Promoting Health Education through Mobile Apps: A Quantitative Analysis of American Hospitals

Using mobile apps as a corporate communication tool helps hospitals to improve their health education initiatives. This paper aims to analyze how these organizations can use mobile apps to implement health education initiatives addressed to patients. To achieve this, we conducted a literature review (health education, mobile apps, role of doctors and patients), and we resorted to using 38 quantitative indicators to evaluate how the 100 best hospitals in the United States manage mobile apps for implementing health education initiatives addressed to patients. Our results prove that 95% of hospitals displayed general mobile apps for patients, but just some of these organizations proposed mobile apps for patients suffering from non-communicable diseases, including: heart diseases (9.47%), cancer (7.37%), chronic respiratory diseases (3.26%), and diabetes (3.16%). We concluded that hospitals should create a department specializing in designing mobile apps that are adapted to patients’ medical and social needs, and that are also consistent with public health priorities.


Introduction
Health education has become a strategic area for hospitals interested in establishing better relationships with stakeholders, including: patients, employees, suppliers, media companies, public authorities, etc. [1]. These organizations resort to different tools, such as artificial intelligence, big data, websites, patient portals, social media platforms, and mobile applications, to design integrated education experiences allowing patients to reinforce their empowerment [2]. Among all these tools, mobile apps are especially useful for patients, allow them to upload medical information, check test results, track medical metrics, manage appointments with health professionals, conduct video consultations with doctors, etc. [3]. However, many hospitals do not adapt these mobile apps to their patients' needs, which constitutes a problem from a public health perspective. This paper aims to better understand how hospitals manage mobile apps to implement health education initiatives addressed to patients. To achieve this, we conducted a literature review on health education, the role of health professionals and patients, health education during crises, and the impact of mobile apps on health education. Then, we resorted to using 38 key performance indicators to analyze how the best 100 hospitals in the United States use their mobile apps for health education initiatives addressed to patients, including those suffering from non-communicable diseases. Finally, we presented our quantitative results, as well as three research avenues and three conclusions.

Role of Hospitals, Doctors, Nurses, and Patients
Many organizations promote health education (public authorities, patients' associations, media companies, etc.); however, hospitals remain the most important ones because they represent scientific credibility [11]. Hospitals carry out four main health education initiatives. First, they promote health professionals' involvement in this area to help patients in a more efficient way [16]. Second, they train doctors and patients to efficiently participate in collective decision-making processes concerning the latter's health [17]. Third, they define patients' empowerment at each level of the care production chain to efficiently implement a new medical approach based on health education [18]. Additionally, fourth, they resort to standard measurement tools to make sure patients understand medical information, and they improve their medical outcomes [16,19].
Hospitals' health education campaigns are mainly based on health professionals' involvement: the latter respect human values (compassion, empathy, etc.), patients' expectations, and legal frameworks to efficiently promote health education [20]. Promoting these human values positively contributes to making health education campaigns more efficient [21], especially when these campaigns aim to influence ethnic minorities with different cultural backgrounds [22]. Integrating human values into health education initiatives is essential for not only doctors, but also nurses. These professionals interact with several patients facing different situations from a medical and emotional perspective [23], which means that they must provide patients with psychosocial and medical support [14].
Hospitals, doctors, and nurses resort to health education to help patients to access medical information, change their attitudes, explain their feelings, and modify their behav-iors [24]. Thanks to health education, patients develop the skills needed to make decisions and contribute to their care process; in other words, health education helps patients to reinforce their empowerment [16]. This last concept means that patients can share their opinions, experiences, and expectations with other patients, as well as with health professionals, to make informed decisions [25]. Empowered patients decide whether to be treated or not, whether to be hospitalized or not, and whether to be active or not; being empowered does not necessarily imply making decisions on a health topic that is related to the guidelines imposed by health professionals [18]. Thanks to empowerment, patients and their relatives reinforce their rights [26].

Health Education in Crises
Promoting health education constitutes a social priority, especially when people face pandemics, as was recently the case with the COVID-19 outbreak [27]. To efficiently manage this pandemic, three main types of organizations were involved: international organizations, governments, and citizens [28]. International organizations worked together to analyze test results, symptoms, and treatments, and based on that, they implemented health education campaigns to curve the COVID-19 pandemic [29]. Governments implemented an integrated health education approach based on mutual trust, calling for collective responsibility and coordination of all stakeholders to protect people against this disease [30]. Finally, citizens made a great effort to read medical information about COVID-19, and in this way protected themselves and limited the spread of the infection [31]. Additionally, they respected different prevention measures, such as social distancing, isolation, PCR tests, vaccines, and masks [32]. International organizations, governments, and citizens were not the only ones to actively fight COVID-19. Health professionals played the most important role: they worked hard to help patients accept new medical protocols and promote healthy habits [28]. Unfortunately, many of these professionals did not receive enough support from their organizations-in the form of security measures, financial help, or psychological support-which made it difficult for them to efficiently implement health education initiatives [33].

Promoting Health Education through Mobile Apps
Health organizations resort to different initiatives to promote health education, such as corporate events, media relations, conferences, websites, social media platforms, and mobile applications. Some hospitals integrate mobile apps into their different protocols to enhance patients' adherence to treatment, disseminate disease-related information, and monitor patients' medical outcomes [34]. When hospitals resort to these apps, they consider three main criteria: patients' perceptions, effort expectancy, and social influence [35]. Mobile apps allow hospitals to change the way they deliver healthcare knowledge [36], improve their relations with patients, especially those having difficulties reaching healthcare services due to distance or costs [2], and reinforce their scientific credibility by disseminating accurate data that positively influence patients' medical outcomes [36].
To efficiently promote mobile apps as a health education tool, hospitals need to train doctors, nurses, and patients on how to use these platforms for educational purposes [35]. Thanks to mobile apps, doctors can interact more often with patients, especially with those suffering from chronic diseases [37], and nurses can monitor patients' medical outcomes more efficiently [38]. On the other hand, patients using mobile apps become more autonomous and participate more actively in collective decision-making processes concerning their health, which positively influences their medical outcomes [35]. In other words, thanks to mobile applications, patients reinforce their empowerment and protect their rights [39].
More and more hospitals are resorting to mobile apps to implement advanced patient education programs that ensure person-centered care [26]. These programs are especially useful for patients suffering from non-communicable diseases such as diabetes, cancer, heart disease, or chronic respiratory disease. Thanks to mobile apps, doctors and nurses can propose a more integrated medical service for patients suffering from diabetes, involving: organizing social support groups, monitoring medical outcomes [40], and disseminating evidence-based educational content [2]. Concerning cancer patients, they can use mobile apps to interact with oncologists, read about cancer treatments, and better understand preoperative requirements [41]. Facing surgery constitutes a risk for patients, regardless of their disease; that is why hospitals should integrate mobile apps into their medical protocols to improve patients' experiences and facilitate doctors' duties [3].

Methodology
To better understand how American hospitals manage mobile apps for health education purposes, we resorted to the World's Best Hospitals 2021, a reference study published by Newsweek and Statista that evaluates hospitals' medical performance. These two institutions analyzed 2.000 hospitals from 25 different countries (United States, United Kingdom, Germany, Canada, etc.) according to three main criteria: (a) recommendations from more than 74.000 medical experts (doctors, managers, healthcare professionals); (b) patient satisfaction surveys (medical care, organizational services, etc.); and (c) medical indicators (quality of treatments, hygiene measures, number of patients per doctor, etc.). Recommendations from medical experts accounted for 55%, patient experience 15%, and medical indicators 30%. Finally, all results obtained were validated by an independent global board of medical experts from different countries, such as the USA, Switzerland, Israel, and Germany. (More information about this methodology is available here: https://d.newsweek.com/en/file/4612 00/worlds-best-hospitals-2021-extended-methodology-20200303.pdf. Document retrieved on 24 August 2022.).
Thanks to this ranking, we identified the 100 best hospitals in the United States (see Appendix A. List of best hospitals in the USA). Afterward, we analyzed how these hospitals managed their corporate websites, patient portals, social media platforms, and mobile apps to promote health education. We focused on corporate websites and patient portals because both platforms allow hospitals to reinforce patients' engagement with health education initiatives [42]. As for social media platforms, we considered them because they are a useful tool for hospitals' health education campaigns, allowing for: disseminating information, organizing online consultations, etc. [43]. Finally, we analyzed mobile apps because these tools allow hospitals to make their health education campaigns more dynamic and creative [28]. Additionally, thanks to these apps, patients can control medical metrics and improve their healthcare outcomes [44]. Given the increasing importance of mobile apps in the healthcare industry, we decided to focus our research on these tools.
To analyze how the best US hospitals managed mobile apps for health education purposes, we carried out a quantitative analysis from 4 September to 9 October 2022. We resorted to 38 key performance indicators grouped into four main categories: (a) online integration, (b) general apps for patients, (c) mobile apps for other targets, and (d) mobile apps for patients suffering from non-communicable diseases (see Table 1). We considered non-communicable diseases (NCDs) because they kill 41 million people each year, accounting for 74% of all deaths globally. We analyzed apps for patients suffering from cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes because these four diseases account for over 80% of all premature NCD deaths [45]. To determine the mobile apps used for this purpose, we analyzed every hospital's corporate website to check if they displayed mobile apps addressed to patients; moreover, we consulted the Apps Store and Google Play to confirm our results. Once all apps were identified, we analyzed them according to different indicators (see Table 1) that were previously gathered from our literature review. To analyze each app function, we read its online corporate description and we confirmed our results by installing each app on our smartphone. However, many functions were only available for patients admitted in the hospital; that is why we could not analyze all functions, only the most important ones. We only analyzed hospitals' corporate profiles (websites, patient portals, social media platforms, mobile apps), and not any other kind of profile (medical departments, events, etc.). Concerning mobile apps, we focused on apps addressed to patients, but not on those used only by health professionals. Additionally, we only evaluated apps developed by the hospital, or apps developed by external providers but adapted to the hospital's system; in other words, we did not consider external apps recommended by hospitals that were not integrated into the organization's medical system. Lastly, all indicators were analyzed according to the binary system, except for one that was evaluated as an absolute number: online integration (5. Number of mobile apps).

Results
Most American hospitals resort to mobile apps to implement health education initiatives. Nevertheless, not all of them manage these platforms in the same way. For example, some organizations belonging to the same hospital group use the same mobile apps -general mobile apps and mobile apps for patients suffering from non-communicable diseases (see Appendix B. Hospitals using the same mobile apps). On the other hand, some hospitals use general apps that are developed by external companies but adapted to the hospital's medical system (see Appendix C. General apps developed by external companies). To better understand how the best American hospitals manage mobile apps for health education purposes, we present our quantitative results, grouped into four main categories: (1) online integration, (2) general apps for patients, (3) mobile apps for other targets, and (4) mobile apps for patients suffering from non-communicable diseases.
1. Online integration. All hospitals analyzed had a corporate website, a patient portal and a corporate profile on at least one social media platform (Facebook, Twitter, YouTube, etc.). On the other hand, 95% of hospitals displayed at least one mobile app. On average, hospitals proposed 3.72 mobile apps. The best hospitals according to the number of mobile apps were The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center (see Table 2 below). These quantitative results prove that 95% of American hospitals integrated websites, patient portals, social media platforms, and mobile apps for health education purposes. 2. General apps for patients. According to our results, 95% of hospitals displayed a general app for patients. Hospitals proposed different services thanks to these apps: reviewing test results and medical records (100%), communicating with doctors (100%), uploading personal health data (98.95%), managing appointments with doctors (98.95%), requesting prescriptions (70.53%), paying bills (69.47%), accessing family's health information (45.26%), finding physicians (35.79%), and conducting video consultations with doctors (32.63%). Most hospitals (72.63%) met between six and seven criteria (see Table 3), and only four of them fulfilled the nine criteria evaluated (see Table 4). Table 3. Hospitals and criteria.  3. Mobile apps for other targets. Some hospitals proposed mobile apps for different targets, such as patients facing particular diseases, including depression, obesity, etc. (40%), employees (38.95%), or media companies (4.2%). However, no hospital displayed a mobile app for their suppliers (logistic companies, pharmaceutical organizations, etc.). On the other hand, the only hospitals proposing apps for at least three different targets (media companies, employees, and patients suffering particular diseases) were Cleveland Clinic, Cleveland Clinic Fairview Hospital, and Cleveland Clinic Florida. Finally, 20 hospitals had apps for two different targets; 31 hospitals, for one target; and 46 hospitals did not propose any app for these particular targets.

Number of Criteria Number of Hospitals
4. Mobile apps for patients suffering from non-communicable diseases. Our results prove that 9.47% of hospitals displaying mobile apps proposed at least one app for patients facing cardiovascular diseases. These apps allowed these patients to access health education information (100%), contact doctors (100%), and track medical metrics (22.22%). However, these apps did not allow patients to conduct online consultations with doctors or request prescriptions. The only app meeting at least three out of five criteria was the Corrie Health App ( Concerning cancer, only 7.3% of hospitals having mobile apps proposed at least one app for this kind of patient. Thanks to these apps, cancer patients could read medical information (100%), contact doctors (57.14%), and track medical metrics (14.29%); however, these apps did not allow them to conduct online consultations or request prescriptions. As for chronic respiratory diseases, only 3.16% of hospitals analyzed displayed an app for these patients. These apps allowed them to read medical information (100%), track medical metrics (100%), contact doctors (100%), and carry out online consultations (100%), but they could not order prescriptions (0%). The Sleep App (Cleveland Clinic, Cleveland Clinic Fairview Hospital, Cleveland Clinic Florida) was the only app in this category.
Finally, only 3.16% of hospitals having mobile apps proposed an app for patients suffering from diabetes. Thanks to these apps, these patients could read medical information (100%), track medical metrics (100%), and contact doctors (100%). However, no hospital proposed an app allowing them to sign up for online consultations with doctors or request prescriptions. The LDL Cholesterol Calculator App (The Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center) and Diabetes Emoticons App (University of Michigan Hospitals-Michigan Medicine) were the only apps in this category.

Discussion
Hospital health education initiatives addressed to patients should consider different stakeholders, such as doctors, patients, relatives, etc. [4]; focus on these stakeholders' needs, including medical outcomes and social support [46]; and integrate different formats, such as storytelling or emotional branding [12]. This integrated approach is essential to allow patients and doctors to engage in medical decision-making processes [47]. Our results prove that most hospitals in America make an effort to implement this integrated approach; in fact, 95% of these organizations displayed, at the same time, a corporate website, a patient portal, different social media platforms, and at least one mobile app. However, out of the 95 hospitals using mobile apps, 31 did not develop their own applications and resorted to external companies; 29 hospitals implemented My Chart, an app developed by Epic; and 2 hospitals used Follow My Health, an app commercialized by All Scripts. Additionally, many hospitals, such as Mayo Clinic Phoenix, Inova Alexandria Hospital, and Brigham And Women's Faulkner Hospital, did not have a mobile app, and used apps implemented by other hospitals belonging to the same hospital group. When hospitals develop their own mobile apps, they can implement efficient health education campaigns based on a more integrated approach (mobile apps, websites, patient portals, and social media platforms).
Besides an integrated approach, hospitals should promote human values. Doctors, nurses, and patients should respect different values, such as compassion, multiculturalism, customization, and ethics, and push hospitals to integrate these values into their online health education initiatives [1]. Respecting human values means that hospitals follow ethical principles [11] and that health professionals consider patients' expectations and beliefs [20]; moreover, these human values should also be integrated into the hospital's medical protocols [21]. These human values must also be present within hospitals' mobile apps. However, our results certify that many hospitals can still improve in this area; on the one hand, 67.35% of hospitals having a general mobile app for patients did not allow them to carry out personal video consultations with doctors and nurses, and on the other hand, 64.21% of hospitals' mobile apps did not permit patients to find physicians' contact details (email, phone number, etc.). Hospitals should evolve from a management approach focused on health information (test results, personal health data, appointments) to a more humanistic approach that considers patients' needs in terms of social and emotional support. This humanistic approach should lead hospitals to develop mobile apps addressed to stakeholders that also play a key role in health education, such as media companies or suppliers. However, our results prove that most hospitals are not following this logic: no hospital displayed an app for suppliers, and only 4.2% of them had an app for media companies.
Integrating mobile apps and human values to reinforce patients' skills in health education constitutes an opportunity to make hospitals' brands more credible. These health education initiatives are especially important when hospitals interact with patients facing non-communicable diseases (heart diseases, cancer, diabetes, and chronic respiratory diseases). Patients suffering from heart disease have to establish an open dialogue with doctors based on honesty and non-judgment [48]; patients facing diabetes need to reinforce their skills in health education to improve their medical outcomes [49]; lastly, cancer patients require accurate information about diseases and treatments [50]. Nevertheless, according to our results, most hospitals do not focus on patients facing non-communicable diseases, and only some of them proposed an adapted mobile app for these patients, including those with: cardiovascular diseases (9.47%), cancer (7.37%), and chronic respiratory disease and diabetes (3.16%). When hospitals invest in patients' needs (knowledge, social help, emotional support), they become more credible, especially when they focus on patients facing serious diseases such as cancer, diabetes, heart disease, or chronic respiratory disease.
Most hospitals analyzed resorted to mobile apps to implement health education initiatives, allowing them to enhance their relationships with stakeholders, especially patients. Despite the interesting ideas explained in this paper, we must highlight three main limitations: (a) a lack of information about how American hospitals integrated mobile apps into their medical protocols, (b) absence of input concerning patients' perceptions about the use of mobile apps for health education, and (c) difficulty finding other papers focused on this area that would allow us to compare our results. Finally, we recommend researchers interested in this topic focus on three main areas that will be especially relevant in the coming years: (a) integration of mobile apps into hospitals' internal protocols, (b) impact of big data and artificial intelligence on mobile applications addressed to patients, and (c) design of training sessions to help patients reinforce their empowerment through mobile apps (medical knowledge, technological expertise, and human values).

Conclusions
Hospitals resort to different technological tools (artificial intelligence, big data, mobile apps) to accelerate their digital transformation, improve their internal functioning, and enhance their patients' satisfaction with medical treatments. However, these organizations should not only focus on treating patients and leading research: they must also promote health education. Additionally, to achieve this, using technological tools such as mobile apps can become a true advantage. This article aimed to evaluate how hospitals manage their mobile apps for health education purposes. Our quantitative results prove that many of these organizations' general mobile apps for patients provide several basic services (reviewing test results-100%, managing appointments-98.95%, paying bills-69.47%), but not true health education initiatives, such as conducting video consultations with doctors to allow these them to treat and educate patients at the same time (32.63%). In other words, American hospitals can still improve in this area, and to achieve this, we propose three last ideas. First, these organizations should create a department integrating doctors, engineers, experts in corporate communication, and patient representatives to develop mobile apps adapted to patients' needs and are also consistent with the hospital's requirements. Second, these mobile apps should focus on social and medical content that is useful for patients (medical information about treatments, emotional support groups, etc.) rather than commercial information (hospital's internal policies, prices of treatments, etc.); in other words, mobile apps must become a tool for reinforcing patients' empowerment, and not a commercial tool for accelerating hospitals' business. Third, hospitals should collaborate with public authorities and international NGOs (Ministry of Health, World Health Organization, International Committee of the Red Cross, etc.) to develop apps that could also fix some of the most important public health challenges, which includes taking care of patients suffering from non-communicable diseases.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest.
Massachusetts General Hospital 4.
The Johns Hopkins Hospital 5.
Ronald Reagan UCLA Medical Center