Digital technologies are becoming more prevalent in pelvic health, and in healthcare in general. Smartphones were used by 6.65 billion people worldwide in 2022 and it is estimated that 85% of the time spent on smartphones is spent on using apps. The average smartphone user uses 9-10 apps per day and 250 million apps were downloaded daily between 2019 and 2020.(1)
Apps are becoming increasingly popular as a way of managing health, from sleep and fitness tracking to medication use and data collection for healthcare professionals. Growth in the healthcare app industry is expected to be 14% year after year, for the next five years (2). Acceptance by patients has increased but was still only 46% in 2021 (2).
In pelvic health, apps are commonly used for supporting and tracking pelvic floor muscle exercises. This abstract refers to one of the apps with a connected platform, which allows clinicians to send their patients a link to the pelvic floor muscle exercise app along with advice and information tailored to their needs, bladder and bowel diaries, symptom trackers and outcome measures. The clinician can view completed diaries and outcomes, track adherence and manage patients remotely where needed. This app is used in the author's clinical practice in the NHS (UK).
The first challenge in using apps in healthcare is to ensure that the patient downloads the app and engages with it. Investigating initial app uptake will provide essential information on what digital barriers may exist. The ability to track a patient's initial engagement may also give us an indication of adherence to clinician requests, which is less easy to track in traditional consultations that do not use digital technologies.

The clinical lead of one NHS Trust using the digital platform set up a small audit of 10 selected patients. All patients had seen a pelvic health nurse or physiotherapist for a face to face assessment for a bladder, bowel or pelvic health condition. All patients were asked if they would like to use the app, and it was explained and demonstrated to them. They all consented to use the app as part of their treatment package. The patients were advised that they would be sent an email link to download the app and register to use it. They also had a text reminder sent to them.

The survey selected ten patients who had not responded to an invitation in the previous month, with at least two weeks having elapsed between their invitation and the audit date.

The ten patients were sent an email to explain that the service was trying to understand what were the barriers were to them downloading the app and completing the registration process. They were invited to choose from a list of possible options and to add their own reasons or any other comments.

Four out of ten emails received a response.

Two emails were immediately bounced back as the email address was incorrect.

One patient responded to report that she had been busy, and had forgotten to download the app but would do it that day.

One patient responded to report that she had difficulty with her internet connection but would now proceed to download the app using her mobile data.

The rate of incorrect email addresses was 20%, which is perhaps unsurprising given that many people have email addresses that are not standard or recognisable names. This highlights the problem of relying on accuracy of data input.

The rate of 25% of response to the email sent out to the remaining respondents is a reasonable response rate for surveys of any type. Both patients had intended to download the app (and did do so after the email exchange) but were distracted by other issues. There are a number of questions that this raises:

How many patients leave a consultation with the intention of carrying out an action, but are distracted and forget?
How many assumptions are made about an individual's digital literacy? For example, the second patient had difficulties with her internet but did not automatically consider downloading the app using mobile data.
What style and frequency of reminders are useful to help improve adherence to clinician requests?

Finally, four of the six patients who did not respond to the email did go on to download the app. This suggests that the email served as an effective reminder.

Clinicians often forget that patients may not be as adherent to our instructions as we expect! Information given in a consultation is often complex, and may be more than someone can take on board at that time. It is important to find ways of ensuring that they understand what they need to do, and there are a number of ways to achieve this.

Digital technologies and apps can be very effective and efficient ways of distributing information, managing patients remotely and supporting patient and clinician interactions. It is important to be aware that not everyone has high levels of digital literacy or confidence, and clinicians must ensure that their instructions are clear and suitable. Written information and a clear way of accessing support are important. Reminders and nudges are of immense value at all stages of an assessment and treatment pathway.

The practical issues around correct data entry suggest that asking patients to enter their own email addresses, or check the entries made by a clinician,  will reduce errors (in this case by 20%).

Digital barriers are likely to be a reflection of barriers that are in place for many "clinician to patient" interactions, but they allow us to identify them in ways that have not always been possible before. It is essential that any true digital barriers are identified and managed so that we can maximise the benefits of these technologies.

40 Fascinating mobile app industry statistics (2023); zippia.com, 3 2023
Health apps usage statistics; vicert.com 12 2022