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 Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.
Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries.
The aim of this paper was to explore the patients’ perspectives of CONEMO (
This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system.
Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine.
Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression.
Mental health disorders are one of the main health burdens worldwide. Of the 20 leading causes of years lived with disability in the world, 9 of them are mental, neurological or substance use disorders [
Access to mental health services is poor across LMICs. For example, in Peru, most health insurance does not cover mental health care [
Other strategies to overcome health system barriers and make mental health care more accessible to the community [
The Latin America Treatment and Innovation Network in Mental Health (LATIN-MH) [
This study analyzes the qualitative information acquired from interviews with patients and nurses about their experiences in 2 pilot studies. Interviews were selected as the most suitable technique, which were applied after their participation in these studies. The data were analyzed using qualitative content analysis, as, for example, described by Bengtsson [
The 2 pilot studies were conducted between 2015 and 2016 in Lima; the first pilot study was implemented in 1 general hospital of the Ministry of Health (MINSA) and the second in 2 primary health care centers of EsSalud, Peru’s Social Security System. Those are 2 distinct public health care systems in Peru, which differ in their organization and functioning. The reason for conducting 2 pilot studies was, first, to pilot test the implementation in the 2 different national health care systems, and second, to test the feasibility of working with staff nurses from the health care system within this study instead of hired nurses, which was not possible in the first pilot study in the MINSA hospital.
The study integrated data from 2 groups of participants: the patient’s experience with CONEMO and the nurses’ experience of conducting the nurse-support of CONEMO within the health care system.
Using a convenience sampling strategy, patients were selected based on the following criteria: having a diagnosis of diabetes, hypertension or both by a physician or receiving treatment for it, being aged at least 21 years, being able to read and write in Spanish (all of the above were self-reported), and experiencing clinically significant depressive symptoms, as measured by the Patient Health Questionnaire-9 (cutoff score ≥10) [
In the first pilot study, implemented in a hospital of the MINSA, 1 nurse was hired by the project. In the second pilot study, nurses from the Social Security System were selected and assigned to the study by the health care centers’ administration. In 1 health care center, all 5 nurses who were working there at the time were assigned to participate in the study, whereas in the other health care center, 1 nurse who was working in the elderly adult program was selected.
In the MINSA hospital, recruitment took place in the endocrinology and cardiology outpatient clinics, whereas in the 2 primary health care centers, patients were recruited in the waiting areas or in the elderly adult consultation unit that monitors people with NCDs. Some patients were approached before or after their regular consultations, whereas others were referred to the fieldwork team by health care providers. Patients were screened by 1 of 4 fieldworkers who were all psychologists. If the inclusion criteria were fulfilled, they were invited to participate in the 6-week study and to sign a consent form.
Afterward, patients were invited to return to the health care center to complete a baseline questionnaire. Subsequently, they were assigned to a nurse who then scheduled an individual appointment with each patient to train them and provide the study materials. As, at the time of the pilot, smartphones were not yet ubiquitous among low-income Peruvians, all patients were given an Android smartphone with CONEMO installed as well as 2 guidebooks: one about how to use the smartphone and CONEMO and one about the research project. The nurses trained the patients in the use of the technology and informed them that their activities could be followed on a Web-based platform and that they would receive at least 2 monitoring phone calls throughout the intervention period to address difficulties if applicable.
The nurses were approached via the centers’ administration. After the managers of the centers accepted to participate, they selected the nurses and facilitated the contact to the research team. Afterward, all nurses underwent a 3-month theoretical and practical training course with 1 to 2 hours of weekly training sessions to perform their activities before starting to receive patients.
Over the 2 pilot studies, 45 patients signed the consent form to participate, but 12 of them did not return to the health care center to receive CONEMO. Of the 33 patients who finally received CONEMO, 29 responded to the interviews (15 of pilot study 1, monitored by a hired nurse, and 14 of pilot study 2, monitored by staff nurses from the health care system).
With regard to the nurses, 6 staff nurses, who were working within the Social Security System and who participated in the second pilot study, were interviewed after finalizing the pilot study activities. The nurse hired in the first pilot study was not considered in the interviews, considering that she would not represent the perspectives of someone working within the health care system.
CONEMO is a technology-driven, psychoeducational, and nurse-supported intervention that was delivered via a smartphone app (see
Behavioral activation aims at reducing depression by motivating patients to identify and complete activities to obtain a sense of pleasure and accomplishment [
Providing a list of suggested activities to the participant was also used in other apps based on behavioral activation to lower depressive symptoms [
For the development of the structure of the CONEMO app, other behavioral activation intervention outlines, as well as existing mobile intervention designs, were considered. Although in-person interventions based on behavioral activation usually have a duration of 5 to 12 weekly sessions, with each session lasting approximately 45 min [
The role of the nurses was to train all patients in the use of the app and the smartphone, followed by regular monitoring of the patients’ participation throughout the 6 weeks of intervention via a Web-based platform, the
The technology and intervention used in this study was created in collaboration with representatives from the Universidad Peruana Cayetano Heredia in Lima, Peru, and the University of São Paulo in São Paulo, Brazil. Northwestern University’s Center for Behavioral Intervention Technologies in Chicago, United States, supported the design work and provided all software programming. CONEMO was developed to be adaptable linguistically and culturally, providing versions in Spanish, Portuguese, and English.
After the 6 weeks of intervention, the trial manager (LRB) and the clinical coordinator (LH)—both female psychologists—conducted the interviews with the patients and nurses. During both the patient and nurse interviews, the interviewers aimed to transcribe as closely as possible the literal content of the participants’ responses and later transferred these notes to the computer to reduce information loss. During some of the patient interviews and all of the nurse interviews, both interviewers took notes simultaneously, compared them afterward, and found high literal consistency between the notes. Subsequently, the digitized notes were integrated into 1 document.
The patients’ semistructured interviews were applied, consisting of 30 questions addressing the 6 areas of interest, which were considered as most important indicators in view of the randomized controlled trial to be implemented subsequently: perceived health benefit, usability, adherence to CONEMO, satisfaction and suggestions for CONEMO, as well as the evaluation of the nurse-support received (see
With the nurses, semistructured interviews consisting of 22 questions to retrieve data about general nurse feedback, evaluation of training received, evaluation of activities related to the study, as well as their perception of feasibility of incorporating CONEMO within primary care (see
The 4 stages of content analysis—
On the basis of this principle, the qualitative data from patients were first divided into 14 principal codes and 39 subcodes (see
Afterward, the data were analyzed within each of the domains (
The formative research and its materials were approved by the Institutional Ethics Committee of the Universidad Peruana Cayetano Heredia in Lima, Peru, as well as by the Data and Safety Monitoring Board of the National Institute of Mental Health in the United States, in accordance with applicable regulations. Informed consent was obtained from all the participants before participating in the study, after screening for fulfillment of inclusion criteria, and having conducted a thorough explanation of the study and all implications of participation. Patients were not paid, but they were reimbursed for transportation costs related to this study.
Domains and codes used for patients’ interviews’ analysis.
Domains | Principal codes | Subcodes |
Perceived health benefit of CONEMO | Perceived health benefit of CONEMO | Perceived benefit on psychological health, perceived benefit on physical health, and other benefits perceived |
Usability | Usability of CONEMO | Difficulties with CONEMO usage, and help from others |
Evaluation of smartphone | Difficulties with smartphone usage | |
Guidebooks | Revision of guidebooks, and utility of guidebooks | |
Interactive tools (notifications, dialogue pop-ups and SMS) | —a | |
Adherence to CONEMO | Adherence to CONEMO | Revision of sessions, performing activities, and difficulties (to perform activities) |
Satisfaction with CONEMO | Satisfaction with CONEMO | General feedback, things most liked about CONEMO, things least liked about CONEMO, things most liked about the sessions, things least liked about the sessions, and using smartphones for intervention delivery |
Suggestions for CONEMO | Design | Design of CONEMO |
Duration and frequency | Duration of intervention, and frequency of sessions | |
Suggestions for CONEMO | Suggestions to improve CONEMO, and preference of how to receive information | |
Evaluation of nurse component | Evaluation of nurse component | Evaluation of training, quantity of contacts, evaluation of contacts, help requests, and suggestions for the nurse component |
aFor some principal codes, further subdivision did not seem to be beneficial; therefore, no subcodes were created.
Domains and codes used for nurses’ interviews’ analysis.
Domains | Principal codes | Subcodes |
General nurse feedback | General experience | —a |
Expectations | Expectations preimplementation, and fulfillment of expectations | |
Overall satisfaction | — | |
Evaluation of study activities | Satisfaction with tasks | |
Benefits | Perceived personal benefits | |
Evaluation of training received | Evaluation of training received | Level of preparedness posttraining, missing subjects, and suggestions for training |
Evaluation of activities related to the study | Evaluation of study activities | Initial appointments, monitoring calls, nonadherence calls, help requests, revision of nurse dashboard, registering tasks in nurse dashboard, supervision meetings, and difficulties |
Feasibility of incorporating CONEMO in primary care | Feasibility of scaling up CONEMO | — |
Incentives | Types of incentives desired | |
Suggestions for the project | — |
aFor some principal codes, further subdivision did not seem to be beneficial, therefore no subcodes were created.
Among the 29 patients, who responded to the interviews, the mean age was 60 years (SD 9.6, range: 47-85 years) and 69% (N=29) were women. Almost half of the patients were diagnosed with both diabetes and hypertension (45%, N=29), whereas 31% were diagnosed with solely diabetes and 24% with solely hypertension. Less than half of the patients, 45% (N=29), reported having experience in using a smartphone. For an overview of the demographic variables of the patients, see
All nurses who participated were women, the mean age was 38 years (SD 6.2, range: 31-46 years) and the mean time working in the health care center where they were currently employed was 6.6 years (SD 5.3, range: 3-16 years). All nurses had higher education and were licensed in nursing, 1 additionally had a PhD degree, and most had previous experience with using smartphones (83%, N=6) or tablets (67%, N=6). In 1 of the 2 health care centers, 1 nurse monitored 7 patients, whereas in the other center, 5 nurses monitored 10 patients, 2 patients each, who participated in the second pilot study.
Almost all patients (93%; if not mentioned otherwise, the denominator for all frequencies in this paper is the total number of patients, N=29) said that CONEMO helped them emotionally. Most patients felt that after having used CONEMO, they were calmer, more cheerful, enthusiastic, motivated, and less worried and stressed out. Although more than half of the patients (59%) mentioned doing new activities or having picked up activities they have not been doing in a while, one-third (34%) attributed their improvement in emotional well-being to being more active. People did not only increase healthy activities, but also pleasant activities, such as reading a book, visiting friends and family, playing soccer with other people, or walking the dog. As 1 patient expressed it:
[CONEMO] has given me the opportunity to rediscover what we have in life.
One patient explained that being more active distracts oneself from the negative thoughts and therefore improves psychological health.
Another important factor related to the perceived improvement was that CONEMO gave them the feeling of not being alone (34%). CONEMO was viewed as a
CONEMO, yes, it improved my emotional health because I felt that I mattered, that I have to allocate some time to myself and that no one matters more than me. I have been feeling better emotionally, freer. I felt that I did not have to depend on anyone and that I can do things for myself.
Some patients also valued positively the study safety procedures—which were not part of the intervention itself—to motivate patients to look for professional help, transfer them to mental health professionals within the health care system, and in cases of severe depressive symptoms, even helping them to receive treatment faster than usual (14%). Some patients felt that this also contributed positively to their psychological health. However, 2 people (7%) thought that the time of the intervention was not sufficient to accomplish groundbreaking improvements and other 2 did not feel that CONEMO improved their psychological health.
As many activities suggested by the intervention were healthy activities that people with NCDs could complete, some of the patients (34%) also felt that CONEMO helped them improve their physical health. For example, some mentioned having lost weight because of their healthier diet or others to have gained mobility because of increased exercising.
In addition, the majority of the patients mentioned changing their daily habits toward a healthier routine (62%). Most of them reported exercising more, eating healthier, taking the bike to buy groceries, walking or running more, and taking their medication more regularly. One person also described that CONEMO motivated her to go the doctor, whereas she had previously tried to avoid all doctor consultations if possible.
In terms of
Most patients encountered some kind of difficulty in using CONEMO or the smartphone (72%) and would have liked to receive more training. Some patients had problems remembering the explanations received from the nurse (14%). Although about half of the patients admitted that they did not know how to handle the technology in the beginning (48%), most patients with difficulties (71% of 21) explained that those generally occurred in the beginning and that, with time and practice, it got easier to use CONEMO and the smartphone. Furthermore, 14 patients (48%) mentioned having received help from others, such as family members, in using CONEMO. The great majority of the patients reported reviewing the guidebooks provided by the research team (90%) and found them helpful (74% of 23).
The specific difficulties with CONEMO and the smartphone mentioned by the patients are described in
Furthermore, many people experienced difficulties with the interactive tools used in this intervention, such as SMS, Android notifications, and dialogue pop-ups. The SMS served as a reminder for the appointments within this study, Android notifications informed patients that a new session had arrived, and dialogue pop-ups were designed to retrieve feedback about the completion of the activities through messages appearing on the screen soliciting a response from the patient. There were some technological and connectivity problems, for example, people did not receive the SMS in time. However, most people did not view or use the Android notifications (51% of 24) and opened CONEMO directly from the home screen (71% of 24) to see if new sessions had arrived, and some people did not know how to open the SMS or could only read them with the help of others (21% of 24). The idea behind the dialogue pop-ups—to give feedback about activity completion—was evaluated positively; however, some did not recall them (25% of 24) when asked about them.
This section refers to the self-reported adherence to CONEMO in the interviews. Another publication by the LATIN-MH team addresses the quantitative adherence data of the pilot studies [
The main barrier reported to performing the activities suggested by CONEMO was the users’ health status (36% of 14), such as limited mobility or memory problems. Time (29% of 14) and economic constraints (21% of 14) were also important barriers to doing activities. Other difficulties mentioned were the low motivation to do activities (9% of 23) as well as sudden changes in their plans because of external factors (14% of 14), for example, receiving a phone call or someone else needing assistance.
Difficulties using CONEMO.
Difficulties with the smartphone.
Satisfaction refers to the statements that patients made about what they liked and disliked about the app and the sessions, comments that could infer satisfaction, as well as the patients’ perception about using technology for intervention delivery.
The majority of patients expressed great satisfaction with CONEMO (96% of 24), some did not make any statements regarding their satisfaction (17% of 29), and 1 was unsatisfied (4% of 24) because he felt that his health status was too compromised to follow all of the instructions. When the patients were asked what they liked most about the CONEMO app and its sessions, most appreciated the information and advice received (37% of 27), for example:
[…] its important guidelines [to do things one step at a time] instead of doing everything at once.
Furthermore, 26% (of 27) of patients most liked the videos incorporated in CONEMO, 15% (of 27) most appreciated that they were reminded by CONEMO to follow their diet, to work out or follow their medication, and 11% (of 27) valued most the types of activities offered, as described by one of the patients:
In the [list of] activities there were things that caught my attention and that I would be able to do. This opened a whole new field for me of other activities I could do and that I had not done before.
Furthermore, 2 patients even transcribed the whole intervention on their computer to be able to re-read it again after giving back the smartphone. Of note, one-third (33% of 27) of the patients especially valued being accompanied by CONEMO and the nurse and receiving monitoring phone calls from the research team, which were implemented as a safety procedure within the research rather than a treatment activity. These contacts transmitted a feeling of being cared for, of someone taking a special interest in them and their health, and of trusting them with a technological device:
I didn’t have anyone to talk to, so I watched the woman in the video, […].
I was surprised and thought “what did I do to deserve something like this?”. And in addition, they gave me 10 Soles (Peruvian currency) to cover my transport. [...] This is the first time in my life that I have received this kind of attention. [...] No one has ever been concerned about me, but now there was someone there, who was worried about my health [...].
Many people (54% of 28) did not spontaneously express negative aspects about CONEMO
Aspects about CONEMO viewed negatively.
Most of the patients (95% of 21) expressed a positive attitude toward using smartphones to deliver the intervention, and 48% (of 21) of people mentioned explicitly the advantage regarding the mobility, whereby the use of the smartphone replaced having to go to the health care center to make an appointment or to see a specialist. This potentially reduces the time spent on health consultation and could “
It is convenient, because we are not as close to the doctor or psychologist… Here, it does not matter, where you are, you can still use it.
The suggestions that patients expressed to improve CONEMO were wide ranged and could be grouped into 2 categories: (1) suggestions for the content and design of the app and (2) communication with the research team.
Regarding suggestions for the
In terms of the
Most patients were satisfied with the nurses’ explanations of how to use CONEMO (59%); however, some patients mentioned that it was still difficult to understand (14%) or that they were not able to use CONEMO at first, directly after the training (17%). Various people said something similar to the following:
The nurse explained well, it is just that maybe I am stupid or something, because when I got home, I did not know how to use it.
However, some of the patients who were accompanied by a nurse from the health system perceived the nurse as being in a hurry during the training (10%) or without interest in explaining the intervention (7%). Comparing both pilot studies, 80% (of 15) of the patients who were accompanied by the hired nurse viewed the training session as useful, with a positive knowledge transfer, whereas only 50% (of 14) of patients monitored by a staff nurse expressed either positive or neutral comments about the quality of the training.
On the basis of the study protocol, all patients should have received at least 2 phone calls by the nurse to see if there are any difficulties with CONEMO and additional calls depending on their adherence and difficulties. Evaluating the quantity of contacts, when working with a hired nurse, most of the patients reported having received between 3 and 4 phone calls from the nurse (53% of 15) during the intervention, whereas most patients accompanied by staff nurses reported to have received 1 to 2 calls (36% of 14; see
Most of the patients in both pilot studies viewed the phone calls as positive (81% of 26) because the nurses helped them to be adherent to the intervention (19% of 26), helped them with their difficulties using CONEMO (19% of 26), paid attention to their health (15% of 26), helped with other problems (8% of 26), and showed the patients that she cared (15% of 26).
Through
Regarding suggestions for improving the nurse-support, almost half of the patients would have liked to receive more phone calls (44% of 27), and ideally a space to talk about their emotional state, instead of only receiving technical support from the nurse. Others suggested amplifying or improving the quality or depth of the training to feel more confident in using CONEMO (11% of 27).
A summary of the main results retrieved from the patients’ interviews can be found in
Suggestions for CONEMO content and design.
Quantity of contact with nurses.
Summary of main results—patients.
Domain | Main results |
Perceived health benefit of CONEMO | Almost all patients perceived improvements in their mental health and some also in their physical health after using CONEMO. |
The majority felt more active after using CONEMO, having mostly increased pleasant and healthy activities. | |
CONEMO was also viewed as a companion, which made them feel less alone. | |
Usability | Initially, most patients encountered difficulties in using CONEMO or the smartphone and with using SMS, Android notifications, and dialogue pop-ups; however, many technological issues also emerged around those elements, which is why the distinction of those two is not completely clear. |
Some patients received help from family members or reviewed the guidebooks, and most patients felt that these difficulties subsided with time and practice. | |
Adherence to CONEMO | Self-reported adherence was high, most patients completed all sessions and the majority completed most or all activities advised by CONEMO. |
The most important barriers to completing the outside-app activities were the patients’ health status, time, and economic constraints. | |
Satisfaction with CONEMO | Satisfaction with CONEMO was high, as it was with using smartphones for intervention delivery. |
Features most appreciated were the advice provided, the videos and types of activities suggested, as well as the monitoring calls received by the nurse. | |
The few critiques were directed at the type of activities suggested by CONEMO and that the sessions were repetitive. | |
Suggestions for CONEMO | Patients suggested increasing the duration of the intervention, the amount of videos and frequency of sessions and improving the in-build training session. |
Many patients also desired a more frequent interaction with the nurses. | |
Evaluation of nurse component | Although most praised the explanation from the nurses, some still experienced difficulties afterward, and therefore, they suggested improving the training. |
The monitoring calls were viewed as positive and helpful to increase adherence and resolve difficulties. |
Most nurses (5/6) felt that CONEMO was an innovative and useful intervention. They thought, it was a good idea, something different, an opportunity to talk more to the patients and something beneficial to them. Some nurses reported that participating in this project benefited themselves as well because they took part in improving the patients’ health (3/6) and gained experience participating in a research project (1/6). However, most nurses (5/6) mentioned having had difficulties in consolidating their CONEMO activities with their workflow and felt that this increased their workload. The difficulties mentioned were related to the fact that before implementation, the health care centers’ management agreed to provide the nurses with reserved hours to participate in the intervention; however, because of logistical and administrative constraints, once the study started, the nurses had to accommodate these additional activities in their daily routine without adjustments to their existing workload, as 1 nurse describes:
At the beginning, I found it tedious, because we did not have protected hours for this task. I took on more [tasks], because I had more free time. [...] When the [chief] doctor saw that we were having trouble, she said that when we were in the clinic, we should ask the auxiliary nurse to cover for us for a moment [to do our tasks related to CONEMO].
All nurses felt strongly that the implementation of CONEMO including nurse-support must imply strictly reserved work hours to be executed as expected.
Most nurses (5/6) stated that the training they had received was appropriate. However, 2 of them felt they were not able to remember all the procedures when the study started because of a lack of practice or a lack of concentration during the training sessions.
[I learned] about 80% [of the procedures] because it was difficult to stay focused during the training, due to the number of tasks that we had [to do] in the health care center.
Regarding the study technology, 3 of the 6 nurses reported that it was more difficult to use the nurse dashboard in the tablet to monitor their patients than to learn and explain how to use CONEMO, and they recommended increasing the time to practice during the training. Of note, the training of the hired nurse was a lot less time intensive compared with the training of the nurses from the public health care system because attendance fluctuated and it was difficult to gather everyone at the same time, maintain their concentration and motivation, and have sufficient time per training session to conduct complete practice runs before the nurses had to leave again.
To complete their tasks, nurses were supposed to use the nurse dashboard to view and log their tasks as well as monitor their patients. Only 2 nurses revised the dashboard regularly, every other day. The other 4 only revised the dashboard 2 or 3 times during the 2 to 3 months they were monitoring patients because they did not have enough time (3/6), they forgot (1/4), or because the tablet was not always accessible to them (1/4) as it was stored in the director’s office.
One of the most important responsibilities of the nurses was the initial appointments in which they trained patients on how to use CONEMO. Most nurses (4/6) emphasized that their patients had some difficulties in understanding the technology, but that they were able to explain it again afterward or that the patients received help from their family members. Some nurses (2/6) had difficulties during the training because they themselves forgot how certain things worked, and another 1 reported time constraints that forced her to complete it as fast as possible.
Nurses were also supposed to complete monitoring calls; ask their patients if they had difficulties in using CONEMO; motivate them, if needed, to increase adherence; and answer help requests. Half of the nurses made the calls by their own initiative, whereas the other 3 did not complete the calls unless they were reminded to do so by the clinical supervisor. In addition, some of the nurses had great difficulties in reaching some of their patients (2/3).
Supervision meetings led by a psychologist were supposed to be conducted on a weekly basis. In 1 health care center, the nurse was very comfortable with the supervision because she felt the research team addressed her doubts. However, at the other health care center, nurses felt pressured to have those supervision meetings (4/5) mainly because they felt overwhelmed because of their workload:
You, [the research team], were not the problem, but the work burden we have here. We just could not do it, it was pretty uncomfortable because we did not have the time to receive you as we should have. [...] It felt like “another thing” that I have to do.
Considering the possibility of scaling up CONEMO plus nurse-support, all nurses identified the lack of time to perform the related activities as the main problem for its implementation within the health care system. All nurses considered it necessary that the activities of the nurse-support would be included as part of the monthly schedule and paid work hours, a decision that depends on the administration of the Social Security System:
You would have to separate [CONEMO] as an independent program because here each nurse is responsible for one program. It cannot interfere with other activities.
Summary of main results—nurses.
Domain | Main results |
General nurse feedback | The intervention was viewed as useful, beneficial, and an opportunity to talk more to their patients. However, most nurses had difficulties to consolidate the study activities with their daily work routine. |
Evaluation of training received | The training was viewed as appropriate, although most nurses had some difficulties because of lack of concentration and fluctuating attendance. |
Evaluation of activities related to the study | Most nurses experienced some difficulties conducting their tasks reliably, especially concerning the review and registry of activities in the dashboard, conducting monitoring calls, and participating in supervision meetings. |
Feasibility of incorporating CONEMO in primary care | The activities related to CONEMO would have to be part of their paid work hours instead of being additional tasks. Some nurses also considered incentives as a possibility to increase the feasibility to scale up. |
One factor related to this issue, which inhibited the nurses from being adherent to the intervention, was their job insecurity (5/6): Each nurse is required to meet a productivity goal and if it is not achieved, their employment contract may not be renewed again.
When nurses were asked if incentives could improve their performance regarding to CONEMO activities, 3 of 6 nurses stated that they would consider incentives, such as a course or regular meals; however, one of them explained that her main interest in participating was based on the perception that CONEMO benefits her patients. Other 2 nurses said that an incentive might motivate their colleagues but they themselves are uncertain if they would be part of the CONEMO nurse-support again because of their personal time constraints, and 1 stated she would not participate in the intervention again, even if she would get paid.
The results for the nurses are summarized in
In this study, we aimed to explore the experience of primary care patients and nurses with CONEMO, a technology-driven, nurse-supported intervention to reduce depressive symptoms in people with diabetes, hypertension or both, to derive lessons informing future adaptations, and to assess the feasibility of using this technology in LMIC settings. Almost all patients felt that CONEMO helped them to improve their mental health by being more active, increasing their self-esteem, and making them feel valuable. Many patients also experienced improvements in their physical health related to healthier diets and more physical activity. The self-reported adherence to this intervention was relatively high. Although most people reported some difficulties with the technology in the beginning and suggested amplifying the training, the majority felt that it got easier with time. Using smartphones for intervention delivery was generally seen as practical and time saving. The main recommendations were to include more sessions and videos, to increase personal contact, and to make it more personalized. Most patients viewed the nurse-support as positive, although the evaluation of the support of the hired nurse was more frequently positive than of the staff nurses. The majority of staff nurses participating in the pilot study felt that the intervention was valuable for patients but that the activities of CONEMO conflicted with their daily work routine.
A growing body of research is aimed at capitalizing on the expansion of technology and its potential to introduce newer vehicles to target mental health, suggesting potential effectiveness of Web-based, text-messaging, and telephone support interventions [
Multimorbidities, defined as having 2 or more diseases, including NCDs and mental conditions, constitute a growing health threat, especially in LMICs. However, most available treatments usually only focus on 1 health condition instead of approaching multimorbidities in a more integrative way [
Although most people found the guidebooks useful and argued that the nurses generally explained well how to handle the technology, the majority reported some kind of difficulty in the beginning and suggested extending or improving the training. Although many difficulties will most likely subside as smartphones become ubiquitous, some changes to the design of CONEMO could also improve usability. Although most patients did not provide more information about how the training or design could be improved, one hypothesis was that a more realistic demonstration (using an in-build training session close to the actual CONEMO sessions) as well as a training video could be helpful to both nurses and patients. This way, the training would be more structured and more standardized over the nurses and, furthermore, would give the patient the opportunity to practice twice, while still being with the nurse: first, when conducting the training session and second, when completing the first real session. Nevertheless, in this study, as well as in others [
Although this intervention was created specifically for people with diabetes, hypertension or both, some of the results could also be relevant for other mental health interventions with different populations. Other studies suggest that key features of acceptable smartphone health apps seem to be self-help suggestions and feedback to the patients’ responses, they should be easy to use (
Nevertheless, some of our interactive features showed low utility, and some technological problems were encountered. For example, most people did not check the Android notifications to see if a new session was available. It is plausible that those notification symbols were too small for this population, considering their average age. Another hypothesis could be that considering most people were novice users, who had not yet integrated the smartphone into their everyday lives and, hence, only used the smartphone for one app—CONEMO—they would not be interested in other Android notifications of the default apps already installed on the smartphone. Therefore, it might have appeared easier to open the one app of interest directly from the home screen. The utility of the other interactive elements, such as SMS and dialogue pop-ups, was difficult to evaluate given the technological problems experienced. Considering that those difficulties were not encountered during the testing phase and some could be related to signal changes in the field, formative research for large studies including technological platforms appears to be of high importance.
Another important consideration about health apps is related to the setting with special emphasis on crime rate. Given the perception of insecurity and fearing a possible robbery, many patients were reluctant to borrow a smartphone from the research team. This fear could be reduced by explaining that in case of a robbery patients would not be charged for the phone. However, as a consequence, many people did not use it as a
Evidence shows that in technology-only interventions, where people are left alone with mobile self-help interventions, participants are less adherent [
In addition to the nurse-support, CONEMO contained an
The importance of the videos was also highlighted by the patients’ suggestion to incorporate more of them. However, when designing this type of intervention and considering the number of videos, developers need to prioritize and contemplate the size of the videos (especially in a fully functioning offline app), which influences the speed of installation versus, for example, relying on a stable internet connection to watch videos on the Web. Those technological considerations need to be in line with the research priorities.
Feasibility of working with nurses within the health system to monitor the patients was low because of the conflicting use of time with their daily activities. Especially given their job uncertainty, many nurses felt pressured. Other studies in a very similar context also identified workload and time constraints as the most important barriers to implementation, especially taking into account that the studies’ activities were additional to their existing tasks, without considering more paid time [
Adherence to the study activities can also be influenced by other factors specific to the health care center settings. For example, in our study, adherence seemed to be to some extent related to the attitudes of the nurses toward the study (positive attitude–higher adherence, and vice versa). This, in turn, could have been influenced by the management style of the health care center; the 5 nurses from 1 health care center who monitored 2 patients each were all assigned by their superiors to this study, although most were initially reluctant to participate. The one nurse with the highest workload—monitoring 7 patients—who had experience participating in different health programs, was asked by her superior beforehand, and she had the most positive attitude toward the intervention, was highly motivated, and ultimately was less affected by the workload of CONEMO. Therefore, although some health care center managers were initially enthusiastic about the study, important factors, distinct for each health care center, such as staff management, work climate, and conditions, could also influence implementation success. Furthermore, although it is ideal to find motivated nurses enthusiastic with this intervention, this may not be feasible across all of Lima or Peru, presenting a challenge to scalability; thus, structured resources should be put in place.
LATIN-MH benefited from this detailed formative phase conducted across 2 distinct health care provider systems in Lima, a large Latin American capital. Conducting qualitative formative research stages to shape mental health interventions has also been beneficial for other studies [
Although this study has provided important insights in the evaluation of an mHealth intervention for people with NCDs and depressive symptoms, this study also had some limitations. For example, although all patients were provided with the same intervention and number of sessions, the intervention uptake might not have been the same for all of the patients, depending on their adherence to review the sessions. However, the number of patients included in this study was sufficient to signal positive and negative experiences with the CONEMO intervention [
Another limitation of this study is related to the fact that for the first pilot study in the MINSA hospital, a nurse was hired, whereas in the second pilot study in the Social Security System, nurses from the health system accompanied the patients. Therefore, although the perspectives of patients from both public health systems were obtained, only the perspectives of the nurses within the Social Security System were analyzed. Furthermore, it is plausible that the patients’ experience differed depending on what type of nurse accompanied them throughout the intervention beyond what has been identified and described here. However, conducting this second pilot study with staff nurses was extremely beneficial for the study purposes to explore feasibility of working with staff nurses and understanding the challenges they encounter, which might be similar in other public health systems. Therefore, after the first experience, it was crucial to conduct a second pilot study with this aim.
Furthermore, the interviews were not recorded and, therefore, there is a possibility that some information from the participants was lost. However, the 2 people who conducted the interviews aimed at writing down the verbal statements literally and took notes simultaneously during some of the interviews, which were contrasted afterward and which showed high literal consistency. This makes us confident that the notes represent the participants’ statements reliably.
Although generalizability is limited, all of these findings are relevant and crucial to inform the development of future complex interventions for mental health conditions, multimorbidity, and specifically for further designing and testing the efficacy of CONEMO under more controlled designs; indeed, CONEMO will be tested in 2 parallel randomized controlled trials. Other studies have demonstrated that mobile apps can effectively change behavior; however, considering the limited evidence, uncertainty of long-term effects and the predominance of those studies in high-income countries so far [
Furthermore, this study is especially relevant considering the current mental health reform in Peru, where for the last 12 years, several efforts have been made aimed at improving the availability of free and universal access to mental health care for Peruvian citizens through a community-based approach, including primary health care centers [
Smartphone apps constitute a potentially cost-effective opportunity in LMIC settings to overcome health system barriers and extend mental health care to large populations. On the basis of the experiences and opinions of the patients, it seems feasible to use this nurse-supported mHealth intervention for people with chronic diseases and comorbid depressive symptoms in Peru. CONEMO is perceived as helpful in improving mental health, but it requires context-specific adaptations, especially regarding the implementation of a task shifting approach within the public health care system; working with staff nurses using a task shifting approach within the public health system in Lima will only be feasible if the nurses’ time is protected for the program. Findings from this study will provide important information to develop a larger study focused on testing the effectiveness of this program on patients’ health and mental health outcomes.
Screenshot of CONEMO.
Interview guide—patients.
Interview guide—nurses.
Codebook—patients.
Codebook—nurses.
Demographic variables—patients.
Original quotes in Spanish with demographic information.
disability-adjusted life year
Latin America Treatment and Innovation Network in Mental Health
low- and middle-income country
mobile health
Ministry of Health
noncommunicable disease
short message service
This study was supported by the National Institute of Mental Health (1U19MH098780).
PRM, RA, JJM, and DM conceptualized the LATIN-MH program of research, for which this was a substudy of the formative phase. FDC and LRB designed this substudy and LRB and LH conducted it (LRB as trial manager and LH as clinical coordinator), under supervision of FDC. LRB and LH created the codebook and codified the interviews. LRB analyzed the data and wrote this paper with guidance from JJM and FDC and contributions from LH. After the first draft, PRM, RA, JJM, DM, and FDC reviewed the paper and contributed to the final version submitted.
None declared.