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Application of mobile health to support the elderly during the COVID-19 outbreak: A systematic review

Background : The COVID-19 outbreak has affected the elderly's physical and mental health. The application of information and communication technology, such as mobile health (m-health), can help control this pandemic by changing the behavior and lifestyle of the elderly during this time of crisis. Objective : This review aimed to synthesize the capabilities of m-health in providing health services to the elderly during the COVID-19 pandemic, and to identify the factors contributing to the success of these tools. Methods : To find the relevant studies, a search was conducted in PubMed, Web of Science, Scopus, ProQuest, and Google Scholar. The inclusion criteria were: studies in English that used m-health intervention in all aspects of elderly healthcare during the COVID-19 outbreak, were published in peer-reviewed journals from 31 December 2019, and had any research design and methodology. Two authors independently took all the steps of this review, and finally performed narrative synthesis to report the findings. Results : Our initial search identified 421 studies, of which 10 met the inclusion criteria. The data analysis showed that all the m-health interventions had positive effects on the health of the elderly. The m-health services for the elderly during the current pandemic were used for therapy, information provision, self-help, monitoring, and mental health consultation purposes. The results also indicated that various factors affected the elderly's use of m-health tools. Conclusion : The application of m-health keeps the elderly and healthcare providers safe, accelerates health service provision, reduces the costs of service provision, and decreases the risk of morbidity and mortality during the COVID-19 outbreak. The successful use of m-health tools for the elderly in health programs during the current crisis greatly depends on supporting the elderly and overcoming the barriers.


Introduction
On December 31, 2019, a cluster of a genus of the Coronaviridae family was officially reported from Wuhan, Hubei Province, China, which caused the novel coronavirus disease   [1,2]. This infection widely spread to other regions of the world, and primary evidence revealed that the elderly and those with underlying medical problems (e.g. cardiac diseases, diabetes, hypertension, and cancers) are more susceptible to the disease in its most intensive form [3].
As the older population has a much higher risk of mortality compared to younger people during the COVID-19 pandemic, it is emphasized that the elderly should be protected with social distancing or, if necessary, social isolation [4,5]. Loneliness and social isolation may lead to many problems such as depression, cognitive dysfunction, disability, cardiovascular diseases, and increased mortality among older adults [6]. The ongoing COVID-19 pandemic has highlighted the need for mobile technology solutions to diminish the risk of cross-contamination caused by close contact [4,7,8]. Smart technology (e.g. mobile-based technology) has been important for exploring meaning in life, self-care, consultation, and creating a positive feeling for confined older adults [9,10].
The term m-health refers to smart phone applications and is increasingly used in the healthcare sector [11]. It is proposed to be a technology which may be either short-or long-distance, or system-driven [12]. More specifically, m-health is defined as the provision of health intervention using mobile-based tools, including phone calls, video consultation, wearable devices, personal digital assistants, tablets, and personal computers (PCs) [13]. The main concept of m-health is that it can provide health services, anytime and anywhere, to anyone, by removing geographical, temporal, and other barriers [14]. It is also reported that mobile-based tele-visits can improve access for an estimated 6.3 million older people who are inexperienced with technology tools or have visual problems [15,36]. Remote interventions are potentially effective and utilized by older people, but healthcare providers should ensure that digital services are suitable for the older demographic and provide both the technology and the technical support needed for interventions in the current pandemic [16].
Previous studies have reported the potential role of m-health tools in providing long-term support and health promotion for the elderly [17][18][19]. For example, the results of a systematic review showed a positive effect of mobile interventions on sexual health outcomes in chronic patients and emphasized that mobile interventions can be more effective in combination with smartphone apps [19]. According to another systematic review, the use of mobile to provide tele-health in the COVID-19 outbreak is very effective in promoting health services [35]. Also, the results of a study showed that mobile applications are a valuable tool for people, healthcare providers and decision makers in the face of critical challenges posed by the COVID-19 epidemic, such as reducing hospital burdens, access to reliable information, tracking symptoms and mental health [37]. However, there is no systematic review on the role of m-health in improving the health of the elderly during the COVID-19 pandemic. Thus, this study aimed to synthesize the literature on the capabilities of m-health in providing health services to the elderly during the COVID-19 outbreak, and to identify the factors associated with the success of these tools. The research questions were: • What are the capabilities of the available m-health services for the elderly during the COVID-19 pandemic? • What factors are associated with the success of m-health tools for the elderly during this global emergency?

Study design
This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All the steps of this review, namely the search in databases, study selection, quality evaluation, data extraction, and data analysis, were independently performed by two authors (S.AB. and S.F.), and in case of any discrepancies, the opinions of the third author were used. Conflicts were also resolved in such a way that the authors convened a meeting and the Conflicts were discussed. Finally, the authors consensus on how to proceed.

Bibliography search strategy
To identify studies on m-health tools used to help the elderly which were published during the COVID-19 pandemic, a comprehensive search was conducted in PubMed, ProQuest, Web of Science, Scopus, and Google Scholar, since the appearance of COVID-19 in Wuhan, Hubei Province, China, from December 31, 2019. Given the aim for this review, the search was conducted on titles and abstracts via a combination of relevant keywords: [1] COVID19, COVID-19, Coronavirus, Novel Coronavirus, 2019-nCoV, Wuhan Coronavirus, SARS-CoV-2, SARS2 [2], Aging, senior, aged, elderly, old* [3] M-health, m-health, handheld computer, mobile phone, smartphone, mobile application, mobile app, cellular phone, mobile device, mobile technology, SMS, or text message. Hand searching in web-based resources was also accomplished, and the selected articles' references were reviewed to identify additional studies (reference by reference). The sources were managed in EndNote x7. The search strategy was adapted for each bibliography database, and the search was conducted on March 30, 2021. As an example, the full search strategy on PubMed is given in Table 1.

Eligibility criteria
All the included studies had to meet the following inclusion criteria: • Study types: interventional, observational, modeling, or case studies. Studies about other technologies (e.g. Internet of medical things or IoMT), studies which had not stated the primary objective of the intervention or reported incomplete information, conference abstracts, review articles, letters to the editor, and opinion papers were excluded.

Study selection
In the process of study selection, first, a screening was performed to remove duplicates from the datasets retrieved from the mentioned databases, and the papers were reviewed based on their titles. Subsequently, relevant papers were screened based on their abstracts. After initial screening, the remaining papers were screened in the third phase by reviewing their full text according to predefined inclusion and exclusion criteria.

Data extraction and quality assessment
The authors used Microsoft Word 2016 to design a standard data extraction form. The following information on the eligible studies was extracted: study identification (authors and publication year), study design, country, population (N), the device or technology used, intervention, and key findings.
We assessed the methodology of each included study in accordance with the Critical Appraisal Skills Program (CASP) checklists. The CASP tools were developed to teach people how to critically appraise different types of evidence [34]. It consists of questions that address issues such as goals, participant selection process, data collection, analysis, the role of researchers in the results, and ethical issues associated with the published study. In the CASP tools, the following responses to questions are possible: [1] yes, [2] no, and [3] cannot tell. Quality assessment was performed independently by two experts in this field and in case of any discrepancies, the opinions of the third author were used. Each question at this checklist valued one score, so studies were divided in poor, average and good groups according to their scores. The criteria for giving a complete score to each checklist item was compliance with the instructions and checklist items in the article under review. The included studies were also divided into three categories of weak, medium, and good based on their quality assessment scoring. The studies were ranked in the following manner: if an study scored <30% it belonged to the weak category, if it scored 30-70% the medium category, and if it scored >70% to the good category.

Evidence analysis
Due to the heterogeneity of the designs and objectives of the included studies, a narrative synthesis was performed to summarize the overall evidence by comparing and contrasting the data. The authors reached a consensus on the findings' categorized data according to the details, and qualitatively described and presented the results.

Selection of articles
All the identified studies were imported into EndNote X7 which retrieved 312 studies after the removal of duplicates. After screening the titles and abstracts of the studies, 47 relevant studies with a full text were appraised according to the inclusion and exclusion criteria. After reading the full text of the articles, the authors included nine papers for evidence synthesis. One study was also added after reference screening (reference by reference) and, finally, 10 articles were included for final analyses. The details of the screening procedure are depicted in the PRISMA flow diagram in Fig. 1. Table 2 presents the details of the included studies. This corpus comprised studies that showed the capability of m-health applications in the elderly's life during this emergency situation, and also reporting factors associated with the success of m-health to ensure the application of m-health tools. The 10 studies that met the eligibility criteria had been conducted in various countries, including the Netherlands, China, Canada, United Kingdom, France, Sweden, Italy, Mexico, Portugal, and Spain. Eight studies (80%) were rated as having good quality, two (20%) had medium quality, and no study was excluded on the basis of the level of quality.

Principal findings
Our review identified precious data on how m-health technologies have been used as a means of supporting the elderly during the COVID-19 outbreak. The data analysis revealed that health organizations, researchers, and companies suggest mobile-based tools as a method of providing information [25,28], facilitating communication, remotely monitoring vital signs [28], and limiting the number of times healthcare professionals and patients need to come into close contact during the COVID-19 pandemic [24,25,28]. Furthermore, the m-health technology (text, apps, calls, etc.) is used for other purposes, e.g. connecting older people with their families and friends during social distancing [20,23,27], purchasing masks, showing the green code for traveling [24], storing health information [21], managing chronic diseases [29], making appointments [22], and creating an upbeat feeling in the elderly [23]. According to these studies, systems supporting the elderly range from simple tablet-and telephone-based systems to mostly app-based platforms [20][21][22][23][24][25][26][27][28][29]. Advantages provided by m-health tools include the ability to massively implement them in all healthcare settings [23,25,28], practicing social distancing [20], decreasing the transmission of diseases to the elderly as high-risk individuals, and reducing the   mortality and morbidity rate among the elderly during this pandemic [25,[27][28][29]. Despite the challenges, the relevance and impact of m-health solutions during the pandemic are important as they allow health service providers to effectively manage the elderly's well-being to prevent pressures on the healthcare system [20][21][22][23][24][25][26][27][28][29]. This novel contribution will provide an evidence-based exemplar for future mobile-based app development pertaining to social isolation and loneliness during crisis [23,26,28]. Generally, m-health tools for the elderly during the current pandemic are used for therapy [25,29], information provision [21,22], self-help [21,27,28], monitoring [21,28], and mental (2020) [29] Observational study

United Kingdom
Elderly patient (N=-) Smartphone-based application and web-portal (smartPDT®) Determine the accuracy of the algorithms used in the commercial SmartPDT® application Provide treatment for the common pre-malignant condition of chronic photo damaged skin actinic keratosis Creating a more convenient and reliable therapy Reducing risk in an elderly patient population during the Covid-19 pandemic health consultation purposes [20,28]. The reviewed studies reported factors associated with the use of mhealth tools by older adults during the COVID-19 pandemic. Most of the reported factors, e.g. the availability of m-health tools [22], Internet access [22,23,24], and the elderly's willingness and capabilities [22,24], are important determinants of the use of m-health tools. Meanwhile, some of the largest facilitators in the adoption of m-health technologies include support from the government and family [21,24,27,28], empowerment of the elderly, addressing the digital problems in deprived areas [20,22,24], and increasing accessibility to simple mobiles or tablets [24], which can directly contribute to the use of m-health tools by the elderly to improve their health and combat the COVID-19 outbreak.

Discussion
This review exhibited evidence on the scope of m-health capabilities in providing health services for the elderly during the COVID-19 pandemic, and reported the factors associated with the success of these tools. The majority of the included studies aimed to design and develop a mobile-based app to address the health and well-being of the elderly by addressing specific COVID-19-related issues. These included apps, web-portals, video consultations, and telephone outreach, and the research population mainly consisted of older people with social isolation and residents of independent elderly, most often in need of communication and mental health promotion. This is not surprising as many psychological problems during quarantine can be prevented through positive communication or by improving the lives of older adults [23,26].
The global confinement during the COVID-19 pandemic has highlighted the effect of social isolation and loneliness on the older population [30][31][32]. In this global isolation, European countries (United Kingdom, France, Sweden, etc.) have designed and deployed health mobile apps to assist families and peer groups in maintaining contact with older people. These mobile apps can tackle new and urgent problems in managing COVID-19, and can be applied as a valuable tool for connecting vast population geographies, especially the elderly [20]. An important issue to consider when using these online services during the pandemic is the willingness and ability of older people to utilize m-health tools. For example, older adults hospitalized in healthcare centers could independently complete phone calls but not video calls, and tended to make phone calls more often than video calls [33]. Older people use phone calls due to their inability and desire, and making video calls is difficult for them and they have problems interacting face to face. Therefore, special attention should be paid to the manner and desire of the elderly to use mobile phones in the COVID-19 epidemic so that they can use the facilities of technology and mobile health without any problems.
Our results showed that m-health tools have been potential solutions for managing the problems of the elderly during the COVID-19 pandemic. For instance, according to a study conducted in the USA, the COVID mobile app is an innovative tool for the management of longterm care facility and can help provide a new channel for real-time communication, promote the early detection of suspected COVID-19 cases, and decrease the number of deaths and confirmed cases of COVID-19 in long-term care settings [28]. Also, the results show that m-health is a more effective way than the old methods of providing services to the elderly during the current epidemic and can promote spirituality, self-growth, physical activity and improve communication the elderly with another peoples [27].
COVID-19 has been a crisis of huge proportions for health delivery services associated with chronic diseases, especially among the elderly, and online services have been recognized as a potential solution for fighting these diseases [25,29]. Van Dijk et al. in the Netherlands have designed an online Psychotherapy Day-treatment Program which provides online psychotherapy sessions, with activities, movements, and mindfulness exercises [25]. This online mobile-based program can help avoid direct physical contact, reduce the risk of exposure to infections, and prevent the potential transmission of infections to the elderly and healthcare providers during the current emergency conditions. Generally, mobile-based online tools can help healthcare institutional staff and clinicians address the COVID-19 pandemic by providing a channel for real-time communication [28].
In this review, we also presented evidence on the factors associated with the use of m-health tools for health promotion among older adults to overcome COVID-19. These factors are major determinants of the use of m-health tools by the elderly. The results of a study in China found that a growing age-based mobile digital divide of China in the last decade and in the COVID-19 pandemic, older people encountered difficulties when using mobile phones to access the internet to seek help, which highlighted the problem of the mobile digital divide [24]. According to Cenzer et al., there are some lingering problems related to the capability and willingness to participate in video visits, particularly among older adults residing in rural areas. Factors affecting the use of VA Video Connect (VVC) by the elderly include Internet access, email access, access to devices with a camera, and the capability/willingness to participate in VVC appointments [22]. To incentivize the elderly and increase their usage of m-health tools, the studies suggest that replacing computers with mobile Internet, providing government and family support, addressing the digital divide, and making educational and policy efforts to combat the COVID-19 pandemic are essential measures [22,24]. Despite the huge potential of m-health tools in the promotion of elderly health, the government and health policy-makers should resolve the mentioned challenges. This can help the management of various problems and improve the control of COVID-19 in the elderly population.

Future research
The majority of the databases reviewed here published studies about the role of m-health tools in the older population, but only a few reports focused on a specific older group during the COVID-19 pandemic. Accordingly, health organizations and researchers should pay more attention to this domain so that the elderly can be taken care of in emergency situations such as COVID-19 with the help of m-health tools. More research has to be conducted to develop and evaluate new methods, and social worker training programs should be provided to ensure that older people can access these services. During this time of crisis, more evidence on the efficacy and cost-effectiveness of m-health tools in promoting the health and well-being of older adults is required. It is recommended that future studies determine how to set up m-health in healthcare settings (e.g. home nursing and elderly care centers), and assess the elderly and healthcare professionals' satisfaction with mobilebased services.

Limitations
The use of multiple and varied outcome measures during the COVID-19 pandemic limits the reliability of judgments about the efficacy of mhealth interventions in supporting the elderly. Moreover, we did not have access to some databases such as CINAHL and PsycINFO, and could not access articles published in languages other than English.

Conclusion
The results of this review highlight the potentials of m-health tools in the promotion of health and well-being among the older population, and show that there is a variety of usages of such tools during the current pandemic. The use of m-health keeps the elderly and healthcare providers safe, accelerates health service provision, reduces the costs of service delivery, and decreases the risk of morbidity and mortality during the pandemic. Despite the advantages of using m-health tools for the elderly people, the results of this review showed that there are some challenges in the implementation of m-health to support the elderly which need attention from the government, healthcare providers, and society.

Patient consent
Not required.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethics approval and consent to participate
Not applicable.

Declaration of Competing Interest
None declared.