4/28) of mHealth intervention program was evidenced by improvements articles used the System Usability Scale [67] to do so; usability in their ability to perform cognitive training tasks. Davis et al scores varied across studies, ranging from marginally acceptable [63] reported that caregivers were capable of learning and [45], moderate [48], and good to excellent [61]. Only 4% (1/28) implementing the prompted toileting strategies to support care of studies compared the system usability scores across 2 phases recipients with the help of an mHealth intervention, as evidenced of their mHealth app intervention. Sourbeer et al [41] found by a reduction in care recipient wetness in 2 out of 3 participant that usability did not significantly improve in a subsequent dyads. version of their mHealth app updated in response to participant feedback. The remaining 18% (5/28) of studies assessed Qualitative Caregiver Findings caregivers’ ease of use or perceived user-friendliness of the Overview mHealth intervention using descriptive statistics or averaged Likert scale scores. These studies generally reported positive Of the 28 studies, 7 (25%) qualitative studies and 7 (25%) mixed results, suggesting that caregivers believed the interventions methods studies presented findings relating to caregivers’ were easy or very easy to use [40,47,58,59,63]. experiences of engaging in mHealth interventions [49-62]. These qualitative findings included (1) positive impacts of caregivers’ Approximately 21% (6/28) of studies examined caregivers’ experiences with mHealth interventions, (2) challenging aspects satisfaction or positive feelings toward the intervention of caregivers’ experiences with mHealth interventions, (3) [39,40,47,48,58-61]. Most reported that caregivers were barriers to caregivers’ engagement with mHealth interventions, generally satisfied with the mHealth intervention, perceived the and (4) caregivers’ suggestions to improve mHealth intervention as relevant and useful to their caregiving activities, interventions. and felt positive about their experiences with the intervention [39,40,47,48,58-61]. However, greater technical difficulties Positive Experiences With mHealth Interventions were reported in a study of participants who lived rurally and Most studies highlighted promising findings related to the reported lower levels of satisfaction [40]. positive impacts of caregivers’ experiences with mHealth interventions. Participants across the included studies found Approximately 29% (8/28) of studies explored the feasibility mHealth interventions to be helpful, user-friendly, and easy to of an mHealth intervention by measuring the regularity, understand [49,50,54,55]. mHealth interventions were perceived frequency, and extent of its use by caregivers over the to help caregivers connect with the care team and provide care intervention period [38,57-60,62]. Use varied across the included for their loved ones [53,55,57,60,61]. The information provided studies, and investigators did not consistently establish through mHealth interventions was described as relevant to expectations of use for their participants nor defined what addressing participants’ educational needs [49,52]. Caregivers constituted adequate use of the intervention. Tyack et al [62] also valued the role of mHealth interventions in detecting their reported that the participants used their app at least five times stress levels [50] and facilitating timely connections to a diverse during the intervention period, as suggested by the study range of professional services and social support investigators. Callan et al [38] found that 22 out of 27 (81.5%) [49,52,54,56,62]. Participants in the included studies reported caregivers used the mHealth intervention regularly (as defined benefits to their emotional and cognitive well-being [60,62] and by the study investigators as at least 3 weeks out of the 4-week described reappraising and feeling closer to the care recipient intervention period). Baseline caregiver stress, worry, and sleep [54,62]. The mobile delivery of the interventions also quality did not adversely affect the use of the mHealth contributed to feelings of safety and security, as caregivers could intervention, and caregivers with the highest self-reported stress https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al participate from their homes [54,56]. Although some participants caregivers who were unfamiliar with using mobile devices initially felt a lack of confidence in using technology, caregivers [51,56]. in 7% (2/28) of studies reported becoming more engaged and The participants also made suggestions to develop more relevant comfortable over time by integrating the mHealth intervention and up-to-date content for mHealth interventions. Several studies into their lives [54,57]. highlighted the need to embed local and national services for caregiver support, including interventionists and respite care Challenging Experiences With mHealth Interventions [58-60]. For interventions that targeted the caregiver–care Several studies described the negative aspects of caregivers’ recipient dyad, participants highlighted the need for more experiences with using mHealth interventions, although these information specifically related to their own health, such as were often reported as being applicable to only a minority of healthy coping [49,52,58,61]. Participants also called for greater participants. Approximately 11% (3/28) of studies indicated emphasis on topics that caregivers often find difficult, including that some participants felt that the mHealth intervention was information about deciding to move to a care home, managing too complex or difficult to understand [49,51,60]. In another activities of daily living and aggressive behaviors, and resources study, participants felt that the intervention included questions for individuals experiencing abuse [49,52,58]. that were overly obtrusive or confronting; for example, participants were not always comfortable answering questions Other findings suggested to improve mHealth engagement they perceived as challenging [55]. Some studies highlighted among caregivers included greater ethnic diversity portrayed caregivers’ concerns regarding the potentially detrimental within the mHealth intervention [49], establishing a reward impacts of mHealth interventions; for example, interventions system to encourage regular use [50], and creating a component that facilitated reminiscence could trigger painful memories for the care recipient to be included when the caregiver uses the and lower mood [54,62]. Hughes et al [50] further described mHealth intervention [50]. caregivers’ concerns regarding the diversion of their time and attention toward the mHealth intervention and away from the Discussion care recipient. One of the studies highlighted the preference of some participants for in-person interventions, citing physical Principal Findings contact as an important element of care (eg, hugging), which This systematic review examined how health and social equity was not possible in a digital environment [56]. are considered in the design, implementation, and evaluation of mHealth interventions developed for caregivers of older Barriers to Caregivers’ Engagement With mHealth adults using the PROGRESS-Plus framework. The interventions Interventions described in the included studies were designed to create Caregivers relayed frustration with the usability of mHealth linkages between caregivers and external supports, streamline interventions, including difficulties navigating the intervention and optimize caregiving activities, and encourage a focus on on their mobile devices [49,50,62]. Challenges included print caregiver health and well-being. As such, evidence on the that was too small [49,50], screens that were overly sensitive impacts of caregiver-focused mHealth interventions was or had too much glare [62], and language that was too complex synthesized across a range of outcomes. [49]. Several studies highlighted a lack of familiarity or The findings indicate that health and social factors are not experience with technology as a key barrier to the use of consistently taken into consideration when designing research mHealth interventions, particularly for older caregivers studies (ie, used to develop and guide recruitment and [51-53,55]. The busy schedules of caregivers for older adults intervention design). Furthermore, participant characteristics were also identified as a barrier to regular mHealth intervention are most often only reported within study results when use, particularly if caregivers were often pulled away from their summarizing participant characteristics or when identifying devices by care recipients or if they were experiencing health limits to the generalizability of the findings. However, this issues themselves [50,52,58,60]. review highlights how mHealth interventions are well-positioned In other cases, participants felt that the intervention’s content to improve caregivers’ self-efficacy and knowledge, their was not relevant to their immediate needs [49,51] or lacked perceived mental and physical wellness, and their relationships realism (eg, lack of ethnic diversity among actors portraying with care recipients. The usability and acceptability of mHealth caregivers in the mHealth intervention) and up-to-date links to interventions were characterized by ease of use, ease of relevant resources [49]. Other barriers included the prohibitive navigating technical challenges, and relevance of intervention cost of mobile devices and internet or data plans [52] and the content to the caregivers’ individual roles and context. availability of a stable internet connection in rural regions [56]. Consideration of PROGRESS-Plus Factors in Studies Caregivers’ Perspectives Regarding Next Steps on mHealth Interventions for Caregivers of Older Qualitative findings frequently incorporated participants’ Adults suggestions to make mHealth interventions more user-friendly Overview and accessible to caregivers. Suggestions included simplifying the intervention’s interface or instructions, enlarging text and Most studies in this systematic review on mHealth interventions images, and including subtitles on video resources for for caregivers of older adults considered some PROGRESS-Plus individuals with hearing impairment [49,52,61,62]. Participants factors, particularly when describing their study samples. voiced the need for ongoing technical support, particularly for However, such demographic reporting reflects standardized https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al reporting practices of participant composition rather than population [24,73]. These findings suggest that exploring deliberate and targeted approaches to recruiting caregivers across barriers and facilitators, as identified by the included qualitative sociodemographic characteristics to determine whether an studies, aimed at educating older adults on how to use mHealth intervention is suitable for a diversity of participants. The factors interventions is essential to facilitate perceived trust, comfort, described in the following sections were considered critical in and usability of technology. Thus, beyond education as a social the intervention design. determinant of health, wide disparities exist across caregivers in comfort with using various technologies, such as tablets, Gender Sex or Sexual Orientation iPads, and mobile phones [73]. Importantly, few studies considered actively recruiting Socioeconomic Status caregivers of different self-reported genders or considered the relevance of gender in intervention design or implementation. Socioeconomic status was minimally considered in the Research suggests that biological and gender differences affect intervention design and was most often addressed when health across a range of parameters such as risk, disease describing sample characteristics. Multiple studies reported incidence, and the need for health services [27]. Furthermore, providing participants with devices to support the use of sexual orientation was, in fact, eclipsed across all studies, mHealth apps [37-41,43,45-47,51,53-57,61-63]. In some cases, particularly when many studies focused on caregiver health and participants were allowed to keep the devices; however, well-being, which includes the relationship they have with care especially in those instances in which they were not, the recipients. Recent evidence indicates that sexual and gender feasibility of such interventions for caregivers across income minority caregivers, such as those identifying as queer and levels needs to be explored. transgender, report higher depressive symptoms (78%) than the Some interventions were designed to facilitate communication overall population of caregivers of people with dementia (34%) access to health professionals and other individuals (eg, support [68]. This finding highlights the importance of diversifying groups), highlighting the need for access to a reliable internet samples across genders and sexual orientations to reliably assess connection. This lack of access may be due in part to financial and address caregivers’ mental health. The importance of constraints, as a survey of caregivers in the United States found considering the intersections among gender, sexual orientation, that cost was a commonly reported barrier to the use of and other sociodemographic factors was also highlighted in the technology [74]. Furthermore, older adults living on fixed survey of a cross-sectional sample of members of the National incomes may be reticent to spend money on devices they do Alliance for Caregiving. Caregivers who identified as lesbian, not value or find overly complicated [75]. Importantly, older gay, bisexual, and transgender were more likely to be racially caregivers tend to have fewer technological devices than their and ethnically diverse and represent lower socioeconomic younger peers, and these technologies are often used for classes than those who did not [69]. communication purposes rather than health management purposes [18]. Although most caregivers report valuing Education technology, those that use it for health-related activities tend to Education, although frequently reported in demographics, was use it for targeted caregiving activities such as medication also rarely considered as an important factor in informing tracking or safety [18]. Therefore, additional support or intervention design and recruitment. Women with lower education may be required to increase caregiver uptake of education are more likely to assume caregiving roles than those mHealth interventions as a tool for addressing broader caregiver who have had additional educational opportunities [11]. Lower needs such as communication with health teams or liaising with literacy levels among caregivers can affect their ability to other caregivers. Computers and smartphones are increasingly navigate the health system and locate appropriate support for being owned by people with higher income and education, and themselves and their care recipient [70], factors that can directly the provision of caregiver support through mHealth apps could influence the design and usability of mHealth interventions. For increase inequalities if economic resources are not considered example, lower literacy can affect comprehension of text-based in the design and implementation of these interventions [71]. content in mHealth apps, the ability to correctly enter spelled words in search functions, and the ability to navigate app menus Culture, Language, and Race [71]. The importance of designing mHealth interventions that The nature of caregiver–care recipient relationships can be an account for varying levels of educational background is important factor in the design of mHealth tools, particularly underscored by the association of literacy with health and digital when it comes to cultural expectations of family members, literacy [72]. gender roles, and other caregiver demographics. The included The findings of the included studies suggest that experience studies had samples primarily made up of women, validating with technology can be a key barrier to the use of mHealth the literature that suggests women are most likely to provide interventions, particularly among older caregivers [51-53,55]. caregiving support, corroborating cultural norms across a range A survey of a broad age range of caregivers suggests that of identities [76]. However, these studies did not address how younger caregivers (aged <50 years) are more than twice as intersecting identities (eg, culture, gender, race and ethnicity, likely than older caregivers to be receptive to using mHealth and socioeconomic status) might shape expectations and apps to support them in their caregiving roles [24]. For older responsibilities within a caregiving role [11,12,68]. Research adults, trust in technology as it relates to privacy and access to suggests that culture strongly affects caregiving but that cultural information can be an important factor in the use of mHealth influences on the caregiver role must be understood within the interventions, especially given the heterogeneity of this context of race and gender socialization [77]. For example, https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al individualistic or Western notions of strategies to address taking away from the time they had to complete other caregiving caregiver burdens, such as spending time alone or sharing tasks [58]. The impact of such detrimental experiences, as they caregiving responsibilities with friends or family, might not relate to, for example, PROGRESS-Plus factors of resonate with caregivers from other cultures, particularly those gender-informed cultural caregiving roles, features of with a strong sense of filial responsibility or immigrant relationships, or caregiver disability, is not well understood. caregivers without local support [78]. Furthermore, mHealth Wasilewski et al [34] found that caregivers’ decline in apps not provided in caregivers’ first languages decrease web-based intervention use may be attributed to a malalignment accessibility and would require careful translation and cultural with their specific needs and capabilities across the caregiving adaptation to remain meaningful [79]. The impact of these trajectory. In such cases, it is important for those recommending factors on caregiver-specific outcomes, such as caregiving mHealth interventions to caregivers to consider whether a self-efficacy, health and well-being, and technology usability, particular intervention itself might increase the caregiver burden is yet to be explored. Intersecting identities are increasingly [81]. Furthermore, research suggests that if older adults perceive important to consider when tailoring web-based caregiver an mHealth app to be beneficial to their health and well-being, interventions to participants’ individual needs [19]. their likelihood of ongoing and increased engagement with other apps increases [82]. Individualized tailoring of mHealth apps mHealth Interventions Developed for Caregivers of and providing the necessary access and universal design can Older Adults foster equitable uptake and increase the potential benefits of mHealth interventions. Impacts of mHealth Interventions on Caregiver Health and Wellness Usability, Feasibility, and Acceptability of mHealth Studies evaluating mobile technology interventions aiming to Interventions promote caregivers’ perceived mental and psychological health Overall, caregivers in the included studies were generally reported benefits to their emotional and cognitive well-being comfortable using mHealth interventions and reported positive [60,62]. Some of these interventions, such as the impacts on their caregiving role [49,50,54,55]. However, videoconferencing platform developed by Lai et al [44], were findings such as the prohibitive costs associated with mobile designed in lieu of in-person community services, following devices and internet and data plans, in combination with the shelter-in-place orders during the COVID-19 pandemic. quality of internet provision to those living in rural settings, Connecting caregivers to professional and peer support using highlight the importance of equitable service provision across web-based technologies has been shown to improve mental the PROGRESS-Plus factors [52,56]. The findings of this review health outcomes and can help caregivers overcome common also showed that 64% (18/28) of studies access-related barriers related to PROGRESS-Plus factors, such [37-41,43,45-47,51,53-57,61-63] provided participants with the as geographical and time constraints or community mobility devices required to engage in the interventions, suggesting that limitations related to physical or mental health [18-20]. the economic feasibility of these interventions needs to be better However, findings from the included studies suggest that understood. caregivers still require opportunities for in-person interaction Technical features such as app use data may provide valuable (eg, hands-on training from a health care provider to successfully insights into the frequency and applicability of interventions to use external support systems), suggesting that the impact of caregiver needs and their unique lifestyles. Furthermore, hybrid models of interventions to improve caregiver health and researchers have been urged to include older adults and their wellness is not well understood [20]. Furthermore, a review of caregivers in the design and development of mobile app these interventions using the PROGRESS-Plus factors suggests technologies [48]. However, a minority of the studies included that, although caregivers stand to benefit from mHealth in this review described stakeholder input as a component of interventions and many older adults report being comfortable their intervention design or implementation [40,50,53-55,58,61]. with smartphone use, uptake may continue to be constrained if Co-design approaches present important opportunities for support is not provided to help caregivers learn and familiarize engaging diverse populations to help ensure that mHealth themselves with mHealth apps at the outset [80]. Hybrid interventions are inclusive and accessible. approaches have the potential to increase caregiver self-efficacy, as opposed to overwhelming caregivers with new tools and Implications technology, which warrants further research. Moving forward, an important reminder is that social Supporting the Caregiver Role Through mHealth determinants of health should be consciously considered in all aspects of mHealth intervention design and implementation to Interventions avoid perpetuating inequities experienced by historically and Caregivers’ ability to perform their roles was a key focus of the currently systemically disadvantaged caregivers of older adults examined mHealth interventions and outcomes of interest within living with chronic conditions [25,83]. Purposeful efforts to the included studies. Although some interventions focused on include a diverse range of participants in research, such as creating external structures that facilitated responsibilities of evidence-based recruitment strategies, can help redress these providing care (eg, medication alarms, and checklists), the use potential inequities and inform the development of more of these tools had the potential to complicate caregiving inclusive interventions [84,85]. The PROGRESS-Plus responsibilities. For example, in one case, caregivers described framework is an appropriate tool to help ensure that a health that the increased screen time to engage in the intervention was https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 18 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al and social equity lens is applied in research design and reporting, North, these institutions use similar health research databases the use of which should be widely endorsed [27,86]. and search algorithms, which can affect future reproducibility (ie, replicating searches in different institutions with different This review highlights the need for high-quality mHealth studies. journal accesses). The identification of potentially eligible Particular attention must be paid to improving the design of literature from the Global South, other disciplines beyond health mHealth interventions and ensuring equality in access and research (eg, technology literature databases), or those that are adoption of mHealth interventions [71]. Participatory action categorized in other ways (eg, gray literature) is another approaches to research, such as co-design, are ideal for ensuring limitation of this review. However, this study highlights that that mHealth interventions meet the needs of diverse caregivers. research on mHealth interventions for caregivers of older adults Furthermore, inclusive design principles can be used in more primarily occurs within applied health settings. As such, future traditional research methodologies to ensure that mHealth reviews should examine non–peer-reviewed evidence such as interventions do not amplify health disparities. This could be reports and program evaluations produced by the government achieved by accommodating low literacy by including audio and health authorities that trial mHealth interventions. narration and visual depictions or by directing funding to increase access to human resource infrastructures (eg, technical This study could have been further strengthened by involving support) that promote mHealth interventions in remote or additional team members, such as administrators of clinical low-income regions [71]. settings who would implement mHealth interventions and, most importantly, caregivers of older adults themselves. By selecting Strengths and Limitations the PROGRESS-Plus framework as a theoretical guide, this The studies included in this systematic review represent the study did not examine the included interventions and diversity of mHealth interventions that have been conceptualized investigations in light of compounding factors that and created to address caregiver needs. Unfortunately, many disadvantaged caregivers (eg, impact of the intervention on studies were found to be poorly designed and executed. older women living in rural settings) or capture other health and Although half of the included studies assessed usability, social factors beyond the framework (eg, access to health feasibility, and acceptability of mHealth interventions, which insurance). However, using the framework as an approach to are all important aspects of technology use, many of these used name and identify how key individual factors have been qualitative approaches and lacked overall methodological rigor. considered in intervention design and evaluation, this study has Given the variety of mHealth apps, technological devices, and set the stage for future investigations that examine the implementation protocols, equivalent comparisons could not confluence of multiple social determinants of health. be made across studies. A small number of studies were Conclusions identified evaluating the impact of caregiver-focused interventions on caregiver-specific outcomes, limiting the ability mHealth supports are well-positioned to support caregivers of to make conclusive recommendations to guide practice. older adults by providing them with information, Encouragingly, some of the included quantitative studies that communication, and assistance in their caregiving role. used valid and reliable standardized tools thoroughly described However, access, uptake, and the ability to benefit from this their approach to statistical analysis and generally addressed technology can be affected by the social determinants of health fidelity of intervention delivery. and inequities among caregivers. This systematic review of mHealth interventions to support caregivers of older adults In this review, multiple steps were taken to achieve suggests that these tools are well-received by caregivers and methodological rigor. The review was conceptualized and have the potential to support caregivers across a variety of designed using an equity framework and the best evidence on parameters by facilitating education, communication, and a interventions for caregivers of older adults. The search strategy sense of security for caregivers. The social determinants of was developed in consultation with a health research librarian, health and equity factors are not widely considered in the design and database searches, screening, data extraction, and risk of and implementation of mHealth interventions, although these bias evaluations were conducted in duplicate, with a strong parameters are frequently collected for demographic reporting. agreement between reviewers. The review protocol was also Recognizing that there are many challenges in designing and made publicly available a priori and was adhered to without implementing mHealth interventions that are equitable, going any deviations. In addition, the PRISMA and PRISMA-Equity forward, it will be important to strive for greater inclusion of guidelines guided each phase of this study [28,87]. the social determinants of health at all stages of mHealth Inevitably, this study has some limitations. Although these development and implementation if there is to be widespread searches were conducted by health and rehabilitation successful uptake of this supportive technology. investigators across 3 large academic institutions in the Global Conflicts of Interest None declared. Multimedia Appendix 1 Search strategies for all databases. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 19 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al [PNG File , 393 KB-Multimedia Appendix 1] Multimedia Appendix 2 Summary table of included studies. [PNG File , 3092 KB-Multimedia Appendix 2] Multimedia Appendix 3 Risk of bias assessments. 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Brewer LC, Fortuna KL, Jones C, Walker R, Hayes SN, Patten CA, et al. Back to the future: achieving health equity through health informatics and digital health. JMIR Mhealth Uhealth 2020 Jan 14;8(1):e14512 [FREE Full text] [doi: 10.2196/14512] [Medline: 31934874] https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 23 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al 84. Ibrahim S, Sidani S. Strategies to recruit minority persons: a systematic review. J Immigr Minor Health 2014 Oct;16(5):882-888. [doi: 10.1007/s10903-013-9783-y] [Medline: 23338906] 85. Welch V, Petticrew M, Ueffing E, Benkhalti Jandu M, Brand K, Dhaliwal B, et al. Does consideration and assessment of effects on health equity affect the conclusions of systematic reviews? A methodology study. PLoS One 2012;7(3):e31360 [FREE Full text] [doi: 10.1371/journal.pone.0031360] [Medline: 22427804] 86. Furler J, Magin P, Pirotta M, van Driel M. Participant demographics reported in "Table 1" of randomised controlled trials: a case of "inverse evidence"? Int J Equity Health 2012 Mar 19;11:14 [FREE Full text] [doi: 10.1186/1475-9276-11-14] [Medline: 22429574] 87. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E, PRISMA-Equity Bellagio group. PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. PLoS Med 2012;9(10):e1001333 [FREE Full text] [doi: 10.1371/journal.pmed.1001333] [Medline: 23222917] Abbreviations mHealth: mobile health PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses PROGRESS-Plus: place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation PROSPERO: International Prospective Register of Systematic Reviews Edited by J Wang; submitted 24.08.21; peer-reviewed by A Sikder, E Brown, J Wolff; comments to author 02.12.21; revised version received 11.04.22; accepted 23.05.22; published 08.07.22 Please cite as: Garnett A, Northwood M, Ting J, Sangrar R JMIR Aging 2022;5(3):e33085 URL: https://aging.jmir.org/2022/3/e33085 doi: 10.2196/33085 PMID: 35616514 ©Anna Garnett, Melissa Northwood, Justine Ting, Ruheena Sangrar. Originally published in JMIR Aging (https://aging.jmir.org), 08.07.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 24 (page number not for citation purposes) XSL FO RenderX http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JMIR Aging JMIR Publications http://www.deepdyve.com/lp/jmir-publications/mhealth-interventions-to-support-caregivers-of-older-adults-equity-C00WdKl39P

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ISSN: 2561-7605
DOI: 10.2196/33085
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Abstract

Background: Informal caregivers, hereafter referred to as caregivers, provide support to older adults so that they can age safely at home. The decision to become a caregiver can be influenced by individual factors, such as personal choice, or societal factors such as social determinants of health, including household income, employment status, and culture-specific gender roles. Over time, caregivers’ health can be negatively affected by their caregiving roles. Although programs exist to support caregivers, the availability and appropriateness of services do not match caregivers’ expressed needs. Research suggests that supportive interventions offered through mobile health (mHealth) technologies have the potential to increase caregivers’ access to supportive services. However, a knowledge gap remains regarding the extent to which social determinants of health are considered in the design, implementation, and evaluation of mHealth interventions intended to support the caregivers of older adults. Objective: This study aimed to conduct a systematic review to determine how health equity is considered in the design, implementation, and evaluation of mHealth interventions for caregivers of older adults using Cochrane Equity’s PROGRESS-Plus (place of residence, race, ethnicity, culture, language, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation) framework and synthesize evidence of the impacts of the identified caregiver-focused mHealth interventions. Methods: A systematic review was conducted using 5 databases. Articles published between January 2010 and June 2021 were included if they evaluated or explored the impact of mHealth interventions on the health and well-being of informal caregivers of older adults. mHealth interventions were defined as supportive services, for example, education, that caregivers of older adults accessed via mobile or wireless devices. Results: In total, 28 articles met the inclusion criteria and were included in the review. The interventions evaluated sought to connect caregivers with services, facilitate caregiving, and promote caregivers’ health and well-being. The PROGRESS-Plus framework factors were mainly considered in the results, discussion, and limitations sections of the included studies. Some PROGRESS-Plus factors such as sexual orientation, religion, and occupation, received little to no consideration across any phase of the intervention design, implementation, or evaluation. Overall, the findings of this review suggest that mHealth interventions were positively received by study participants. Such interventions have the potential to reduce caregiver burden and positively affect caregivers’ physical and mental health while supporting them as caregivers. The study findings highlight the importance of making support available to help facilitate caregivers’ use of mHealth interventions, as well as in the use of appropriate language and text. Conclusions: The successful uptake and spread of mHealth interventions to support caregivers of older adults will depend on creating opportunities for the inclusive involvement of a broad range of stakeholders at all stages of design, implementation, and evaluation. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al (JMIR Aging 2022;5(3):e33085) doi: 10.2196/33085 KEYWORDS caregivers; older adults; mobile health; social determinants of health; intervention; mobile phone mobile apps have the potential to have a greater positive impact Introduction on caregivers by providing support, communication, and facilitation of care, thereby reducing the burden and positively Background affecting caregiver health outcomes [24]. However, to the best Globally, it is estimated that 101 million older adults require of our knowledge, a systematic review of the impact of mHealth care from a friend or family caregiver (informal caregiver; support on caregivers of older adults does not currently exist. hereafter referred to as caregiver), with women providing most Furthermore, to date, reviews on standard caregiver interventions of the support [1]. The support provided by these informal suggest that limited work has been conducted to determine the caregivers is often crucial for enabling older adults to safely suitability of these interventions for caregivers from remain in their home environment [2-4]. Caregiving support, backgrounds representing diverse social determinants of health such as assistance with activities of daily living, attending characteristics [25]. Individual characteristics, such as appointments, and health management, is associated with sociodemographic characteristics and the ability to engage with positive outcomes for both caregivers [5,6] and care recipients technology, should be considered in the design of mHealth [7]. Although caregivers often willingly engage in caring, their interventions [26]. role can negatively affect their psychological well-being, Therefore, the objectives of this systematic review were to (1) particularly when care is provided over a prolonged period determine how health equity is considered in the design, [8-10]. implementation, and evaluation of mHealth interventions aimed The Social Determinants of Health and Inequities at caregivers of older adults using the Cochrane Equity Among Caregivers PROGRESS-Plus (place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus The social determinants of health can influence entry into the age, disability, and sexual orientation) framework [27] and (2) caregiving role and the subsequent experience of being a synthesize the evidence on the impacts of caregiver-focused caregiver. For example, factors such as being a woman, lower mHealth interventions, subsequently discussed through a health educational attainment, and living in a rural setting can bias equity lens. caregiving toward individuals who may perceive that they have little agency in their choice to become a caregiver [11]. Furthermore, a greater intensity of caregiving has been identified Methods among caregivers who are female, people of color, and of lower A systematic review was conducted in accordance with the socioeconomic status [12]. These inequities highlight the need PRISMA (Preferred Reporting Items for Systematic Reviews for interventions with both scope and accessibility to support and Meta-Analyses) statement guidelines [28]. The protocol caregivers with varied demographic characteristics. for this systematic review was registered on PROSPERO Although some programs and community initiatives are (International Prospective Register of Systematic Reviews; available to support caregivers, the literature suggests that CRD42021239584) and is available for electronic access [29]. caregivers struggle to access these supportive services [13-15]. Research Questions Challenges in system navigation, accessing support, geographic location, and scheduling factors can impede the successful use The research questions guiding this systematic review were as of services [16,17]. Recent research indicates that supportive follows: services provided or augmented through mobile health • To what extent is health and social equity considered in the (mHealth) technologies have the potential to make services design, implementation, and evaluation of mHealth more accessible to caregivers [18-20]. interventions for caregivers of older adults? mHealth Interventions as a Potential Solution for • What are the impacts of the examined mHealth interventions on caregivers of older adults based on the following Caregiver Support outcomes: caregiver mental and physical health, caregivers’ The term mobile health (mHealth) was first coined in 2003 in ability to provide care, usability or feasibility of the mHealth response to the rapid development and expansion of mobile intervention for caregivers, and caregivers’ experiences and communication technologies being used within the health care perspectives of engaging in an mHealth intervention industry [21]. The World Health Organization defines mHealth intended to support them? as a “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, Eligibility Criteria personal digital assistants, and other wireless devices” [22]. The Eligible articles were available in full text in the English use of health information technology (computer, internet, and language and were published from 2010 onward to reflect the email) to access health records or locate health information on recent surge in mHealth interventions, concurrent with the rapid the web has become commonplace among caregivers as a means increase in mobile device ownership within the past decade of informing their caregiving role [23]. Research suggests that [30,31]. This review included both quantitative (experimental, https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al quasi-experimental, and observational studies with or without strategy development. Database searches combined a control or comparison groups) and qualitative study designs, comprehensive suite of similar and related terms for the key which evaluated or explored the impacts of mHealth domains of caregivers, older adults, and mHealth interventions. interventions aimed at improving the health of, or providing Detailed search strategies for each database are provided in support to, informal caregivers of older adults. Mixed methods Multimedia Appendix 1. The search results were limited by the studies were also included. mHealth interventions were defined year of publication from 2010 to February 2021, when the search as those that the caregivers of older adults accessed via mobile was initially conducted. The search strategy was repeated in or wireless devices (including mobile phones, tablets, handheld June 2021 to capture newly published articles. Ancestry searches computers, and PDAs). Interventions not accessed by mobile were also conducted using the reference lists of eligible studies, or wireless devices (eg, interventions applied or accessed by as well as related reviews [19,32-34], to search for additional landline telephone as opposed to mobile phone) were excluded, potential articles for inclusion. as were mHealth interventions that targeted the recipient of care Eligible studies identified from the database and ancestry only or only assessed outcomes focused on the recipient of care. searches were independently assessed by a group of 4 reviewers Studies that exclusively included formal caregivers of older (AG, MN, RS, and JT). Each document was reviewed by 2 adults (eg, nurses and personal support workers) or caregivers reviewers (AG, MN, RS, or JT) based on the title and abstract. of individuals who were not identified as older adults (eg, The full texts of relevant studies were then obtained, and 2 children, adolescents, young and middle-aged adults, or adults reviewers (AG, MN, RS, or JT) independently examined the aged <65 years) were also excluded. full texts of the selected studies to determine the final included Eligible studies were also required to report at least one articles in accordance with the eligibility criteria outlined caregiver-specific outcome or finding, including those relating previously. Covidence systematic review software (Veritas to (1) caregiver mental and physical health, (2) caregivers’ Health Innovation) was used to organize the search results and ability to provide care, (3) usability or feasibility of the mHealth facilitate communication between the reviewers. Disagreements intervention by caregivers, and (4) caregivers’ experiences and were resolved by consensus. In cases where consensus could perspectives of engaging in mHealth interventions intended to not be reached, a third reviewer resolved the disagreement. support them. Research protocols, dissertations, reviews, The search strategy yielded an initial 1629 articles for screening commentaries, and abstracts were also excluded. of titles and abstracts. On the basis of the initial screening, the full texts of the 3.31% (54/1629) of articles were assessed. Of Search Strategy and Study Selection the 54 articles, 26 (48%) were subsequently excluded after a A systematic search was conducted on five databases: PubMed, full-text review. The literature search and study selection PsycINFO (ProQuest), CINAHL, Scopus, and Cochrane Library. processes are shown in Figure 1. A total of 28 articles met the An academic librarian was consulted during database search inclusion criteria and were included in the review. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 1. Literature search and study selection process. mHealth: mobile health. sections: (1) mHealth intervention design, (2) study participant Data Extraction recruitment, (3) study results or findings, and (4) discussion or The data were extracted using reviewer-designed data extraction limitations of the investigation. forms in Covidence. A total of 2 reviewers independently Risk of Bias Assessment performed the data extraction. Disagreements were resolved by consensus. In cases where consensus could not be achieved, a Risk of bias (quality) assessments were performed for each third reviewer was consulted. study using standardized critical appraisal tools from the Joanna Briggs Institute Manual for Evidence Synthesis [36]. The Joanna Data extracted from full-text articles included (1) country of Briggs Institute provides distinct critical appraisal checklists investigation; (2) study design and methods; (3) participant for experimental, quasi-experimental, observational, and recruitment, demographics, and baseline characteristics; (4) qualitative study design. One of the reviewers performed the description of the mHealth intervention; and (5) risk of bias assessments for each study, which was then checked caregiver-specific outcomes or findings. In addition, the review by a second reviewer. Disagreements were resolved by team identified which (if any) social determinants of health and discussion and consensus. No studies were excluded from the factors contributing to health inequities were addressed by study review based on quality assessments to achieve a comprehensive investigators, as described by the PROGRESS-Plus framework understanding of the quality of the available literature exploring [27,35]. the impacts of mHealth interventions for caregivers of older PROGRESS-Plus is a framework developed with evidence from adults. The findings of the quality assessments and the working groups from the Campbell and Cochrane limitations of the included articles are summarized in the results, Collaborations, which can be applied to determine whether an and the summary scores of the quality assessments are presented equity lens has been used throughout the stages of study design, in the Results section. implementation, and reporting of research [27]. The framework Data Synthesis includes the following equity factors: place of residence, race, A narrative synthesis of findings was pursued because of the ethnicity, language, culture, occupation (eg, full-time range of included mHealth interventions, caregiver employment or retirement), gender or sex, religion, education, characteristics, and caregiver-related outcome measures, as well socioeconomic status, and social capital, as well as age, as the inclusion of both quantitative and qualitative study disability, sexual orientation, features of relationships, and designs. The narrative synthesis was organized under the time-dependent relationships (Plus factors) [27]. The manner following categories: (1) study characteristics; (2) mHealth in which investigators addressed these factors within the intervention characteristics; (3) consideration of social intervention itself and the study of the intervention was determinants and factors contributing to health inequities in considered in their report of these factors within the following https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al mHealth intervention design, participant recruitment, study [41,56]. Most of the included quantitative studies recruited small results or findings, and discussion or limitations; (4) quantitative convenience samples of caregivers or caregiver–care recipient caregiver-related outcomes; and (5) qualitative caregiver-related dyads; for example, recruiting from single clinics [38,39] or findings. from attendees of an Alzheimer’s Association chapter event [50]. Included qualitative studies were most often limited by a Results lack of clear alignment between philosophical underpinnings, methodology, and research questions or objectives A total of 28 articles were included in this review. A summary [49-53,55-58,60,62]. Although most studies provided sufficient of the included articles is presented in Multimedia Appendix 2 information to demonstrate a logical flow from the analysis and [37-62]. interpretation of data to the overall conclusions, few studies addressed the potential influence of the researcher on the Characteristics of Included Studies research (eg, positionality, trustworthiness, and rigor) [54,62]. Among the 28 included studies, 14 (50%) were quantitative In addition, only 7% (2/28) of qualitative studies provided [37-48,63,64], 7 (25%) were qualitative [49-55], and 7 (25%) information on the location of the researcher’s theoretical used mixed methods [56-62]. Studies were most frequently approach [53,54]. Although other studies may also have used conducted in the United States [38,41,45-48,50,53,58,60], the a theoretical lens or framework to guide their intervention and Netherlands [37,55,57,59], the United Kingdom [54,62], and analysis, they did not report this information. Australia [52,56]. Most studies targeted nonspecific informal mHealth Intervention Characteristics caregivers of older adults; however, 25% (7/28) targeted family or spousal caregivers specifically [38,44,51,52,54,60,64]. The included studies’ interventions were web-based or Approximately 7% (2/28) of studies targeted caregivers who non–web-based applications, interventions, or videoconferencing reported being isolated [56] or experiencing caregiving strain software, which were delivered via mobile phones, tablets, and [38]. Caregivers most commonly provided care to older adults handheld computers. The intervention details, including with dementia or other forms of cognitive impairment intervention description, hardware, stakeholder input, and [37-39,41-44,46,47,50-56,58-60,62,64]. Other studies recruited comparison groups, are outlined in Table 1. caregivers who provided care to older adults with urinary The aims of these interventions fell under three interrelated incontinence [63], older veterans who were medically complex categories: making connections, facilitating caregiving, and [45], and older adults with functional loss or struggling to remain promoting caregiver health and well-being (Figure 2). The independent at home [49,57,61]. included mHealth interventions facilitated various linkages and Risk of Bias Within Included Studies connections between caregivers and supportive services, such as (1) connecting the care recipient’s circle of care, including The full risk of bias assessments for the 28 included studies are caregivers and health professionals [44,45,48,51,53,55, presented in Multimedia Appendix 3 [37-62]. The potential for 57,58,61]; (2) connecting the caregiver to existing social support bias within the 11% (3/28) included randomized controlled trials or facilitating new connections to peer support [40,43,46,56,59]; [37,45,46] most commonly stemmed from a lack of blinding of and (3) connecting the caregiver to services and resources for participants and outcome assessors. Potential sources of bias both themselves and the recipient of care [37,43,47,50,51,53,58]. within other quantitative studies include a lack of control groups [60,62,63] and limited consideration of potential confounders https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Table 1. Details of mobile health interventions of included studies. Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Quantitative studies—randomized controlled trials Beentjes et al [37] FindMyApps, a web-based selection tool Yes; tablet No Caregiver controls re- 8/13 and learning training program to help ceived a tablet but no caregivers find user-friendly apps FindMyApps training or access; received a list of links to websites with apps for people with dementia or mild cognitive impairment Hastings et al [45] Video-enhanced care management: a 14- Yes; tablet No One group received the 5/13 week care management intervention that intervention (video); the included 3 monthly video calls with nurses comparator group re- via a secure internet-based web-based ceived telephone-based meeting room care management Kales et al [46] WeCareAdvisor, a web-based tool for Yes; tablet No Waitlist for the tool; 8/13 family caregivers, which guided them this group received the through a clinical reasoning process to tool 1 month later identify, monitor, and manage behaviors while addressing their motivation, self-ef- ficacy, and problem-solving skills Quantitative studies—quasi-experimental Davis et al [63] TelePrompt, a tablet-based, prompted Yes; tablet No No comparison group; 6/9 voiding and educational intervention to the study was described support caregivers of older adults with by authors as a quasi- urinary incontinence experimental, single- group pre-post design Lai et al [44] Telehealth delivered via videoconferenc- No No Received a weekly care 7/9 ing platforms (apps) aimed at minimizing service via telephone the possible negative impact of social dis- covering information tancing measures made necessary by the relevant to caregiving; COVID-19 pandemic did not receive the inter- vention of weekly health services deliv- ered through video communication apps Park et al [64] Comprehensive Mobile Application Pro- No No Comparator interven- 5/9 gram, a tool providing real-time support tion was a handbook to families caring for patients with demen- that contained the same tia by helping family caregivers manage information as the mo- behavior and psychological symptoms bile app Watcharasarnsap et al A mobile app system based on the reminis- No No Control group did not 9/9 [42] cence therapy framework; the app was use the intervention (no developed to promote the relationship be- intervention) tween caregivers and people with demen- tia and better the mental well-being of both parties Quantitative s tudies — other (ie, noncomparative) Callan et al [38] A self-administered cognitive training in- Yes; hand- No 6/10 N/A tervention using an adaptive, paced serial held comput- attention task, targeting the dorsolateral er prefrontal cortex, which is implicated in regulating emotions, anxiety, and stress https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Davis et al [43] An e-mobile multimedia app for commu- Yes; mobile No N/A 1/10 nity-based dementia caregiver support, phone designed to offer reassurance, information, and services to caregivers and facilitate the implementation of other interventions by nurses and therapists Ptomey et al [47] A remotely delivered exercise intervention Yes; tablet No N/A 4/10 to increase moderate physical activity in caregivers Quinn et al [48] A mobile app designed to improve engage- No No N/A 4/10 ment of the patient-informal caregiver team; the mobile web-based app allowed older adult users to record social and health information and share this informa- tion with their caregivers Lai et al [39] A simple smartphone app for people with Yes; mobile No N/A 6/10 mild cognitive impairment and their fami- phone ly caregivers living in the community; the app supported communication with friends and family, navigation, and serving as a memory prompt and emergency alert sys- tem Salin and Laaksonen A multicomponent intervention, including Yes; tablet Yes N/A 2/10 [40] live broadcasts related to caregiver self- care exercises, informational videos, and videoconferencing web-based meetings to connect informal caregivers Sourbeer et al [41] A preliminary tablet app developed for the Yes; tablet No N/A 2/11 Behavioral and Environmental Sensing and Intervention for Dementia Caregiver Empowerment; the goal of this app is to support the early detection of signs of agi- tation, allowing caregivers to intervene early Mixed methods studies Banbury et al [56] A telehealth peer-support program for Yes; not No N/A 3/8 and 3/10 isolated caregivers of people with demen- specified tia via group videoconferencing Breebaart and van A groupware app for digital network Yes; not No N/A 1/10 and 3/10 Groenou [57] communication to promote collaboration specified among informal and formal caregivers in a mixed care network of home-dwelling older adults Brown et al [58] CareHeroes, an app providing caregivers No Yes N/A 4/10 and 3/10 with a platform for bidirectional sharing of observations and knowledge with providers about care recipients and, in so doing, provide them with information and support for caregiving activities Dam et al [59] Inlife, a web-based social support platform No No Control group did not 4/10 and 7/10 for caregivers of individuals with dementia receive the intervention aiming to enhance positive interaction, (waiting list) involvement, and social support Sikder et al [60] A mobile app intervention delivering No No N/A 5/9 and 3/10 mentalizing imagery therapy (a guided imagery and mindfulness intervention) for family caregivers https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study Intervention description Hardware Stakeholder input Comparator interven- Study quality provided described tion (as applicable) appraisal scores Stutzel et al [61] A mobile phone app, The Mobile System Yes; mobile Yes N/A 5/10 and 7/10 for Elderly Monitoring, which aimed to phone support caregivers in monitoring care re- cipients with functional loss and to im- prove support for caregivers’ communica- tion with the health team Tyack et al [62] An art-based app intervention delivered Yes; tablet Yes N/A 6/9 and 8/10 via a touch screen tablet displaying art images aiming to stimulate and benefit the well-being of caregivers and care recipi- ents with dementia Qualitative studies Garvelink et al [49] A decision support website to inform No No N/A 3/10 caregivers about ways of staying indepen- dent at home for as long as possible, called Supporting Seniors and Caregivers to Stay Mobile at Home Hughes et al [50] A tablet app with multiple components, No Yes N/A 5/10 including games and a stress questionnaire for caregivers Killin et al [51] The Digital Support Platform, an internet- Yes; tablet No N/A 6/10 based, postdiagnostic support tool for families of individuals who had recently received a diagnosis of dementia Rathnayake et al [52] Mobile health apps used for health infor- No No N/A 7/10 mation seeking Ruggiano et al [53] CareIT, a multifunctional smartphone and Yes; mobile Yes N/A 5/10 web-based app designed to meet the edu- phone cation and support needs of caregivers; the app allowed caregivers to self-assess for depression and burden and linked caregivers to resources Ryan et al [54] InspireD—Individual Specific Reminis- Yes; tablet Yes N/A 10/10 cence in Dementia, a personalized reminis- cence program for family carers and peo- ple living with dementia Span et al [55] The DecideGuide, an interactive web tool Yes; tablet Yes N/A 5/10 that helps informal caregivers, people with dementia, and case managers make shared decisions Complete quality appraisal tools and scores are presented in Multimedia Appendix 3. N/A: not applicable. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 2. Mobile health (mHealth) interventions for caregivers of older adults. mHealth interventions included in the review also facilitated [41,50,53,58,61]; (2) promoting self-care and healthy coping caregiving by (1) assisting with daily caregiving activities (eg, behaviors (eg, encouraging physical activity or suggesting digital calendars to organize appointments, providing reminders evidence-based coping strategies for care recipient behaviors) for medication administration, helping caregivers manage care [40,43,47,63,64]; and (3) providing therapeutic interventions recipient behaviors, and tracking information related to the care (eg, art-based interventions [62], reminiscence therapy [42,54], recipient) [39,41,46,48,51,53,57,59,61,63,64], (2) providing cognitive training therapy [38], and mentalizing imagery therapy support for decisions related to care [46,49,55,58], (3) providing [60]). information or education (eg, regarding the care recipient’s Consideration of Factors That Influence Health condition) [40,43-46,48,49,51-53,56,58,63,64], and (4) sending Inequities emergency alerts to the caregiver or to the care team if needed Figure 3 provides a visual summary of the number of studies [39,61]. that included or considered the factors listed in the Finally, the mHealth interventions represented in the review PROGRESS-Plus framework in their report on (1) the design promoted caregiver health and well-being by (1) monitoring or of their mHealth intervention, (2) participant recruitment, (3) assessing caregiver stress, depression, and burden to facilitate study results or findings, and (4) study discussion or limitations. early detection and intervention before reaching crisis levels https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Figure 3. Consideration of place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation (PROGRESS-Plus) factors in included studies. inexpensive mobile apps and devices [61]. Features of Reporting of PROGRESS-Plus Factors in Intervention relationships between caregivers and care recipients were Design considered in the study design such that the mHealth When describing the design of their interventions, 36% (10/28) intervention was a collaborative tool whereby older adults and of studies provided considerations for ≥1 PROGRESS-Plus their caregivers worked together on their health management factor [37,40,41,46,48,49,56,59,61,63]. Approximately 11% [48]. None of the studies mentioned considering participants’ (3/28) of studies considered the place of residence in their occupation, religion, education, disability, sexual orientation, recruitment approaches as their interventions were designed or time-dependent relationships when describing the design of specifically for geographically isolated caregivers [40,56,61]. their mHealth interventions. Approximately 11% (3/28) considered languages through the Reporting of PROGRESS-Plus Factors in Participant provision of alternative language options in the mobile app, Recruitment readability (ie, lay language), and accessibility options such as larger font or less text [37,46,49]. Approximately 11% (3/28) At the participant recruitment stage, 57% (16/28) of studies described social capital as an element of the intervention itself considered ≥ 1 PROGRESS-Plus factor (eg, intervention aimed at providing a platform to organize and [38,40,42,44-46,49,51-53,56-60,64]. Approximately 32% (9/28) access social support) [56,59,63]. Approximately 7% (2/28) considered features of relationships (eg, living situation) described considerations for caregivers’ age in the design of [38,40,44,46,51,52,58,60,64]. Approximately 18% (5/28) of their interventions by improving readability, comprehensibility, studies considered place of residence in participant recruitment and clarity of the language used in the intervention; providing (eg, recruiting participants dwelling in rural areas) caregivers with assistance in completing web-based forms; and [40,42,53,56,57]. Approximately 14% (4/28) of studies reported integrating opportunities for regular check-ins to support that they used specific recruitment strategies to help ensure that mHealth tool use [41,46]. One of the studies considered gender various races, ethnicities, cultures, and languages were or sex, as the intervention was tailored to address the unique represented in their study samples (eg, recruiting from minority needs of caregivers of different genders [46]. Another study populations) [46,49,53,58]. Approximately 11% (3/28) of studies considered socioeconomic status by deliberately selecting considered age (eg, recruiting older caregivers) [38,45,60]. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Approximately 7% (2/28) of studies considered social capital characteristics of the caregivers in the included studies are (eg, recruiting caregivers with an existing social support presented in Table 2. The most commonly reported network) [56,59] and 7% (2/28) considered disability (eg, PROGRESS-Plus factors within the included articles’ results excluding caregivers with sensory impairment) [38,46]. One of or findings were age and gender or sex [37-50,52,53,55-64]; the studies considered time-dependent relationships (eg, features of relationships [37,39,40,42,43,45,46,48,49,51-53, excluding dyads where the care recipient was awaiting imminent 55-59,61,63]; education [37-39,44,46-50,52,55,56,58,61,63,64]; institutional placement) [46], and another considered gender or and race, ethnicity, culture, and language sex [59] at the stage of participant recruitment. No studies [38,41,43,45-49,53,58,60,62,63]. Other factors reported in the mentioned occupation, religion, education, socioeconomic status, results or findings included socioeconomic status or sexual orientation during participant recruitment. [38,44,48,53,61,63,64], social capital [48,55-57,59,61,64], place of residence [40,49,53,56,62,64], and occupation Reporting of PROGRESS-Plus Factors in Results or [50,52,56,61,63,64]. A small number of studies reported on Findings caregivers’ disabilities [49,61,63], time-dependent relationships All but 1 study [54] described ≥1 PROGRESS-Plus factor within (eg, participants’ housing situation) [49,58], and religion [64]. their results or findings. These factors were typically reported No studies reported on sexual orientation in their results or as part of the sample demographics. The key demographic findings. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 11 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Table 2. Demographic characteristics of caregiver participants of included studies. Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Banbury et al [56], Aus- 69 Mean 62.6 (SD 13.54) 50 (72.5) female 6 (8.7) did not complete high Not reported • • • tralia 19 (27.5) male school 6 (8.7) completed high school 17 (24.6) had technical and further education or trade 24 (34.8) attended university 16 (23.2) had postgraduate qualifications Beentjes et al [37], 59 Experimental group 38 (64.4) female 12 (20.3) had secondary edu- Not reported • • • Netherlands mean 65.61 (SD 21 (35.6) male cation (vocational) 10.196); control group 8 (13.6) had secondary educa- mean 68.03 (SD tion (academic) 11.675) 11 (18.6) had further educa- tion (vocational) 20 (33.9) had higher educa- tion (vocational) 8 (13.6) had higher education (academic) Breebaart and van Groe- 7 1 (14.3%) middle-aged, 3 (42.9) female 4 (57.1) had low education Not reported • • • nou [57], Netherlands 1 (14.3%) aged between 3 (42.9) male 2 (28.6) had average educa- • • 60 and 65, and 5 1 (14.3) not tion (71.4%) aged ≥70 specified 1 (14.3) did not specify Brown et al [58], United 11 Mean 56.6 (SD 13.6) 9 (81.8) female Not reported 3 (27.3%) White • • • States 2 (18.2) male 7 (63.6%) African • • American 1 (9.1%) Hispanic 1 (9.1) other Callan et al [38], United 27 Mean 74.61 (SD 6.52) 22 (81.5) female 11 (40.7) had middle school 26 (96.3) White • • • States 5 (18.5) male to technical school education 14 (51.9) had some college to college graduate education 2 (7.4) had some postgradu- ate to postgraduate degree Dam et al [59], Nether- 10 Range 49-71 6 (60) female Not reported Not reported • • • lands 4 (40 male) Davis et al [43], United 4 Mean 52 4 (100) female Not reported Not reported • • • States Davis et al [63], United 3 Range 54-85 3 (100) female 2 (66.7) attended college 3 (100) White • • • States 1 (33.3) had a master’s de- gree Garvelink et al [49], 10 Mean 56.9 (SD 14) 6 (60) female 10 (100) had a university de- Not reported • • • Canada and France 4 (40) male gree Hastings et al [45], Unit- 40 Mean 64.7 (SD 10.8) 40 (100) female Not reported 11 (27.5) Black • • • ed States Hughes et al [50], United 10 Mean 60 (range 48-76) 10 (100) female 10 (100) had high school edu- Not reported • • • States cation 9 (90) had higher education Kales et al [46], United 57 Mean 65.9 (SD 14.0) 43 (75.4) female 48 (84.2) had greater than 36 (63.2) White • • • States 14 (24.6) male high school education 18 (31.6) African • • 9 (15.8) had high school or American GEDa 3 (5.3) other https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 12 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Killin et al [51] [51], 10 Not reported Not reported Not reported Not reported • • • Scotland Lai et al [44], Hong 60 Experimental group 35 (58.3) female Experimental group: 7.90 Not reported • • • Kong, China mean 72.43 (SD 0.80, 25 (41.7) male (SD 0.25, range 5-11) years range 66-82); control of education group mean 71.83 (SD Control group: 7.04 (SD 0.31, 0.80, range 66-82) range 5-9) years of education Lai et al [39], Germany 24 Mean 62.4 y (SD 16.0, 9 (37.5) female 11 (45.8) had >12 years of Not reported • • • range 31-83) 15 (62.5) male education Park et al [64], South 24 Experimental group 14 (58.3) female 15 (62.5) were high school Not reported • • • Korea mean 54.50 (SD 3.71); 10 (41.7) male graduates or below control group mean 9 (37.5) were college gradu- 61.00 (SD 6.42) ates or above Ptomey et al [47], United 9 Mean 67 3 (33.3) female 3 (33.3) had high school 8 (88.9) White • • • States 6 (66.7) male diploma or GED 1 (11.1) Black • • 6 (67.6) attended postgradu- ate classes Quinn et al [48], United 12 Mean 54.8 (SD 13.3) 11 (91.7) female 6 (50) had a business or some 6 (50) Black • • • States 1 (8.3) male college degree or graduate 6 (50) White • • degree 6 (50) graduated school Rathnayake et al [52], 10 8 (80%) aged <65; 2 9 (90) female 5 (50) had high school educa- Not reported • • • Australia (20%) aged ≥65 1 (10) male tion and below 5 (50) had above high school education Ruggiano et al [53], 36 Mean 65.7 (range 42- 26 (72.2) female Not reported 13 (36.1) non-His- • • • United States 89) 10 (27.8) male panic White 23 (63.9) African American Ryan et al [54], United 17 Mean 69.1 (SD 15.1, 13 (76.5) female Not reported Not reported • • • Kingdom range 31-91) 4 (23.5) male Salin and Laaksonen 20 Range 61-88 15 (75) female Not reported Not reported • • • [40], Finland 5 (25) male Sikder et al [60], United 17 Mean 66.52 (SD 9.61) 12 (70.6) female Not reported 17 (100) White • • • States 5 (29.4) male Sourbeer et al [41], Unit- 46 42 (91.3%) aged >60; 4 38 (82.6) female Not reported 39 (84.8) White • • • ed States (8.7%) aged <60 8 (17.4) male 6 (13.0) African • • American 1 (2.2) Hispanic Span et al [55], Nether- 12 Mean 54.3 (range 19- 7 (58.3) female 1 (8.3) had low education Not reported • • • lands 86) 5 (41.7) male 4 (33.3) had medium educa- • • tion 6 (50) had high education 1 (8.2) did not specify Stutzel et al [61], Brazil 38 Mean 61 (SD 10.75) 32 (84.2) female 21 (55.3) had ≤12 years of Not reported • • • 6 (15.8) male education 17 (44.7) had >12 years of education Tyack et al [62], United 12 Mean 66 (range 48-77) 10 (83.3) female Not reported 12 (100) White • • • Kingdom 2 (16.7) male https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 13 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al Study and country Sample Age (years) Sex, n (%) Education, n (%) Ethnicity, n (%) size Watcharasarnsap et al 60 8 (13.3%) aged between 31 (51.7) female Not reported Not reported • • • [42], Thailand 18 and 27, 19 (31.7%) 29 (48.3) male aged between 28 and 37, 15 (25%) aged be- tween 38 and 47, 10 (16.7%) aged between 48 and 57, and 8 (13.3%) aged ≥58 GED: General Educational Development. [63]; however, study investigators noted that the intervention Reporting of PROGRESS-Plus Factors in Discussion did not worsen caregiver burden [63]. or Limitations Outcomes Relating to Caregivers’ Health and Well-being Approximately 79% (22/28) of studies considered ≥1 Approximately 39% (11/28) of studies assessed the impact of PROGRESS-Plus factor in the discussion or limitations sections mHealth interventions on various aspects of caregivers’ health of their studies [37,38,40,41,43,44,47-56,58-63]. The most and well-being [37,40,42-44,46,47,60-62,64]. Impacts on frequently discussed PROGRESS-Plus factors in the included caregivers’ mental and psychological health status were assessed articles’ discussion or limitations were age in 25% (7/28) of studies [42,44,46,60-62,64], with generally [37,38,40,41,43,48,50,51,53,54,60,62,63], such as challenges positive results. Specifically, mental health status [44], faced by older caregivers in using mobile devices; race, psychological well-being [42], depression [46,60], mood [60], ethnicity, culture, and language [40,41,43,47,49,52,53,55,58,60], distress [46], and fatigue [64] were each noted to have improved such as a lack of diversity of the study sample; and place of after the implementation of an mHealth intervention. For residence [40,44,47,49,51,53,55,56,61], such as challenges example, the implementation of the WeCareAdvisor tool, related to the lack of access to stable internet in rural locations. designed to provide caregivers with peer navigation, Other PROGRESS-Plus factors described in the study information, and daily messaging, led to significant discussions or limitations were gender or sex improvement in self-reported distress (−6.08, SD 6.31 points; [38,41,52,54,55,63], education [37,38,49,52,56,63], and P<.001) [46]. In this study, those in the control group socioeconomic status [44,47,48,52,53,63]. To a lesser extent, demonstrated a significant decrease in their confidence in caregivers’ social capital [48,56,59], disabilities [38,49], features caregiving (−6.40, SD 10.30; P=.002) [46]. Conversely, a study of relationships (eg, nature of relationship between caregiver that assessed caregiver stress by testing cortisol levels in saliva and care recipient) [54,55], and time-dependent relationships in a pretest-posttest design found no differences after the use (eg, the impact of COVID-19 on the amount of time caregivers of an mHealth intervention designed to manage the behavioral could spend visiting the care recipient) [37,49] were also and psychological symptoms of dementia [64]. Caregivers’ discussed. No studies considered occupation, religion, or sexual self-appraised happiness was also unchanged after the orientation in their discussion or limitations sections. intervention in one of the studies [62]. Quantitative Caregiver Outcomes Approximately 11% (3/28) of studies assessed outcomes related Outcomes Relating to Caregiving to caregivers’ physical health and well-being [44,47,64]. Caregivers self-reported improvements in their general physical Approximately 21% (6/28) of studies assessed the impact of health status following the use of an mHealth intervention to mHealth interventions on outcomes related to caregivers’ support the well-being and community living of older adults capabilities or experiences in providing care. These outcomes and their spousal caregiver dyads [44]. Ptomey et al [47], who included caregivers’ self-efficacy [44,63], sense of competence implemented an mHealth app to encourage exercise, observed [37] and confidence [46] in their caregiving role, knowledge that caregivers’ weekly moderate physical activity increased by related to the care recipient’s condition [63], positive care 49 minutes (30% increase) per week over the 12-week experience [37], and caregiver burden [43,44,46,63,64]. intervention period, whereas light physical activity increased Although some studies found that caregiving self-efficacy and by 11.6 minutes (3% increase) per week. However, Park et al knowledge improved after the implementation of an mHealth [64] found no difference in caregivers’ sleep quality after the intervention [44,63], other studies observed no difference after implementation of a supportive mHealth app. the intervention in caregivers’ sense of competence [37], confidence [46], or positive caregiving experience [37]. Approximately 14% (4/28) of studies used caregivers’ quality of life as an outcome measure for their respective interventions, Approximately 14% (4/28) of studies using the Zarit Burden with mixed findings. Ptomey et al [47] found nonsignificant Inventory [65] found that mHealth interventions led to trends toward improvement in quality of life after the improvements in caregiver burden [43,44,46,64]. However, one implementation of an mHealth intervention. Beentjes et al [37] of the studies, which specifically assessed caregiver burden and Tyack et al [62] found no significant changes in quality of related to the management of urinary incontinence, found that life following their interventions aimed at supporting caregivers burden was similar before and after the mHealth intervention in finding user-friendly apps and viewing art to encourage https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 14 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al therapeutic reminiscence, respectively. Salin and Laaksonen and worry reported the highest levels of mHealth intervention [40] observed that some aspects of quality of life, in fact, use [38]. Sikder et al [60] reported that over half of their 17 worsened, albeit mildly (breathing, sexual activity, vitality, study participants accessed ≥75% of the informational depression, and usual activities). One of the studies assessed documents in their mHealth app. The remaining 11% (3/28) of the impact of an mHealth intervention on caregivers’ social studies reported varying frequencies or hours of use per week engagement and found high positive responses using the Kaye during the intervention period [57-59]; however, these studies Gain Through Involvement Scale [66], suggesting that the gains did not comment on whether these frequencies constituted low, in well-being experienced while using the mHealth intervention medium, or high use of their mHealth interventions. may be applicable when tested in a larger sample [43]. However, Approximately 11% (3/28) of studies assessed feasibility by the study investigators noted that their sample was meant only measuring the intervention attendance and retention of for determining intervention efficacy and warranted testing with caregivers during the intervention period [40,45,47]. The a larger sample [43]. attendance rates for caregivers varied from 72% (13.7/19) [40] to 97.1% (34/35) [45]. Ptomey et al [47] and Hastings et al [45] Outcomes Related to Usability, Feasibility, and reported similar figures (7/9, 78% dyads, and 31/40, 78% dyads, Acceptability of mHealth Interventions respectively) for the caregiver–care recipient dyads completing Half of the reviewed studies assessed outcomes related to the their interventions. usability, acceptability, or feasibility of mHealth interventions for caregivers of older adults [38-41,45,47,48,57-63]. Other feasibility measures used by the reviewed studies included the extent to which caregivers followed or adhered to the Approximately 32% (9/28) of studies measured the usability or mHealth intervention [38,63]. Callan et al [38] reported that ease of use of mHealth interventions by caregivers caregivers’ continued engagement in a cognitive training [40,41,45,47,48,58,59,61,63]. Approximately 14% (4/28) of mHealth intervention program was evidenced by improvements articles used the System Usability Scale [67] to do so; usability in their ability to perform cognitive training tasks. Davis et al scores varied across studies, ranging from marginally acceptable [63] reported that caregivers were capable of learning and [45], moderate [48], and good to excellent [61]. Only 4% (1/28) implementing the prompted toileting strategies to support care of studies compared the system usability scores across 2 phases recipients with the help of an mHealth intervention, as evidenced of their mHealth app intervention. Sourbeer et al [41] found by a reduction in care recipient wetness in 2 out of 3 participant that usability did not significantly improve in a subsequent dyads. version of their mHealth app updated in response to participant feedback. The remaining 18% (5/28) of studies assessed Qualitative Caregiver Findings caregivers’ ease of use or perceived user-friendliness of the Overview mHealth intervention using descriptive statistics or averaged Likert scale scores. These studies generally reported positive Of the 28 studies, 7 (25%) qualitative studies and 7 (25%) mixed results, suggesting that caregivers believed the interventions methods studies presented findings relating to caregivers’ were easy or very easy to use [40,47,58,59,63]. experiences of engaging in mHealth interventions [49-62]. These qualitative findings included (1) positive impacts of caregivers’ Approximately 21% (6/28) of studies examined caregivers’ experiences with mHealth interventions, (2) challenging aspects satisfaction or positive feelings toward the intervention of caregivers’ experiences with mHealth interventions, (3) [39,40,47,48,58-61]. Most reported that caregivers were barriers to caregivers’ engagement with mHealth interventions, generally satisfied with the mHealth intervention, perceived the and (4) caregivers’ suggestions to improve mHealth intervention as relevant and useful to their caregiving activities, interventions. and felt positive about their experiences with the intervention [39,40,47,48,58-61]. However, greater technical difficulties Positive Experiences With mHealth Interventions were reported in a study of participants who lived rurally and Most studies highlighted promising findings related to the reported lower levels of satisfaction [40]. positive impacts of caregivers’ experiences with mHealth interventions. Participants across the included studies found Approximately 29% (8/28) of studies explored the feasibility mHealth interventions to be helpful, user-friendly, and easy to of an mHealth intervention by measuring the regularity, understand [49,50,54,55]. mHealth interventions were perceived frequency, and extent of its use by caregivers over the to help caregivers connect with the care team and provide care intervention period [38,57-60,62]. Use varied across the included for their loved ones [53,55,57,60,61]. The information provided studies, and investigators did not consistently establish through mHealth interventions was described as relevant to expectations of use for their participants nor defined what addressing participants’ educational needs [49,52]. Caregivers constituted adequate use of the intervention. Tyack et al [62] also valued the role of mHealth interventions in detecting their reported that the participants used their app at least five times stress levels [50] and facilitating timely connections to a diverse during the intervention period, as suggested by the study range of professional services and social support investigators. Callan et al [38] found that 22 out of 27 (81.5%) [49,52,54,56,62]. Participants in the included studies reported caregivers used the mHealth intervention regularly (as defined benefits to their emotional and cognitive well-being [60,62] and by the study investigators as at least 3 weeks out of the 4-week described reappraising and feeling closer to the care recipient intervention period). Baseline caregiver stress, worry, and sleep [54,62]. The mobile delivery of the interventions also quality did not adversely affect the use of the mHealth contributed to feelings of safety and security, as caregivers could intervention, and caregivers with the highest self-reported stress https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 15 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al participate from their homes [54,56]. Although some participants caregivers who were unfamiliar with using mobile devices initially felt a lack of confidence in using technology, caregivers [51,56]. in 7% (2/28) of studies reported becoming more engaged and The participants also made suggestions to develop more relevant comfortable over time by integrating the mHealth intervention and up-to-date content for mHealth interventions. Several studies into their lives [54,57]. highlighted the need to embed local and national services for caregiver support, including interventionists and respite care Challenging Experiences With mHealth Interventions [58-60]. For interventions that targeted the caregiver–care Several studies described the negative aspects of caregivers’ recipient dyad, participants highlighted the need for more experiences with using mHealth interventions, although these information specifically related to their own health, such as were often reported as being applicable to only a minority of healthy coping [49,52,58,61]. Participants also called for greater participants. Approximately 11% (3/28) of studies indicated emphasis on topics that caregivers often find difficult, including that some participants felt that the mHealth intervention was information about deciding to move to a care home, managing too complex or difficult to understand [49,51,60]. In another activities of daily living and aggressive behaviors, and resources study, participants felt that the intervention included questions for individuals experiencing abuse [49,52,58]. that were overly obtrusive or confronting; for example, participants were not always comfortable answering questions Other findings suggested to improve mHealth engagement they perceived as challenging [55]. Some studies highlighted among caregivers included greater ethnic diversity portrayed caregivers’ concerns regarding the potentially detrimental within the mHealth intervention [49], establishing a reward impacts of mHealth interventions; for example, interventions system to encourage regular use [50], and creating a component that facilitated reminiscence could trigger painful memories for the care recipient to be included when the caregiver uses the and lower mood [54,62]. Hughes et al [50] further described mHealth intervention [50]. caregivers’ concerns regarding the diversion of their time and attention toward the mHealth intervention and away from the Discussion care recipient. One of the studies highlighted the preference of some participants for in-person interventions, citing physical Principal Findings contact as an important element of care (eg, hugging), which This systematic review examined how health and social equity was not possible in a digital environment [56]. are considered in the design, implementation, and evaluation of mHealth interventions developed for caregivers of older Barriers to Caregivers’ Engagement With mHealth adults using the PROGRESS-Plus framework. The interventions Interventions described in the included studies were designed to create Caregivers relayed frustration with the usability of mHealth linkages between caregivers and external supports, streamline interventions, including difficulties navigating the intervention and optimize caregiving activities, and encourage a focus on on their mobile devices [49,50,62]. Challenges included print caregiver health and well-being. As such, evidence on the that was too small [49,50], screens that were overly sensitive impacts of caregiver-focused mHealth interventions was or had too much glare [62], and language that was too complex synthesized across a range of outcomes. [49]. Several studies highlighted a lack of familiarity or The findings indicate that health and social factors are not experience with technology as a key barrier to the use of consistently taken into consideration when designing research mHealth interventions, particularly for older caregivers studies (ie, used to develop and guide recruitment and [51-53,55]. The busy schedules of caregivers for older adults intervention design). Furthermore, participant characteristics were also identified as a barrier to regular mHealth intervention are most often only reported within study results when use, particularly if caregivers were often pulled away from their summarizing participant characteristics or when identifying devices by care recipients or if they were experiencing health limits to the generalizability of the findings. However, this issues themselves [50,52,58,60]. review highlights how mHealth interventions are well-positioned In other cases, participants felt that the intervention’s content to improve caregivers’ self-efficacy and knowledge, their was not relevant to their immediate needs [49,51] or lacked perceived mental and physical wellness, and their relationships realism (eg, lack of ethnic diversity among actors portraying with care recipients. The usability and acceptability of mHealth caregivers in the mHealth intervention) and up-to-date links to interventions were characterized by ease of use, ease of relevant resources [49]. Other barriers included the prohibitive navigating technical challenges, and relevance of intervention cost of mobile devices and internet or data plans [52] and the content to the caregivers’ individual roles and context. availability of a stable internet connection in rural regions [56]. Consideration of PROGRESS-Plus Factors in Studies Caregivers’ Perspectives Regarding Next Steps on mHealth Interventions for Caregivers of Older Qualitative findings frequently incorporated participants’ Adults suggestions to make mHealth interventions more user-friendly Overview and accessible to caregivers. Suggestions included simplifying the intervention’s interface or instructions, enlarging text and Most studies in this systematic review on mHealth interventions images, and including subtitles on video resources for for caregivers of older adults considered some PROGRESS-Plus individuals with hearing impairment [49,52,61,62]. Participants factors, particularly when describing their study samples. voiced the need for ongoing technical support, particularly for However, such demographic reporting reflects standardized https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al reporting practices of participant composition rather than population [24,73]. These findings suggest that exploring deliberate and targeted approaches to recruiting caregivers across barriers and facilitators, as identified by the included qualitative sociodemographic characteristics to determine whether an studies, aimed at educating older adults on how to use mHealth intervention is suitable for a diversity of participants. The factors interventions is essential to facilitate perceived trust, comfort, described in the following sections were considered critical in and usability of technology. Thus, beyond education as a social the intervention design. determinant of health, wide disparities exist across caregivers in comfort with using various technologies, such as tablets, Gender Sex or Sexual Orientation iPads, and mobile phones [73]. Importantly, few studies considered actively recruiting Socioeconomic Status caregivers of different self-reported genders or considered the relevance of gender in intervention design or implementation. Socioeconomic status was minimally considered in the Research suggests that biological and gender differences affect intervention design and was most often addressed when health across a range of parameters such as risk, disease describing sample characteristics. Multiple studies reported incidence, and the need for health services [27]. Furthermore, providing participants with devices to support the use of sexual orientation was, in fact, eclipsed across all studies, mHealth apps [37-41,43,45-47,51,53-57,61-63]. In some cases, particularly when many studies focused on caregiver health and participants were allowed to keep the devices; however, well-being, which includes the relationship they have with care especially in those instances in which they were not, the recipients. Recent evidence indicates that sexual and gender feasibility of such interventions for caregivers across income minority caregivers, such as those identifying as queer and levels needs to be explored. transgender, report higher depressive symptoms (78%) than the Some interventions were designed to facilitate communication overall population of caregivers of people with dementia (34%) access to health professionals and other individuals (eg, support [68]. This finding highlights the importance of diversifying groups), highlighting the need for access to a reliable internet samples across genders and sexual orientations to reliably assess connection. This lack of access may be due in part to financial and address caregivers’ mental health. The importance of constraints, as a survey of caregivers in the United States found considering the intersections among gender, sexual orientation, that cost was a commonly reported barrier to the use of and other sociodemographic factors was also highlighted in the technology [74]. Furthermore, older adults living on fixed survey of a cross-sectional sample of members of the National incomes may be reticent to spend money on devices they do Alliance for Caregiving. Caregivers who identified as lesbian, not value or find overly complicated [75]. Importantly, older gay, bisexual, and transgender were more likely to be racially caregivers tend to have fewer technological devices than their and ethnically diverse and represent lower socioeconomic younger peers, and these technologies are often used for classes than those who did not [69]. communication purposes rather than health management purposes [18]. Although most caregivers report valuing Education technology, those that use it for health-related activities tend to Education, although frequently reported in demographics, was use it for targeted caregiving activities such as medication also rarely considered as an important factor in informing tracking or safety [18]. Therefore, additional support or intervention design and recruitment. Women with lower education may be required to increase caregiver uptake of education are more likely to assume caregiving roles than those mHealth interventions as a tool for addressing broader caregiver who have had additional educational opportunities [11]. Lower needs such as communication with health teams or liaising with literacy levels among caregivers can affect their ability to other caregivers. Computers and smartphones are increasingly navigate the health system and locate appropriate support for being owned by people with higher income and education, and themselves and their care recipient [70], factors that can directly the provision of caregiver support through mHealth apps could influence the design and usability of mHealth interventions. For increase inequalities if economic resources are not considered example, lower literacy can affect comprehension of text-based in the design and implementation of these interventions [71]. content in mHealth apps, the ability to correctly enter spelled words in search functions, and the ability to navigate app menus Culture, Language, and Race [71]. The importance of designing mHealth interventions that The nature of caregiver–care recipient relationships can be an account for varying levels of educational background is important factor in the design of mHealth tools, particularly underscored by the association of literacy with health and digital when it comes to cultural expectations of family members, literacy [72]. gender roles, and other caregiver demographics. The included The findings of the included studies suggest that experience studies had samples primarily made up of women, validating with technology can be a key barrier to the use of mHealth the literature that suggests women are most likely to provide interventions, particularly among older caregivers [51-53,55]. caregiving support, corroborating cultural norms across a range A survey of a broad age range of caregivers suggests that of identities [76]. However, these studies did not address how younger caregivers (aged <50 years) are more than twice as intersecting identities (eg, culture, gender, race and ethnicity, likely than older caregivers to be receptive to using mHealth and socioeconomic status) might shape expectations and apps to support them in their caregiving roles [24]. For older responsibilities within a caregiving role [11,12,68]. Research adults, trust in technology as it relates to privacy and access to suggests that culture strongly affects caregiving but that cultural information can be an important factor in the use of mHealth influences on the caregiver role must be understood within the interventions, especially given the heterogeneity of this context of race and gender socialization [77]. For example, https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 17 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al individualistic or Western notions of strategies to address taking away from the time they had to complete other caregiving caregiver burdens, such as spending time alone or sharing tasks [58]. The impact of such detrimental experiences, as they caregiving responsibilities with friends or family, might not relate to, for example, PROGRESS-Plus factors of resonate with caregivers from other cultures, particularly those gender-informed cultural caregiving roles, features of with a strong sense of filial responsibility or immigrant relationships, or caregiver disability, is not well understood. caregivers without local support [78]. Furthermore, mHealth Wasilewski et al [34] found that caregivers’ decline in apps not provided in caregivers’ first languages decrease web-based intervention use may be attributed to a malalignment accessibility and would require careful translation and cultural with their specific needs and capabilities across the caregiving adaptation to remain meaningful [79]. The impact of these trajectory. In such cases, it is important for those recommending factors on caregiver-specific outcomes, such as caregiving mHealth interventions to caregivers to consider whether a self-efficacy, health and well-being, and technology usability, particular intervention itself might increase the caregiver burden is yet to be explored. Intersecting identities are increasingly [81]. Furthermore, research suggests that if older adults perceive important to consider when tailoring web-based caregiver an mHealth app to be beneficial to their health and well-being, interventions to participants’ individual needs [19]. their likelihood of ongoing and increased engagement with other apps increases [82]. Individualized tailoring of mHealth apps mHealth Interventions Developed for Caregivers of and providing the necessary access and universal design can Older Adults foster equitable uptake and increase the potential benefits of mHealth interventions. Impacts of mHealth Interventions on Caregiver Health and Wellness Usability, Feasibility, and Acceptability of mHealth Studies evaluating mobile technology interventions aiming to Interventions promote caregivers’ perceived mental and psychological health Overall, caregivers in the included studies were generally reported benefits to their emotional and cognitive well-being comfortable using mHealth interventions and reported positive [60,62]. Some of these interventions, such as the impacts on their caregiving role [49,50,54,55]. However, videoconferencing platform developed by Lai et al [44], were findings such as the prohibitive costs associated with mobile designed in lieu of in-person community services, following devices and internet and data plans, in combination with the shelter-in-place orders during the COVID-19 pandemic. quality of internet provision to those living in rural settings, Connecting caregivers to professional and peer support using highlight the importance of equitable service provision across web-based technologies has been shown to improve mental the PROGRESS-Plus factors [52,56]. The findings of this review health outcomes and can help caregivers overcome common also showed that 64% (18/28) of studies access-related barriers related to PROGRESS-Plus factors, such [37-41,43,45-47,51,53-57,61-63] provided participants with the as geographical and time constraints or community mobility devices required to engage in the interventions, suggesting that limitations related to physical or mental health [18-20]. the economic feasibility of these interventions needs to be better However, findings from the included studies suggest that understood. caregivers still require opportunities for in-person interaction Technical features such as app use data may provide valuable (eg, hands-on training from a health care provider to successfully insights into the frequency and applicability of interventions to use external support systems), suggesting that the impact of caregiver needs and their unique lifestyles. Furthermore, hybrid models of interventions to improve caregiver health and researchers have been urged to include older adults and their wellness is not well understood [20]. Furthermore, a review of caregivers in the design and development of mobile app these interventions using the PROGRESS-Plus factors suggests technologies [48]. However, a minority of the studies included that, although caregivers stand to benefit from mHealth in this review described stakeholder input as a component of interventions and many older adults report being comfortable their intervention design or implementation [40,50,53-55,58,61]. with smartphone use, uptake may continue to be constrained if Co-design approaches present important opportunities for support is not provided to help caregivers learn and familiarize engaging diverse populations to help ensure that mHealth themselves with mHealth apps at the outset [80]. Hybrid interventions are inclusive and accessible. approaches have the potential to increase caregiver self-efficacy, as opposed to overwhelming caregivers with new tools and Implications technology, which warrants further research. Moving forward, an important reminder is that social Supporting the Caregiver Role Through mHealth determinants of health should be consciously considered in all aspects of mHealth intervention design and implementation to Interventions avoid perpetuating inequities experienced by historically and Caregivers’ ability to perform their roles was a key focus of the currently systemically disadvantaged caregivers of older adults examined mHealth interventions and outcomes of interest within living with chronic conditions [25,83]. Purposeful efforts to the included studies. Although some interventions focused on include a diverse range of participants in research, such as creating external structures that facilitated responsibilities of evidence-based recruitment strategies, can help redress these providing care (eg, medication alarms, and checklists), the use potential inequities and inform the development of more of these tools had the potential to complicate caregiving inclusive interventions [84,85]. The PROGRESS-Plus responsibilities. For example, in one case, caregivers described framework is an appropriate tool to help ensure that a health that the increased screen time to engage in the intervention was https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 18 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al and social equity lens is applied in research design and reporting, North, these institutions use similar health research databases the use of which should be widely endorsed [27,86]. and search algorithms, which can affect future reproducibility (ie, replicating searches in different institutions with different This review highlights the need for high-quality mHealth studies. journal accesses). The identification of potentially eligible Particular attention must be paid to improving the design of literature from the Global South, other disciplines beyond health mHealth interventions and ensuring equality in access and research (eg, technology literature databases), or those that are adoption of mHealth interventions [71]. Participatory action categorized in other ways (eg, gray literature) is another approaches to research, such as co-design, are ideal for ensuring limitation of this review. However, this study highlights that that mHealth interventions meet the needs of diverse caregivers. research on mHealth interventions for caregivers of older adults Furthermore, inclusive design principles can be used in more primarily occurs within applied health settings. As such, future traditional research methodologies to ensure that mHealth reviews should examine non–peer-reviewed evidence such as interventions do not amplify health disparities. This could be reports and program evaluations produced by the government achieved by accommodating low literacy by including audio and health authorities that trial mHealth interventions. narration and visual depictions or by directing funding to increase access to human resource infrastructures (eg, technical This study could have been further strengthened by involving support) that promote mHealth interventions in remote or additional team members, such as administrators of clinical low-income regions [71]. settings who would implement mHealth interventions and, most importantly, caregivers of older adults themselves. By selecting Strengths and Limitations the PROGRESS-Plus framework as a theoretical guide, this The studies included in this systematic review represent the study did not examine the included interventions and diversity of mHealth interventions that have been conceptualized investigations in light of compounding factors that and created to address caregiver needs. Unfortunately, many disadvantaged caregivers (eg, impact of the intervention on studies were found to be poorly designed and executed. older women living in rural settings) or capture other health and Although half of the included studies assessed usability, social factors beyond the framework (eg, access to health feasibility, and acceptability of mHealth interventions, which insurance). However, using the framework as an approach to are all important aspects of technology use, many of these used name and identify how key individual factors have been qualitative approaches and lacked overall methodological rigor. considered in intervention design and evaluation, this study has Given the variety of mHealth apps, technological devices, and set the stage for future investigations that examine the implementation protocols, equivalent comparisons could not confluence of multiple social determinants of health. be made across studies. A small number of studies were Conclusions identified evaluating the impact of caregiver-focused interventions on caregiver-specific outcomes, limiting the ability mHealth supports are well-positioned to support caregivers of to make conclusive recommendations to guide practice. older adults by providing them with information, Encouragingly, some of the included quantitative studies that communication, and assistance in their caregiving role. used valid and reliable standardized tools thoroughly described However, access, uptake, and the ability to benefit from this their approach to statistical analysis and generally addressed technology can be affected by the social determinants of health fidelity of intervention delivery. and inequities among caregivers. This systematic review of mHealth interventions to support caregivers of older adults In this review, multiple steps were taken to achieve suggests that these tools are well-received by caregivers and methodological rigor. The review was conceptualized and have the potential to support caregivers across a variety of designed using an equity framework and the best evidence on parameters by facilitating education, communication, and a interventions for caregivers of older adults. The search strategy sense of security for caregivers. The social determinants of was developed in consultation with a health research librarian, health and equity factors are not widely considered in the design and database searches, screening, data extraction, and risk of and implementation of mHealth interventions, although these bias evaluations were conducted in duplicate, with a strong parameters are frequently collected for demographic reporting. agreement between reviewers. The review protocol was also Recognizing that there are many challenges in designing and made publicly available a priori and was adhered to without implementing mHealth interventions that are equitable, going any deviations. In addition, the PRISMA and PRISMA-Equity forward, it will be important to strive for greater inclusion of guidelines guided each phase of this study [28,87]. the social determinants of health at all stages of mHealth Inevitably, this study has some limitations. Although these development and implementation if there is to be widespread searches were conducted by health and rehabilitation successful uptake of this supportive technology. investigators across 3 large academic institutions in the Global Conflicts of Interest None declared. Multimedia Appendix 1 Search strategies for all databases. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 19 (page number not for citation purposes) XSL FO RenderX JMIR AGING Garnett et al [PNG File , 393 KB-Multimedia Appendix 1] Multimedia Appendix 2 Summary table of included studies. [PNG File , 3092 KB-Multimedia Appendix 2] Multimedia Appendix 3 Risk of bias assessments. 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PLoS Med 2012;9(10):e1001333 [FREE Full text] [doi: 10.1371/journal.pmed.1001333] [Medline: 23222917] Abbreviations mHealth: mobile health PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses PROGRESS-Plus: place of residence, race, occupation, gender, religion, education, social capital, socioeconomic status–plus age, disability, and sexual orientation PROSPERO: International Prospective Register of Systematic Reviews Edited by J Wang; submitted 24.08.21; peer-reviewed by A Sikder, E Brown, J Wolff; comments to author 02.12.21; revised version received 11.04.22; accepted 23.05.22; published 08.07.22 Please cite as: Garnett A, Northwood M, Ting J, Sangrar R JMIR Aging 2022;5(3):e33085 URL: https://aging.jmir.org/2022/3/e33085 doi: 10.2196/33085 PMID: 35616514 ©Anna Garnett, Melissa Northwood, Justine Ting, Ruheena Sangrar. Originally published in JMIR Aging (https://aging.jmir.org), 08.07.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Aging, is properly cited. The complete bibliographic information, a link to the original publication on https://aging.jmir.org, as well as this copyright and license information must be included. https://aging.jmir.org/2022/3/e33085 JMIR Aging 2022 | vol. 5 | iss. 3 | e33085 | p. 24 (page number not for citation purposes) XSL FO RenderX

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JMIR Aging – JMIR Publications

Published: Jul 8, 2022

Keywords: caregivers; older adults; mobile health; social determinants of health; intervention; mobile phone

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mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

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mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

mHealth Interventions to Support Caregivers of Older Adults: Equity-Focused Systematic Review

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