Technology and Health Care 22 (2014) 847–855 DOI 10.3233/THC-140861 IOS Press
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Methodology of development and students’ perceptions of a psychiatry educational smartphone application Melvyn W.B. Zhang∗ , Cyrus S.H. Ho and Roger C.M. Ho Department of Psychological Medicine, National University Healthcare Systems, Singapore
Received 21 June 2014 Accepted 24 August 2014 Abstract. BACKGROUND: The usage of Smartphones and smartphone applications in the recent decade has indeed become more prevalent. Previous research has highlighted the lack of critical appraisal of new applications. In addition, previous research has highlighted a method of using just the Internet Browser and a text editor to create an application, but this does not eliminate the challenges faced by clinicians. In addition, even though there has been a high rate of smartphone applications usage and acceptance, it is common knowledge that it would cost clinicians as well as their centers a lot to develop smartphone applications that could be catered to their needs, and help them in their daily educational needs. OBJCETIVE: The objectives of the current research are thus to highlight a cost-effective methodology of development of interactive education smartphone applications, and also to determine whether medical students are receptive towards having smartphone applications and their perspectives with regards to the contents within. METHODOLOGY: In this study, we will elaborate how the Mastering Psychiatry Online Portal and web-based mobile application were developed using HTML5 as the core programming language. The online portal and web-based application was launched in July 2012 and usage data were obtained. Subsequently, a native application was developed, as it was funded by an educational grant and students are recruited after their end of posting clinical examination to fill up a survey questionnaire relating to perspectives. RESULTS: Our initial analytical results showed that since inception to date, for the online portal, there have been a total of 15,803 views, with a total of 2,109 copies of the online textbook being downloaded. As for the online videos, 5,895 viewers have watched the training videos from the start till the end. 722 users have accessed the mobile textbook application. A total of 185 students participated in the perspective survey, with the majority having positive perspectives about the implementation of a smartphone application in psychiatry. CONCLUSIONS: This is one of the few studies that describe how an educational application could be developed using a simple and cost effective methodology and this study has also demonstrated students’ perspectives towards Smartphone in psychiatric education. Our methods might apply to future research involving the use of technology in education. Keywords: Education, technology, smartphone applications, under-graduate psychiatry education innovations, developmental models
∗
Corresponding author: Melvyn Zhang, Psychiatry Resident, Level 9, Department of Psychological Medicine, National University Healthcare Systems (NUHS) Tower Block, 5 Lower Kent Ridge Road, 119074, Singapore. Tel.: +65 7725555; Fax: +65 7725555; E-mail: [email protected]. c 2014 – IOS Press and the authors. All rights reserved 0928-7329/14/$27.50
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M.W.B. Zhang et al. / Development and students’ perceptions of a psychiatry educational smartphone application
1. Introduction The worldwide prevalence of mobile phones has made them a very useful and innovative platform for provision of patient’s care, as well as in helping clinicians with management decisions. Over the past few years, smartphones have advanced drastically in terms of both their functionality and design and they are currently more than what used to be a simple call and messaging device [1]. They have literally been transformed into sophisticated mini-personal computers. Previous reviews have highlighted the worldwide prevalence and the global acceptance of smartphones and commercial smartphone applications by medical students, trainees and interns. In 2012, a questionnaire based survey was distributed amongst interns in the Republic of Ireland [2], and it has demonstrated that smartphones are being used daily by the interns to perform their job. The questionnaire study noted that that most commonly used application by interns was that of the British National Formulary, and the most commonly used website was that of Wikipedia [2]. It is thus beyond doubts, that trainees and medical students now recognize the usefulness of these new technologies. With regards to education using advances in web-based information technologies and also smartphone technologies, the National Kidney Foundation in 2013 has highlighted the current deficiencies in their nephrology residents’ knowledge and awareness of Chronic Kidney Diseases (CKD) and its complications and has recommended alternatives methods, in addition to traditional training methodologies, such as encouraging residents to use internet-based educational resources, which include that of website, blogs, online modules and smartphone applications to minimize their existing knowledge gaps [3]. For the medical specialty, recent studies have demonstrated that smartphone use would increase supervision by supervisors and would help to make teaching activities easier [4]. For ophthalmology, recent studies have acknowledged the increased usage of smartphone applications within their specialty. There are currently more than 342 applications that have been identified from the respective application stores that would be of benefit to physicians and patients. Of significance, current research highlighted that current applications available are gradually turning smartphones into medical devices that could help in the detection of specific conditions [5]. There have been numerous literatures demonstrating the acceptability of smartphone usage in education for medical student. A questionnaire survey done at the University of Birmingham, United Kingdom, has highlighted that students generally find smartphones useful as educational aids, with at least 84% believing so. This has been replicated in other studies, which has highlighted that there has been a high level of smartphone ownership and usage amongst medical students and junior doctors [6]. Along with the enhancements in smartphone functionality, there has been an increased in the number of educational smartphone applications made available for users to download and install. However, it is a well-known fact that anyone could publish a medical application, and the application stores do not routinely do a rigorous review of the accuracy of the content of the application prior to publication [7]. Although smartphones have been used by the majority of interns on a daily basis in performing their job [7], there still need to be more guidance and advice with regards to the accuracy and the credibility of the information provided within the applications [8]. Even though there has been a high rate of smartphone applications usage and acceptance, it is common knowledge that it would cost clinicians as well as their center a lot to develop smartphone applications that could be catered to their needs, and help them in their daily educational needs. In addition, the issue pertaining to the accuracy of the application is also of doubts when external vendors produce applications for clinicians, especially so without much clinician directed inputs. This might be changed if clinicians were to be more involved and are able to create their own applications. Recent studies have highlighted the need for clinicians to be more involved in the smartphone application development process and a research article highlighted
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a simple methodology of creating an application using just an Internet browser and a text editor [9]. The methodology shared previously might help to overcome the fears of clinicians, who might be keen to develop their own applications, but are lacking in technical skills. However, there might be still some resistance, given the fact that some coding in computer programming language will still be required. In addition, there are limited features that could be integrated in the application based on the methodology that was shared previously. In psychiatry, the latest application of the advances in technology has been the limited to the usage of unique tele-technologies in augmenting resident’s training in psychodynamic therapy [10]. A search through the existing published literature using the keywords “psychiatry, smartphone, education” has not yield any published papers to date, that has looked into the application of the latest web based and smartphone technologies in psychiatry education. An extensive search has also been conducted in the application stores. Whilst there are more than 166 and 240 psychiatry applications on the Apple and the Android application stores respectively, there seemed to be a scarcity of high-quality, comprehensive, textbook grade e-learning materials. Most of the textbook materials are limited to a mere reproduction of the contents of the hardcopy version of popular psychiatry textbooks. With this in mind, the authors have applied a simple and cost effective smartphone application developmental process to build a psychiatry smartphone application as described below. Our research objectives were: (a) to highlight a cost-effective methodology of development of interactive education smartphone applications that clinicians themselves could adopt without technical knowledge; and (b) to determine whether the local undergraduate students are receptive towards web-based and smartphone technologies in helping them to master psychiatry and if so, (c) what are their perspectives with regards to these smartphone technologies in augmenting their educational needs?
2. Methodology 2.1. The Mastering Psychiatry Online Portal and Smartphone Application (Web-application) The web-based portal and web based smartphone application was developed between February 2012 to June 2012. 2.1.1. Formulation of requirements For the online portal, apart from the provision of a newly written textbook that integrates local clinical guidelines specific to Singapore, there are other features that could help augment student’s educational needs. These include the inclusion of videos demonstrating how to assess patients for a particular psychiatric disorder, and how to elicit basic psychopathologies. The authors have made use of digital technologies and have filmed the following videos: 1. Psychosis: History taking 2. Depression: History taking 3. Anxiety: History taking 4. Explanation of antidepressants 5. Explanation of Cognitive behavioral therapy 6. Assessment of Borderline Personality disorder 7. Suicide risk assessment 8. Explanation of Electro-convulsive therapy treatment
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M.W.B. Zhang et al. / Development and students’ perceptions of a psychiatry educational smartphone application Table 1 Online portal and web-based application Online portal Web-based Smartphone Application Apple Store Native Application Android Store Native Application
www.masteringpsychiatry.com http://ibuildapp.com/app-50319-MP2014 https://itunes.apple.com/sg/app/mastering-psychiatry-core/id720709591?mt=8 https://play.google.com/store/apps/details?id=com.tiseno.psychiatry
9. Frontal Lobe Examination 10. Mini Mental State examination 11. Explanation of Lithium therapy 12. Explanation of Neuroleptic Malignant Syndrome 13. Violence Risk Assessment 14. Explanation of Dementia Medications 15. Sleep disorder assessment. In addition, there is also integration of an interactive multiple-choice survey that students could use for rapid revision for the multiple-choice component of their end of posting examinations. For the webbased application, it was designed to be a handy reference for students to use in their clinical settings. The web-based application has included the same contents as what was available on the online portal, but has been further sub-classified into 4 individual tabs. Table 1 show the features available online on the web based portal as well as on the smartphone application. 2.1.2. Developmental process The developmental process was undertaken by the author, MWBZ. The online portal was build using a web portal designer that utilized graphic user interface (www.wordpress.com), and the web-based smartphone application was programmed using an online application builder (www.ibuildapp.com), to program the specific features in the application. Videos are stored online on a web-based video storage service (www.vimeo.com). The entire developmental process did not require any knowledge of any programming language. In addition, apart from the US $ 18 spend on purchasing the domain, there were no other cost incurred. The hosting of the smartphone application by the online application builder was free, with the caveat that there is an advertisement “Powered by IBuildapp” on the main page. Questionnaires were crafted and online database software (www.polldaddy.com) was used to capture responses and mark the questionnaire immediately when users participate in it. The usability of the online portal and smartphone application was evaluated by the authors across several different computing platforms to ensure the robustness of the system. In 2013, in view of the initial pilot success of the web-based smartphone application, the authors MWBZ and RCMH secured an educational grant and a native application version of “Mastering Psychiatry” was developed and launched in October and November 2013, on both the Apple ITunes as well as the Android Play store. The native application has the similar content to the web-based self developed application, but it facilitated access as it could be easily found in the application stores. 2.1.3. Dissemination and collation of perspectives With regards to the deployment of the application, all of the students who were posted for their clinical psychiatry posting were provided with information about the portal and the web-based on the first day of their clinical posting. A ten minutes demonstration of the features of the online portal as well as the native application was conducted by the first author, MWBZ, on the first day of their clinical posting.
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With ethics approval from the National University of Singapore, a user perspective survey was administered to the students, right after the completion of their end of posting clinical assessment. Participation in the survey is entirely voluntary and relevant participant information handout were provided to all the participants prior to the start of the survey. The user perspective survey looks specifically into the students’ perception of the web-based and the native based smartphone application developed. The questions asked involved the themes as to whether students perceive smartphone applications to be relevant and helpful for psychiatry education; as well the core content that will be of benefit to them. 3. Results The online portal and the web-based smartphone application were launched on the 15th of July 2012 via direct dissemination of the web-links of the portal and the links of the smartphone application. The native smartphone application was introduced in late 2013. Since inception till today, there have been a cumulative total of 15,083 views of the online portal. The majority of the users are from Singapore, with total views of 12,159 as of the 27th of March 2014. The other 2 countries that ranked highest include that of the United States as well as Malaysia, which have a cumulative view of 421 and 346 as of the 27th of March 2014. The total number of views is defined as the total cumulative number of visits. With regards to the utilization of the online “Mastering Psychiatry” textbook, a total of 2,109 copies have been downloaded. As for the videos, there have been a total of 65,325 loads of the videos, and with 5,895 viewers who have viewed the videos from the start till the end of the training video. From the analytics, it seemed that the top 3 videos are that of Frontal lobe assessment, Violence risk assessment and Mini Mental State Examination. With regards to the utilization of the smartphone application, a cumulative total of 722 users have used the mobile application since inception, based on our analytics. A cumulative total of 185 students took part voluntarily in the user’s perspective survey, which measured their perspectives towards both the web-based as well as the native smartphone applications in late 2013. The total number of students for each year was 300, and hence the response rate was 61.7%. Around 79.2% of the students were of the age of 22 years old, and the majority of the students (53.3%) used an Apple IOS device, whereas around 21.6% of the students used an Android device. The majority of the students (66.7%) had between 1 to 5 medical applications in their smartphones. The purposes of the medical applications they have downloaded previously were mainly for educational purposes, as well as for usage in the clinics and also in the wards. The demographics of the sample population who has taken part in the survey is reflected in Table 2. 95.2% of the students indicated that having a psychiatry smartphone application would be useful. The majority of the students will like the smartphone application to have textbook contents within and clinical videos within the application, and found these to be particularly useful. Students did perceive that having an event management system within the smartphone app would be helpful towards coordination of tutorials. 57.1% of the students have agreed that having a smartphone application for Psychiatry is helpful, and 71.4% of the students also agreed that having a smartphone application would be a good companion to a traditional textbook. Table 3 gives an overview about students’ perspective towards smartphone applications and its content. 4. Discussion From our current knowledge, this is one of the first few studies to formally describe a simple and cost effective methodology of web-based application development that requires the authors to have nil
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M.W.B. Zhang et al. / Development and students’ perceptions of a psychiatry educational smartphone application Table 2 Student’s baseline demographic information Demographic variable Gender Male Female Age Age 20 Age 21 Age 22 Age 23 Age 24 More than Age 25 Smartphone Ownership No IPhone Google Android Ipad Android Tablet Laptop/Notebook computer Medical related app No 1–5 Apps 6–10 Apps 11–15 Apps More than 15 Purpose of medical related application Education – Revision Education – Learning Clinical (wards) Clinical (Clinics) Others
Frequency (N)
Percentage
100 85
54.1% 45.9%
1 12 141 11 12 1
0.56% 6.74% 79.21% 6.18% 6.74% 0.56%
3 121 49 24 8 22
1.32% 53.3% 21.59% 10.57% 3.52% 9.69%
40 124 15 3 4
21.51% 66.67% 8.06% 1.61% 2.15%
40 74 84 55 17
14.81% 27.41% 31.11% 20.37% 6.30%
programming knowledge, and one of the initial studies that have looked into the receptiveness of such a web-based application amongst medical students, trainees and residents. Based on our Mastering Psychiatry Textbook based smartphone application, our current initial findings showed that our Asian students are amenable to trying out new modalities of self-developed technologies to help them with their educational needs on the go, for example, in the wards or even in the clinics. The perspective user survey results showed that a high proportion of students have hoped that a Psychiatry Smartphone application for education needs will have the following: textbook based contents, Clinical OSCE videos as well as an event notification service. A high proportion of students concurred with the perception that smartphone application will be helpful in Psychiatry education and that smartphone will be a viable and good alternative to a book. As there are no previous studies looking into the application of web-based smartphone technologies in Psychiatry, the current interpretation of our results pertaining to the utilization of smartphones would rely on previous studies that have looked into smartphones as a toolkit for education amongst medical students. Waldmann and Weckbecker [11] have designed a web-based application, much similar to ours in conception, that enable teaching medical students more about the primary care guidelines. In their web-based application, a total of 15 guidelines from the German College of General Practitioners and Family Physicians (DEGAM) were included. Their study, amongst a group of 14 student testers showed that students prefer the web-based application as compared to a printed hard copy guideline. It was noted that students use the application much more frequently, and they would make use of their waiting periods
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Table 3 Student’s perspectives about application content and usefulness Perspectives Having Smartphone app in learning Psychiatry Absolutely useless Useless Of some use Useful Very useful Having textbook contents in smartphone application Absolutely useless Useless Of some use Useful Very useful Having Clinical OSCE videos in smartphone applications Absolutely useless Useless Of some use Useful Very Useful Having SMS notification/Events management services in App Absolutely useless Useless Of Some use Useful Very useful Usefulness of Smartphone app in Psychiatry Very useful Useful Of Some use Useless Absolutely useless Good companion to book Very useful Useful Of Some use Useless Absolutely useless
Frequency (N)
Percentage
2 7 93 60 24
1.08% 3.76% 50.0% 32.26% 12.9%
4 8 53 84 36
2.16% 4.32% 28.65% 45.41% 19.46%
2 12 49 81 43
1.07% 6.42% 26.20% 43.32% 22.99%
4 10 50 71 51
2.15% 5.38% 26.88% 38.17% 27.42%
19 86 73 5 1
10.33% 46.74% 39.67% 2.72% 0.54%
38 94 38 11 4
20.54% 50.81% 20.54% 5.95% 2.16%
to go through the guidelines. They have highlighted how the simple web-based application has helped to create an interest amongst students, and helped them acquire valuable knowledge when they are on the go, or in their waiting time. This might account for the results that we have obtained. Our sample cohort might be similar to the cohort that has been studied by Waldmann and Weckbecker [11], and have perceived self-developed smartphone psychiatry application as a useful tool for mastering psychiatry and preparing for examinations on the go. The main strength of the current study is that we managed to describe a cost effective and a simple methodology of creation of educational smartphone applications that clinicians could adopt. By enabling clinicians to be involved in the development process, this also helps to ensure that information within is accurate and is based on existing evidence. Our current study, using a self-designed application for medical students has managed to identify preferences of students in terms of their online learning technology needs. Our current study has empowered students, trainees and residents to have an opportunity to make use of the latest innovations in technology. In addition, the initial results also demonstrate the feasibility of adopting this methodology in creation of applications for education. We hope that other
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disciplines could adopt our methodologies to create similar applications, and by pooling the results from several studies, we could better determine the perception of the students. Nevertheless, there remains to be several limitations in the current study. Our sample size is relatively small. In addition, our results are mainly derived from an Asian cohort and hence, cannot be entirely generalized to a Western cohort. We acknowledge that the response rate to our questionnaire is not 100%, as students might have skipped questions and not answered all the questions within. We have sampled students’ perspectives from a sample that comprised mainly of students who have access to a smartphone. However, we do acknowledge that there are students with financial difficulties, who might not have a smartphone and hence, our results might have an inherent bias. The authors acknowledged that there are limitations pertaining to the assessment of usability, as the statistics captured online reflect the total number of visits to the site by all visitors; which in turn implies that the authors were not able to identify the absolute number of unique visitors to the site. In addition, the authors have only have had one cohort of students to administer the questionnaires to, and hence it is currently not possible to do comparative analysis of the data acquired. Diversity in terms of the opinions of the students could not be assessed, as focus group analysis was not conducted. It is tough to identify students who have not used the on-line resources, as pertinent information about the online resources was disseminated since the first day of their clinical attachment. 5. Conclusions This is one of the initial studies that have demonstrated a simple and cost effective methodology of application development; as well as, students’ receptiveness towards self-created web-based and native smartphone applications. It is hoped that more clinicians will be willing to consider using our methodology and create their own applications; and by pooling the results of several studies, we will have more rigorous evidence of the effectiveness of self-created smartphone applications. Our methods might apply to future research involving the use of technology, not only in undergraduate education, but also potentially for postgraduate education. Our current study demonstrated the feasibility of such technologies in education and has also demonstrated that students perceive videos and web-based smartphone applications as useful modalities to aid their education. These have been proven in previous research in other medical domains and have been replicated in our current study. Conflicts of interest The authors disclose that there have been nil conflicts of interest. References [1] [2] [3] [4]
Kirwan M, Vandelanotte C, Fenning A, Duncan MJ: Diabetes Self-Management Smartphone Application for Adults with Type 1 Diabetes: Randomized Controlled Trial. J Med Interest Res 2013; 15(11): e235. O’Conner P, Byrne D. Butt M, et al. Interns and their smartphones: Use for clinical practice. Postgrad Med J, 2014 Feb; 90(1060): 75-79. Bhasin B, Estrella MM, Chio MJ. Online CKD education for medical students, residents and fellows: training in a new era. Adv Chronic Kidney Dis, 2013 Jul 20(4): 347-356. Wu Rc, Tzanetos K, Morra D, et al. Educational Impact of using smartphone for clinical communication on general medicine: more global, less local. J Hosp Med 2013; Jul 8(7): 365-372.
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Tahiri R, El M, Dupont S, et al. Smartphone in ophthalmology. J Fr Ophthalamo 2013 June 36(6): 499-525. Robinson T, Cronin T, Ibramin H, et al. Smartphone use and acceptability among clinical medial students: a questionnaire-based study. J Med Syst 2013 Jun 37(3); 9936. Barton AJ: The regulation of mobile health applications. BMC Med 2012, 10: 36. O’Connor P, Byrne D, Butt M, Offiah G, Lydon S, Mc Inerney K, Stewart B, Kerin MJ: Interns and their smartphones: use for clinical practice. Postgrad Med J. 2014 Feb; 90(1060); 75-79. Subhi Y, Todsen T, Ringstd C, Konge L: Designing web-apps for smartphones can be easy as making slideshow presentations. BMC Res Notes, 2014 Feb 20; 7(1): 94. Katzman J, Abass A, Coughlin P, et al. Building connections through teletechnologies to augment resident training in psychodynamic psychotherapy. Acad Psychiatry: 2014 Mar 25. Waldmann UM, Weckbecker K. Smartphone application of primary care guidelines used in education of medical students. GMS Z Med Ausbid 2013; 3(1); Doc6.
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Methodology of development and students’ perceptions of a psychiatry educational smartphone application Melvyn W.B. Zhang∗ , Cyrus S.H. Ho and Roger C.M. Ho Department of Psychological Medicine, National University Healthcare Systems, Singapore
Received 21 June 2014 Accepted 24 August 2014 Abstract. BACKGROUND: The usage of Smartphones and smartphone applications in the recent decade has indeed become more prevalent. Previous research has highlighted the lack of critical appraisal of new applications. In addition, previous research has highlighted a method of using just the Internet Browser and a text editor to create an application, but this does not eliminate the challenges faced by clinicians. In addition, even though there has been a high rate of smartphone applications usage and acceptance, it is common knowledge that it would cost clinicians as well as their centers a lot to develop smartphone applications that could be catered to their needs, and help them in their daily educational needs. OBJCETIVE: The objectives of the current research are thus to highlight a cost-effective methodology of development of interactive education smartphone applications, and also to determine whether medical students are receptive towards having smartphone applications and their perspectives with regards to the contents within. METHODOLOGY: In this study, we will elaborate how the Mastering Psychiatry Online Portal and web-based mobile application were developed using HTML5 as the core programming language. The online portal and web-based application was launched in July 2012 and usage data were obtained. Subsequently, a native application was developed, as it was funded by an educational grant and students are recruited after their end of posting clinical examination to fill up a survey questionnaire relating to perspectives. RESULTS: Our initial analytical results showed that since inception to date, for the online portal, there have been a total of 15,803 views, with a total of 2,109 copies of the online textbook being downloaded. As for the online videos, 5,895 viewers have watched the training videos from the start till the end. 722 users have accessed the mobile textbook application. A total of 185 students participated in the perspective survey, with the majority having positive perspectives about the implementation of a smartphone application in psychiatry. CONCLUSIONS: This is one of the few studies that describe how an educational application could be developed using a simple and cost effective methodology and this study has also demonstrated students’ perspectives towards Smartphone in psychiatric education. Our methods might apply to future research involving the use of technology in education. Keywords: Education, technology, smartphone applications, under-graduate psychiatry education innovations, developmental models
∗
Corresponding author: Melvyn Zhang, Psychiatry Resident, Level 9, Department of Psychological Medicine, National University Healthcare Systems (NUHS) Tower Block, 5 Lower Kent Ridge Road, 119074, Singapore. Tel.: +65 7725555; Fax: +65 7725555; E-mail: [email protected]. c 2014 – IOS Press and the authors. All rights reserved 0928-7329/14/$27.50
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1. Introduction The worldwide prevalence of mobile phones has made them a very useful and innovative platform for provision of patient’s care, as well as in helping clinicians with management decisions. Over the past few years, smartphones have advanced drastically in terms of both their functionality and design and they are currently more than what used to be a simple call and messaging device [1]. They have literally been transformed into sophisticated mini-personal computers. Previous reviews have highlighted the worldwide prevalence and the global acceptance of smartphones and commercial smartphone applications by medical students, trainees and interns. In 2012, a questionnaire based survey was distributed amongst interns in the Republic of Ireland [2], and it has demonstrated that smartphones are being used daily by the interns to perform their job. The questionnaire study noted that that most commonly used application by interns was that of the British National Formulary, and the most commonly used website was that of Wikipedia [2]. It is thus beyond doubts, that trainees and medical students now recognize the usefulness of these new technologies. With regards to education using advances in web-based information technologies and also smartphone technologies, the National Kidney Foundation in 2013 has highlighted the current deficiencies in their nephrology residents’ knowledge and awareness of Chronic Kidney Diseases (CKD) and its complications and has recommended alternatives methods, in addition to traditional training methodologies, such as encouraging residents to use internet-based educational resources, which include that of website, blogs, online modules and smartphone applications to minimize their existing knowledge gaps [3]. For the medical specialty, recent studies have demonstrated that smartphone use would increase supervision by supervisors and would help to make teaching activities easier [4]. For ophthalmology, recent studies have acknowledged the increased usage of smartphone applications within their specialty. There are currently more than 342 applications that have been identified from the respective application stores that would be of benefit to physicians and patients. Of significance, current research highlighted that current applications available are gradually turning smartphones into medical devices that could help in the detection of specific conditions [5]. There have been numerous literatures demonstrating the acceptability of smartphone usage in education for medical student. A questionnaire survey done at the University of Birmingham, United Kingdom, has highlighted that students generally find smartphones useful as educational aids, with at least 84% believing so. This has been replicated in other studies, which has highlighted that there has been a high level of smartphone ownership and usage amongst medical students and junior doctors [6]. Along with the enhancements in smartphone functionality, there has been an increased in the number of educational smartphone applications made available for users to download and install. However, it is a well-known fact that anyone could publish a medical application, and the application stores do not routinely do a rigorous review of the accuracy of the content of the application prior to publication [7]. Although smartphones have been used by the majority of interns on a daily basis in performing their job [7], there still need to be more guidance and advice with regards to the accuracy and the credibility of the information provided within the applications [8]. Even though there has been a high rate of smartphone applications usage and acceptance, it is common knowledge that it would cost clinicians as well as their center a lot to develop smartphone applications that could be catered to their needs, and help them in their daily educational needs. In addition, the issue pertaining to the accuracy of the application is also of doubts when external vendors produce applications for clinicians, especially so without much clinician directed inputs. This might be changed if clinicians were to be more involved and are able to create their own applications. Recent studies have highlighted the need for clinicians to be more involved in the smartphone application development process and a research article highlighted
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a simple methodology of creating an application using just an Internet browser and a text editor [9]. The methodology shared previously might help to overcome the fears of clinicians, who might be keen to develop their own applications, but are lacking in technical skills. However, there might be still some resistance, given the fact that some coding in computer programming language will still be required. In addition, there are limited features that could be integrated in the application based on the methodology that was shared previously. In psychiatry, the latest application of the advances in technology has been the limited to the usage of unique tele-technologies in augmenting resident’s training in psychodynamic therapy [10]. A search through the existing published literature using the keywords “psychiatry, smartphone, education” has not yield any published papers to date, that has looked into the application of the latest web based and smartphone technologies in psychiatry education. An extensive search has also been conducted in the application stores. Whilst there are more than 166 and 240 psychiatry applications on the Apple and the Android application stores respectively, there seemed to be a scarcity of high-quality, comprehensive, textbook grade e-learning materials. Most of the textbook materials are limited to a mere reproduction of the contents of the hardcopy version of popular psychiatry textbooks. With this in mind, the authors have applied a simple and cost effective smartphone application developmental process to build a psychiatry smartphone application as described below. Our research objectives were: (a) to highlight a cost-effective methodology of development of interactive education smartphone applications that clinicians themselves could adopt without technical knowledge; and (b) to determine whether the local undergraduate students are receptive towards web-based and smartphone technologies in helping them to master psychiatry and if so, (c) what are their perspectives with regards to these smartphone technologies in augmenting their educational needs?
2. Methodology 2.1. The Mastering Psychiatry Online Portal and Smartphone Application (Web-application) The web-based portal and web based smartphone application was developed between February 2012 to June 2012. 2.1.1. Formulation of requirements For the online portal, apart from the provision of a newly written textbook that integrates local clinical guidelines specific to Singapore, there are other features that could help augment student’s educational needs. These include the inclusion of videos demonstrating how to assess patients for a particular psychiatric disorder, and how to elicit basic psychopathologies. The authors have made use of digital technologies and have filmed the following videos: 1. Psychosis: History taking 2. Depression: History taking 3. Anxiety: History taking 4. Explanation of antidepressants 5. Explanation of Cognitive behavioral therapy 6. Assessment of Borderline Personality disorder 7. Suicide risk assessment 8. Explanation of Electro-convulsive therapy treatment
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M.W.B. Zhang et al. / Development and students’ perceptions of a psychiatry educational smartphone application Table 1 Online portal and web-based application Online portal Web-based Smartphone Application Apple Store Native Application Android Store Native Application
www.masteringpsychiatry.com http://ibuildapp.com/app-50319-MP2014 https://itunes.apple.com/sg/app/mastering-psychiatry-core/id720709591?mt=8 https://play.google.com/store/apps/details?id=com.tiseno.psychiatry
9. Frontal Lobe Examination 10. Mini Mental State examination 11. Explanation of Lithium therapy 12. Explanation of Neuroleptic Malignant Syndrome 13. Violence Risk Assessment 14. Explanation of Dementia Medications 15. Sleep disorder assessment. In addition, there is also integration of an interactive multiple-choice survey that students could use for rapid revision for the multiple-choice component of their end of posting examinations. For the webbased application, it was designed to be a handy reference for students to use in their clinical settings. The web-based application has included the same contents as what was available on the online portal, but has been further sub-classified into 4 individual tabs. Table 1 show the features available online on the web based portal as well as on the smartphone application. 2.1.2. Developmental process The developmental process was undertaken by the author, MWBZ. The online portal was build using a web portal designer that utilized graphic user interface (www.wordpress.com), and the web-based smartphone application was programmed using an online application builder (www.ibuildapp.com), to program the specific features in the application. Videos are stored online on a web-based video storage service (www.vimeo.com). The entire developmental process did not require any knowledge of any programming language. In addition, apart from the US $ 18 spend on purchasing the domain, there were no other cost incurred. The hosting of the smartphone application by the online application builder was free, with the caveat that there is an advertisement “Powered by IBuildapp” on the main page. Questionnaires were crafted and online database software (www.polldaddy.com) was used to capture responses and mark the questionnaire immediately when users participate in it. The usability of the online portal and smartphone application was evaluated by the authors across several different computing platforms to ensure the robustness of the system. In 2013, in view of the initial pilot success of the web-based smartphone application, the authors MWBZ and RCMH secured an educational grant and a native application version of “Mastering Psychiatry” was developed and launched in October and November 2013, on both the Apple ITunes as well as the Android Play store. The native application has the similar content to the web-based self developed application, but it facilitated access as it could be easily found in the application stores. 2.1.3. Dissemination and collation of perspectives With regards to the deployment of the application, all of the students who were posted for their clinical psychiatry posting were provided with information about the portal and the web-based on the first day of their clinical posting. A ten minutes demonstration of the features of the online portal as well as the native application was conducted by the first author, MWBZ, on the first day of their clinical posting.
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With ethics approval from the National University of Singapore, a user perspective survey was administered to the students, right after the completion of their end of posting clinical assessment. Participation in the survey is entirely voluntary and relevant participant information handout were provided to all the participants prior to the start of the survey. The user perspective survey looks specifically into the students’ perception of the web-based and the native based smartphone application developed. The questions asked involved the themes as to whether students perceive smartphone applications to be relevant and helpful for psychiatry education; as well the core content that will be of benefit to them. 3. Results The online portal and the web-based smartphone application were launched on the 15th of July 2012 via direct dissemination of the web-links of the portal and the links of the smartphone application. The native smartphone application was introduced in late 2013. Since inception till today, there have been a cumulative total of 15,083 views of the online portal. The majority of the users are from Singapore, with total views of 12,159 as of the 27th of March 2014. The other 2 countries that ranked highest include that of the United States as well as Malaysia, which have a cumulative view of 421 and 346 as of the 27th of March 2014. The total number of views is defined as the total cumulative number of visits. With regards to the utilization of the online “Mastering Psychiatry” textbook, a total of 2,109 copies have been downloaded. As for the videos, there have been a total of 65,325 loads of the videos, and with 5,895 viewers who have viewed the videos from the start till the end of the training video. From the analytics, it seemed that the top 3 videos are that of Frontal lobe assessment, Violence risk assessment and Mini Mental State Examination. With regards to the utilization of the smartphone application, a cumulative total of 722 users have used the mobile application since inception, based on our analytics. A cumulative total of 185 students took part voluntarily in the user’s perspective survey, which measured their perspectives towards both the web-based as well as the native smartphone applications in late 2013. The total number of students for each year was 300, and hence the response rate was 61.7%. Around 79.2% of the students were of the age of 22 years old, and the majority of the students (53.3%) used an Apple IOS device, whereas around 21.6% of the students used an Android device. The majority of the students (66.7%) had between 1 to 5 medical applications in their smartphones. The purposes of the medical applications they have downloaded previously were mainly for educational purposes, as well as for usage in the clinics and also in the wards. The demographics of the sample population who has taken part in the survey is reflected in Table 2. 95.2% of the students indicated that having a psychiatry smartphone application would be useful. The majority of the students will like the smartphone application to have textbook contents within and clinical videos within the application, and found these to be particularly useful. Students did perceive that having an event management system within the smartphone app would be helpful towards coordination of tutorials. 57.1% of the students have agreed that having a smartphone application for Psychiatry is helpful, and 71.4% of the students also agreed that having a smartphone application would be a good companion to a traditional textbook. Table 3 gives an overview about students’ perspective towards smartphone applications and its content. 4. Discussion From our current knowledge, this is one of the first few studies to formally describe a simple and cost effective methodology of web-based application development that requires the authors to have nil
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M.W.B. Zhang et al. / Development and students’ perceptions of a psychiatry educational smartphone application Table 2 Student’s baseline demographic information Demographic variable Gender Male Female Age Age 20 Age 21 Age 22 Age 23 Age 24 More than Age 25 Smartphone Ownership No IPhone Google Android Ipad Android Tablet Laptop/Notebook computer Medical related app No 1–5 Apps 6–10 Apps 11–15 Apps More than 15 Purpose of medical related application Education – Revision Education – Learning Clinical (wards) Clinical (Clinics) Others
Frequency (N)
Percentage
100 85
54.1% 45.9%
1 12 141 11 12 1
0.56% 6.74% 79.21% 6.18% 6.74% 0.56%
3 121 49 24 8 22
1.32% 53.3% 21.59% 10.57% 3.52% 9.69%
40 124 15 3 4
21.51% 66.67% 8.06% 1.61% 2.15%
40 74 84 55 17
14.81% 27.41% 31.11% 20.37% 6.30%
programming knowledge, and one of the initial studies that have looked into the receptiveness of such a web-based application amongst medical students, trainees and residents. Based on our Mastering Psychiatry Textbook based smartphone application, our current initial findings showed that our Asian students are amenable to trying out new modalities of self-developed technologies to help them with their educational needs on the go, for example, in the wards or even in the clinics. The perspective user survey results showed that a high proportion of students have hoped that a Psychiatry Smartphone application for education needs will have the following: textbook based contents, Clinical OSCE videos as well as an event notification service. A high proportion of students concurred with the perception that smartphone application will be helpful in Psychiatry education and that smartphone will be a viable and good alternative to a book. As there are no previous studies looking into the application of web-based smartphone technologies in Psychiatry, the current interpretation of our results pertaining to the utilization of smartphones would rely on previous studies that have looked into smartphones as a toolkit for education amongst medical students. Waldmann and Weckbecker [11] have designed a web-based application, much similar to ours in conception, that enable teaching medical students more about the primary care guidelines. In their web-based application, a total of 15 guidelines from the German College of General Practitioners and Family Physicians (DEGAM) were included. Their study, amongst a group of 14 student testers showed that students prefer the web-based application as compared to a printed hard copy guideline. It was noted that students use the application much more frequently, and they would make use of their waiting periods
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Table 3 Student’s perspectives about application content and usefulness Perspectives Having Smartphone app in learning Psychiatry Absolutely useless Useless Of some use Useful Very useful Having textbook contents in smartphone application Absolutely useless Useless Of some use Useful Very useful Having Clinical OSCE videos in smartphone applications Absolutely useless Useless Of some use Useful Very Useful Having SMS notification/Events management services in App Absolutely useless Useless Of Some use Useful Very useful Usefulness of Smartphone app in Psychiatry Very useful Useful Of Some use Useless Absolutely useless Good companion to book Very useful Useful Of Some use Useless Absolutely useless
Frequency (N)
Percentage
2 7 93 60 24
1.08% 3.76% 50.0% 32.26% 12.9%
4 8 53 84 36
2.16% 4.32% 28.65% 45.41% 19.46%
2 12 49 81 43
1.07% 6.42% 26.20% 43.32% 22.99%
4 10 50 71 51
2.15% 5.38% 26.88% 38.17% 27.42%
19 86 73 5 1
10.33% 46.74% 39.67% 2.72% 0.54%
38 94 38 11 4
20.54% 50.81% 20.54% 5.95% 2.16%
to go through the guidelines. They have highlighted how the simple web-based application has helped to create an interest amongst students, and helped them acquire valuable knowledge when they are on the go, or in their waiting time. This might account for the results that we have obtained. Our sample cohort might be similar to the cohort that has been studied by Waldmann and Weckbecker [11], and have perceived self-developed smartphone psychiatry application as a useful tool for mastering psychiatry and preparing for examinations on the go. The main strength of the current study is that we managed to describe a cost effective and a simple methodology of creation of educational smartphone applications that clinicians could adopt. By enabling clinicians to be involved in the development process, this also helps to ensure that information within is accurate and is based on existing evidence. Our current study, using a self-designed application for medical students has managed to identify preferences of students in terms of their online learning technology needs. Our current study has empowered students, trainees and residents to have an opportunity to make use of the latest innovations in technology. In addition, the initial results also demonstrate the feasibility of adopting this methodology in creation of applications for education. We hope that other
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disciplines could adopt our methodologies to create similar applications, and by pooling the results from several studies, we could better determine the perception of the students. Nevertheless, there remains to be several limitations in the current study. Our sample size is relatively small. In addition, our results are mainly derived from an Asian cohort and hence, cannot be entirely generalized to a Western cohort. We acknowledge that the response rate to our questionnaire is not 100%, as students might have skipped questions and not answered all the questions within. We have sampled students’ perspectives from a sample that comprised mainly of students who have access to a smartphone. However, we do acknowledge that there are students with financial difficulties, who might not have a smartphone and hence, our results might have an inherent bias. The authors acknowledged that there are limitations pertaining to the assessment of usability, as the statistics captured online reflect the total number of visits to the site by all visitors; which in turn implies that the authors were not able to identify the absolute number of unique visitors to the site. In addition, the authors have only have had one cohort of students to administer the questionnaires to, and hence it is currently not possible to do comparative analysis of the data acquired. Diversity in terms of the opinions of the students could not be assessed, as focus group analysis was not conducted. It is tough to identify students who have not used the on-line resources, as pertinent information about the online resources was disseminated since the first day of their clinical attachment. 5. Conclusions This is one of the initial studies that have demonstrated a simple and cost effective methodology of application development; as well as, students’ receptiveness towards self-created web-based and native smartphone applications. It is hoped that more clinicians will be willing to consider using our methodology and create their own applications; and by pooling the results of several studies, we will have more rigorous evidence of the effectiveness of self-created smartphone applications. Our methods might apply to future research involving the use of technology, not only in undergraduate education, but also potentially for postgraduate education. Our current study demonstrated the feasibility of such technologies in education and has also demonstrated that students perceive videos and web-based smartphone applications as useful modalities to aid their education. These have been proven in previous research in other medical domains and have been replicated in our current study. Conflicts of interest The authors disclose that there have been nil conflicts of interest. References [1] [2] [3] [4]
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