Received: 1 April 2019 | Revised: 18 October 2019 | Accepted: 3 December 2019

DOI: 10.1111/jan.14287

ORIGINAL RESEARCH: CLINICAL TRIAL

The impact of an mHealth app on knowledge, skills and anxiety

about dressing changes: A randomized controlled trial

Hsiao-Yun Chang RN, PhD, Professor1 | Ya-Ping Hou NP, MN, Nurse Practitioner2 |
Fu-Hao Yeh PhD, Associate Professor3 | Su-Shin Lee MD, Associate Professor4

1
School of Nursing, Fooyin University,
Kaohsiung, Taiwan Abstract
2
Department of Nursing, Kaohsiung Medical Aims: To evaluate the effectiveness of a mobile health (mHealth) application, based
University Hospital, Kaohsiung, Taiwan
on self-regulation theory, on patients’ knowledge of wound care, skills in changing
3
Department of Information Technology,
Fooyin University, Kaohsiung, Taiwan
dressings and anxiety.
4
Division of Plastic Surgery, Department Design: A prospective randomized controlled trial.
of Surgery, Kaohsiung Medical University Methods: Seventy patients (or family members) at a 1,500-bed university hospital
Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan in Taiwan were randomized into an experimental (N = 35) or control group (N = 35)
from March to December 2016. The experimental group used a mHealth applica-
Correspondence
Hsiao-Yun Chang, School of Nursing, Fooyin tion for wound care; the control group received verbal instructions and a booklet.
University, 151 Jinxue Rd., Daliao Dist., Instruments to collect data were a wound care knowledge scale, wound care skills
Kaohsiung City 83102, Taiwan (ROC).
Email: [email protected] scale, State-Trait Anxiety Inventory, and a digital heart variability device. Data were

Funding information
collected at baseline, after three additional demonstrations and before discharge.
The study was supported by Fooyin The generalized estimating equation was used for statistical analysis.
University (FYU1300-105-20).
Results: The experimental group showed significantly higher levels of wound care
knowledge, improved wound care skills, lower levels of state anxiety, and lower heart
rate variability than the control group after baseline data collection.
Conclusions: Results support hat a mHealth application may be effective in health
education. Clinicians can use the results to promote patients’ wound care knowledge,
enhance their wound care skills, and reduce anxiety related to dressing changes.
Impact: Lack of wound care knowledge and skills can affect the willingness and abil-
ity to perform effective wound dressing changes, producing anxiety and having an
impact on a patient's self-care after hospital discharge. mHealth applications (apps)
have the potential to deliver health information in targeted and tailored ways that
strengthen the self-management of diseases. mHealth app can increase wound care
knowledge, improve care skills, and reduce anxiety related to wound care. mHealth
app effectively supports self-monitoring of the wound healing process, self-judge-
ment of the wound condition, and self-reaction of wound care accuracy. mHealth app
provides step-by-step visual tutorials on wound care that allow patients and family
caregivers to take pictures of the wounds and monitor the wound healing process.
mHealth app for wound care knowledge is an effective and individualized method
for learning.

The peer review history for this article is available at https​://publo​ns.com/publo​n/10.1111/jan.14287​

1046 | © 2019 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jan J Adv Nurs. 2020;76:1046–1056.
CHANG et al. | 1047

Clinical Trial: This study was registered by U.S. National Library of Medicine,
ClinicalTrials.gov (ID: NCT03683303).

KEYWORDS

anxiety, health education, nursing, self-regulation theory, Taiwan, telemedicine, wound healing

1 | I NTRO D U C TI O N patients and families to self-care with a versatile and individualized

approach (Silva, Rodrigues, Torre Díez, López-Coronado, & Saleem,
Wound infections are common postoperative complications after 2015). mHealth applications (apps) have the potential to deliver
hospital discharge. They not only significantly decrease a person's health information in targeted and tailored ways that strengthen the
quality of life (Badia et al., 2017) but also account for 22.1% of un- self-management of diseases (Gunter et al., 2018).
planned hospital readmissions in the USA (Kassin et al., 2012), re-
sulting in an increase in financial burden and healthcare costs (Badia
et al., 2017). Lack of knowledge and skill can contribute to a per- 1.1 | Background
son's readiness to change wound dressings safely and effectively
after hospital discharge, thus affecting their self-care ability (Fearns, mHealth apps provide benefits for both healthcare providers and
Heller-Murphy, Kelly, & Harbour, 2017). Regardless of wound size, receivers by transforming how health information and services
people experience anxiety when faced with wound care at home. are delivered, managed, exchanged, and stored. Friesen, Hamel,
Family caregivers can also be fearful of making mistakes when and McLeod (2013) undertook a survey to study the benefits of
changing wound dressings (Reinhard & Levine, 2012). using an app on chronic wound care by nursing staff (healthcare
In Taiwan, traditional extended families are multigenerational, providers) with varying levels of experience. They identified three
living together, or in close proximity (Scroope, 2016). Family mem- types of potential benefits of the app: providing remote consul-
bers, who customarily stay with hospitalized relatives, have mutual tation, organizing, and analysing wound data with text-based and
obligations and supportive responsibilities related to the Confucian graph-based wound and providing tutorial support for nonspecial-
concepts of filial piety or guanxi [strong social networks]. When pa- ized caregivers. Wound care apps that help healthcare providers
tients are discharged from hospital to home, there are expectations acquire accurate wound care knowledge based on current pro-
for family members, when possible, to be caregivers. Therefore, fessional standards and guidelines can increase their confidence
both patients and family caregivers need education about changing and expertise (Cottom, 2014; Jordan, McSwiggan, Parker, Halas,
wound dressings to optimize their skills, recognize abnormal condi- & Friesen, 2018).
tions, and alleviate fear (Kirkland-Kyn et al., 2018). For healthcare recipients, mHealth apps have the ability to direct
Anxiety and stress can affect a person's ability to concentrate and the learning needs on particular areas of interest or concerns of pa-
respond appropriately (Almonacid, Ramos, & Rodríguez-Borrego, tients and family caregivers in the scope of wound care information
2016). There is evidence that different forms of psychological and available in the app. Recent mHealth apps have focused on measur-
behavioural stress hinder wound healing based on hormonal dis- ing wounds (Foltynski, 2018; Gunter et al., 2018; Wang et al., 2017)
ruptions and other impairments to physiologic processes (Gouin & and selecting wound dressings (Jordan et al., 2018). In one qualitative
Kiecolt-Glaser, 2012). Prior to hospital discharge, a comprehensive study (Sanger et al., 2014), respondents expressed the view that an
assessment of physiological and psychological factors should be mHealth app would be acceptable to use, provide comprehensive in-
undertaken with attention to whether the treatment and care will formation, and facilitate communication that could reduce post-dis-
cause a life burden to patients and family caregivers (Fearns et al., charge anxiety compared with the current practice. Thus, mHealth
2017). Stress can be amenable to psychological interventions to pro- apps have the potential to affect health management and health be-
mote healing (Robinson, Norton, Jarrett, & Broadbent, 2017). haviours, particularly by providing health knowledge and encouraging
Health education about changing wound dressings is usually ini- health behaviour change (Free et al., 2013; Yi, Kim, Cho, & Kim, 2018).
tiated before discharge. Health education for patient self-manage- It is important to recognize that mHealth apps are different
ment has traditionally relied on face-to-face instruction by nurses from traditional verbal health education because users can seek and
or nurse practitioners (NP) with print media that are distributed apply targeted text and visual content at their virtual disposal, such
to patients. The knowledge content of these materials is typically as remote wound monitoring using the digital images of a wound to
general and not individualized. More contemporary approaches to improve learning and stimulate interest (Gunter et al., 2018). This
health education and healthcare delivery involve computer tech- contributes to users acquiring relevant and accurate wound care
nologies, digital multimedia, and mobile telecommunications. The knowledge (Ye et al., 2016). To our awareness, however, there was no
emergence of mobile health (mHealth) provides customized health- mHealth app for patients’ or family caregivers’ health education on
care delivery that is more timely and convenient and empowers wound care before hospital discharge prior to undertaking this study.
1048 | CHANG et al.

Self-regulation theory relies on observation and judgement patient and caregiver during self-care activities (Buck et al., 2018). The
through self-monitoring, self-judgement, and self-reaction to in- caretaker may need to assume management of a wound until the pa-
dividuals’ behaviours (Clark, Gong, & Kaciroti, 2001). Setting clear tient regains self-management. Alternatively, the family caregiver
and feasible goals for problems, using strategies to achieve these co-participates in the patient's self-regulation as a partner who sup-
goals and evaluating this progress can enable people to strengthen ports self-managing wound care. Regardless of the health condition,
their ability in self-managing health with the support of healthcare self-regulation theory still functions in the dyadic relationship. Figure 1
professionals (Febbraro & Clum, 1998). The theory emphasizes a details how the theory was integrated into the app's construction.
person-centric approach, in sequence from defining the question,
judging individual behavioural/environmental problems and devel-
oping strategies to solve problems (Clark et al., 2001). Three pro- 2 | TH E S T U DY
cesses are related to self-regulation:
2.1 | Aims
1. Self-monitoring is the process of identifying the causes of
behaviour and consequent effects through systematic obser- The aim of this study was to evaluate the effectiveness of a mHealth
vation of self-behaviour and recording of behavioural problems application on patients’ or their family caregivers’ knowledge of
(Bandura, 1991). It is key to the success of self-regulation. wound care, skills in changing dressings and anxiety.
2. Self-judgement is the process of comparing observed behav-
iours with standard behaviours (Bandura, 1991) and determining
whether the behaviours, psycho-physiological status, or envi- 2.2 | Design
ronmental relationships require corrective response (Clark et al.,
2001). It is based on what problems were self-identified during This study employed a randomized control trial with a single-blind,
self-monitoring. experimental design. Participants were unaware of which group
3. Self-reaction is the process of coping to potential threats uncov- they had been assigned.
ered in the stage of self-judgement (Bandura, 1991). Self-reaction
can be an action (behavioural modification), response to the en-
vironment (situational readjustment), or a psychological response 2.3 | Participants
(acknowledgement/self-affirmation) (Clark et al., 2001).
Two co-authors identified patients targeted for home discharge from a
The relationship continuum that can exist between patients and plastic surgery ward for plastic and reconstructive wound operations
family caretakers varies based on supportive interdependencies. This (e.g., skin grafts, pressure ulcers, trauma, burn/friction ulcerations) at
can occur spontaneously in the context of dyadic engagement between a 1,500-bed university hospital in Southern Taiwan from March to

mHealth App for wound care

Wound care instructions Individualised wound care Wound healing record

(Self-monitoring) (Self-judgment) (Self-reaction)
Step 1: Preparation

Step 4: Apply dressing or ointment

Step 5: Wound coverage

Step 2: Remove the dressing
Basic wound care knowledge

Wound dressing introduction

Individual wound image

Step 3:Wound cleaning

Common wound characteristics compared

F I G U R E 1 mHealth application
program for wound care. mHealth, mobile
health
CHANG et al. | 1049

December 2016. Inclusion criteria were adults aged ≥20 years who and content presentation (Figure 1). mHealth was successfully
understood Mandarin Chinese, ability to see and read text and colour beta-tested on five patients/families prior to implementation. The
images on a smartphone, a wound classification score of 6–10 points app requires 1.5 Mb with up to 5 Mb of text and storage of images
(Strauss et al., 2016), required self-care of wound at home and self- 1,280 × 720 pixels. The experimental group received mHealth on
reported familiarity with using an Android smartphone. Exclusion cri- their smartphones by matrix barcode or email.
teria were comorbidities (e.g., severe infection, compression injuries Mobile health's opening screen presents three links with the
severe mental illness) requiring special care. Sample estimation based theoretical terminology (Figure 1). Users self-select requisite knowl-
on the multivariate analysis of variance (F test) was calculated using edge by scrolling through content (self-monitoring). Users review
the G*Power 3.1 software. Each group had at least 31 people. The their own dressing change procedure as demonstrated by the
effect sizes of the study variables ranged from 0.26–0.53 (α = 0.05, wound care NP (self-judgement). Using the phone's camera, the app
power = 0.85). The convenience sample of 70 participants was ran- attaches photos sequentially to the last photo taken so that par-
domly assigned to an experimental or control group (Figure 2). The ticipants can observe the procedure and progress in wound heal-
concealed allocation was done by drawing lots from a computer-gen- ing. Individualized descriptive text can be attached to the photos
erated list of numbers. The 70 participants were blinded after assign- (self-reaction). To standardize the process, only one wound care
ment to one of the two groups; none withdrew from the study. NP interacted with participants for their health education using the
mHealth app. Actualization of the intervention is described in the
data collection and wound education section.
2.4 | Technology and experimental intervention

Mobile health was built on the Android programming platform be- 2.5 | Control intervention
cause of its dominant market penetration in Taiwan (Statcounter,
2017). The apps’ user interface operationalizes self-regulation the- The control group received the usual health education of verbal
ory by its underlying code that follows a syntax and structure to pro- instructions and a standard booklet for discharge planning by the
vide the conceptual logic of the overall layout, screen sequencing, wound care NP. They received the same basic information to prepare

Randomised 70 Participants
(Caregivers: N = 36, Patients: N = 34)

Experimental Control group

group (N = 35) (N = 35)

Completed the questionnaire, began

data collection (pre-test,T1)

Instruction
mHealth App
Booklet

After three additional

Lost case (N = 0) Lost case (N = 0)
demonstrations

Fill in the questionnaire and

collect data (post-test,T2)

Lost case (N = 0) Lost case (N = 0)

Before discharge

Fill in the questionnaire and

collect data (post-test,T3)

F I G U R E 2 Flow chart of data Analysed (N = 35) Analysed (N = 35)

collection process
1050 | CHANG et al.

them to change the wound dressings at hospital discharge. They also systems and humeral factors (Chalmers, Quintana, Abbott, & Kemp,
received the same process of wound demonstrations by the wound 2014). When the level of anxiety is high, physiological effects in-
care NP (Data collection and wound education). The control group clude not only a decreasing heart rate variability but also high-fre-
had no visual record of the wound care procedure as a learning rein- quency power; whereas BP, heart rate, low-frequency power, and
forcement tool nor did they have photos of their wounds as a daily the ratio of LF/HF may increase (LF/HF↑) (Koenig & Thayer, 2016).
reference of wound healing. The manufacturer's representative trained the wound care NP on
using the digital device.

2.6 | Validity and reliability of instruments

2.7 | Data collection and wound education
All participants responded to a baseline questionnaire on socio-de-
mographics and clinical characteristics: age, gender, occupation, ed- Figure 2 displays the study's process. Ten to 28 days prior to
ucational level, marital status, diagnosis, type of wound, wound site discharge (pre-test T1, baseline), the wound care NP asked par-
and size, post-operative wound infection (yes-no), past experience in ticipants (patients or family caregivers) to complete the question-
wound care (yes-no), and past experience in wound care education naire/instruments and then measured physiological variables.
(yes-no). The primary outcome measures were collected using the While the NP watched, participants initiated a dressing change
following instruments: based on observations when their primary care nurse had per-
formed wound care. The NP recorded the baseline skill level, ap-
1. Wound Score (Straus et al., 2016) measures wound base, size, plied a new dressing and explained the 5-step procedure as the
depth, bio-burden, and perfusion, each on a 0–2 scale, then normative procedure participants should follow (preparation with
summed. Lower scores indicate more serious wounds. The verbal instruction; dressing removal; wound cleansing; dressing/
wound care NP assessed all wounds. ointment application, based on wound type; wound coverage). A
2. Wound Care Knowledge Scale (Li, 2008) is an unpublished 16- family member took wound photos using the mHealth app at each
item scale in Mandarin, with self-report yes-no responses used step. Participants learned the required steps of wound care to be
by Shao (2013) and Liu (2016). More frequent ‘yes’ responses able to identify potential problems and healing (Self-monitoring).
indicate higher levels of wound care knowledge. The reported The app becomes a visual record for later reference to reinforce
content validity index was 1.00 for its feasibility, 0.94 for defi- learning and monitor the wound.
niteness, and 0.98 for appropriateness. For our study, Cronbach's After T1 (Table 1) and during the 6–18 days with average of
alpha for internal reliability was 0.73. 9 days prior to time 2 (post-test T2), the wound care NP demon-
3. Wound Care Skills Scale (Chen, 2010) is an unpublished 11-item strated the dressing change procedure another three times. At post-
scale in Mandarin assessed by the wound care NP during dressing test T2, the participants completed the instruments for the second
changes (three time periods). Higher scores indicate higher levels time and then the NP measured physiological variables. Participants
of wound care skills. The reported content validity for each item gave the NP a return demonstration showing an understanding of
ranged between 0.8–1.0. For our study, Cronbach's alpha for in- the procedure, similar to the Teach-Back Method (Peter et al., 2015);
ternal reliability was 0.85. if skill deficits were observed, the NP would intervene. Participants
4. State-Trait Anxiety Inventory (STAI) (Spielberger, Gorsuch, compared self-behavioural performance with ideal standards of be-
Lushene, Vagg, & Jacobs, 1983) measures trait and state anxi- haviour (Self-judgement).
ety. We used only the 20-item, self-report state anxiety subscale After T2 and during the 4–11 days with average of 7 days prior
in Mandarin (Cao & Liu, 2015). Higher scores indicate increased to time 3 (post-test T3), the patient's primary care nurse changed
state anxiety. Cronbach's alpha for internal reliability was 0.95. the dressing. At post-test T3, either the day of discharge or the day
5. Seven physiological variables for anxiety were measured by having before, participants completed the instruments for the third time
the wound care NP place a digital device on a participant's wrist and the NP measured physiological variables. Participants also per-
with the sensor placed over the left apical pulse (ANSWatch®, formed a final return demonstration for the wound care NP, hope-
Taiwan Scientific Corporation; certified by the Department of fully more confident based on successful behaviour modification
Health Medical Device, Taiwan Ministry of Health and Welfare, (Self-reaction).
permit number 001525): (a) Heart rate, (b) heart rate variability in
time intervals between heartbeats, (c) systolic blood pressure (BP),
(d) diastolic BP, (e) low-frequency power (LF), (f) high-frequency 2.8 | Research ethics
power (HF) for the sympathetic and parasympathetic nervous sys-
tems and (g) LF-HF ratio for the degree of sympatho-vagal balance. Prior to undertaking the study, the appropriate university ethics
committee approved the research (KMUHIRB-E(II)-20160030).
Decreased heart rate variability indicates higher levels of anx- Volunteers signed informed consent forms describing possible risks
iety based on sympathetic and the parasympathetic nervous and benefits from participating and that they could withdraw from
CHANG et al. | 1051

TA B L E 1 Comparison of demographic characteristics in the experimental and control groups

Total Control Experimental

Variables N Mean (SD) N Mean (SD) N Mean (SD) t p

Age 70 47.1 (13.87) 35 49.7 (12.95) 35 44.5 (14.47) 1.58 .120

3
Wound size (cm ) 70 26.1 (10.42) 35 24.1 (10.44) 35 28.2 (10.13) −1.69 .097
Strauss score 70 8.5 (0.76) 35 8.6 (0.88) 35 8.5 (0.61) 0.95 .346
T1-T3 interval 70 16.9 (3.69) 35 17.3 (3.86) 35 16.5 (3.51) 0.97 .335
T1-T2 interval 70 9.8 (3.27) 35 10.5 (3.39) 35 9.1 (3.05) 1.74 .086
T2-T3 interval 70 7.1 (1.7) 35 6.9 (1.68) 35 7.3 (1.78) −1.17 .245
2
N % N % N % χ p

Sex 0.23 .629

Male 40 57.1% 21 60.0% 19 54.3%
Female 30 42.9% 14 40.0% 16 45.7%
Occupation 0.07 .967
None 8 11.4% 4 11.4% 4 11.4%
Employment 37 52.9% 18 51.4% 19 54.3%
Housewife 25 35.7% 13 37.1% 12 34.3%
Education level 9.32 .097
≤Junior school 14 20.0% 9 25.7% 5 14.3%
High school 23 32.9% 14 40.0% 9 25.7%
Technical school 17 24.2% 9 25.7% 8 22.9%
≥University 16 22.9% 3 8.6% 13 37.1%
Participants 0.37 .946
Spouse 19 27.1% 9 25.7% 10 28.6%
Adult children 12 17.1% 6 17.1% 6 17.1%
Patients 34 48.6% 18 51.4% 16 45.7%
Other family members 5 7.1% 2 5.7% 3 8.6%
Sites of wound 3.15 .369
Face/neck 6 8.6% 2 5.7% 4 11.4%
Upper limb 11 15.7% 8 22.9% 3 8.6%
Lower limb 43 61.4% 20 57.1% 23 65.7%
Body 10 14.3% 5 14.3% 5 14.3%
Types of wound 2.82 .589
Ulcer 21 30.0% 8 22.9% 13 37.1%
Skin graft 13 18.6% 8 22.9% 5 14.3%
Burn/friction 15 21.4% 9 25.7% 6 17.1%
Pressure ulcer 3 4.3% 1 2.9% 2 5.7%
Trauma 18 25.7% 9 25.7% 9 25.7%
Infection during hospitalization 0.56 .454
No 45 64.3% 21 60.0% 24 68.6%
Yes 25 35.7% 14 40.0% 11 31.4%
Wound care education 0.07 .799
No 47 67.1% 23 65.7% 24 68.6%
Yes 23 32.9% 12 34.3% 11 31.4%
Wound care experience 0.06 .811
No 35 50.0% 17 48.6% 18 51.4%
Yes 35 50.0% 18 51.4% 17 48.6%
1052 | CHANG et al.

TA B L E 2 Comparison of mean scores between the experimental and control groups at pre-test T1, first post-test T2, and second post-
test T3

Control (N = 35) Experimental (N = 35)

Effect
Variables Time Mean (SD) Mean (SD) B (95% CI) Wald χ 2 p size d

Wound care T1 9.1 (3.10) 9.3 (2.65) .869a

knowledge T2 12.3 (1.68) 13.6 (1.26) 1.14 (−0.08, 2.37) 3.35 .067b
T3 14.2 (1.32) 15.8 (0.38) 1.51 (0.19, 2.84) 5.01 .025b 0.56
a
Wound care skills T1 11.2 (3.38) 12.0 (4.41) .397
T2 16.0 (2.31) 18.9 (2.20) 2.03 (0.78, 3.28) 10.10 .001b 0.82
b
T3 19.3 (1.45) 21.7 (0.44) 1.60 (−0.04, 3.24) 3.65 .056
Wound care anxiety T1 46.5 (12.27) 44.7 (12.56) .546a
(STAI) T2 40.3 (9.77) 29.9 (6.16) −8.57 (−12.36, −4.79) 19.69 <.001b 1.25
T3 34.9 (8.77) 23.0 (2.72) −10.11 (−14.70, −5.53) 18.70 <.001b 1.21
a
Heart rate T1 78.8 (10.05) 80.5 (10.56) .502
T2 75.4 (7.72) 77.9 (8.36) 0.89 (−2.38, 4.15) 0.28 .595b
T3 77.3 (7.26) 76.9 (9.20) −1.97 (−4.53, 0.59) 2.27 .132b
Systolic blood T1 135.8 (19.05) 133.1 (19.99) .568a
pressure T2 135.4 (18.94) 132.3 (19.06) −0.54 (−3.52, 2.43) 0.13 .721b
T3 136.6 (20.61) 129.5 (18.74) −4.46 (−9.56, 0.65) 2.93 .087b
Diastolic blood T1 81.3 (10.62) 83.1 (9.55) .464a
pressure T2 79.8 (10.10) 80.5 (9.25) −1.06 (−3.73, 1.61) 0.60 .438b
T3 77.5 (9.55) 77.7 (8.74) −1.54 (−4.23, 1.14) 1.27 .260 b
Heart rate variability T1 40.4 (19.84) 46.4 (19.45) .191a
T2 40.5 (17.94) 49.3 (19.19) 2.74 (−0.62, 6.11) 2.55 .110 b
T3 41.3 (17.83) 51.0 (20.39) 3.69 (0.13, 7.24) 4.14 .042b 0.50
a
Low frequency (LF) T1 62.2 (12.36) 61.9 (14.39) .928
T2 59.5 (12.63) 59.00 (13.55) −0.26 (−2.18, 1.66) 0.07 .793b
T3 59.4 (12.18) 57.4 (11.87) −1.69 (−3.98, 0.61) 2.08 .150 b
High frequency (HF) T1 41.5 (12.14) 41.8 (12.08) .928a
T2 45.5 (11.13) 44.4 (10.28) −1.34 (−2.77, 0.08) 3.40 .065b
T3 46.8 (11.35) 47.7 (9.48) 0.66 (−1.61, 2.93) 0.32 .570 b
LF/HF T1 1.6 (0.81) 1.6 (0.73) .938a
T2 1.4 (0.50) 1.4 (0.56) 0.05(−0.12, 0.21) 0.33 .565b
T3 1.3 (0.50) 1.2 (0.48) −0.06 (−0.24, 0.12) 0.42 .516b
a
Based on independent samples t test.
b
Based on the generalized estimating equation test using pre-test T1 as a reference (group × time).

the study at any time without penalty or affecting post-operative on self-care knowledge, skills, and anxiety in participants because
wound care. If a family caregiver was to be the participant, both time intervals varied slightly between each data collection time pe-
patient and caregiver signed consent. No harmful effects were ob- riod. Statistical significance was set at p < .05. All data were analysed
served in the study. using IBM® SPSS® version 22 software.

2.9 | Data analysis 3 | R E S U LT S

Descriptive and chi-square statistics tested for homogeneity of There were no reported issues about mHealth's interface, storage,
the variables. Independent samples t tests compared differences camera, lighting, or loss of data. There were no significant differ-
between the two groups at each time period. The generalized es- ences at baseline between the experimental and control groups for
timating equation was used to test the effects of the intervention age, occupation, educational level, wound size, wound site, type
CHANG et al. | 1053

of wound, hospital infection, and wound care education (Table 1). 4 | D I S CU S S I O N

Neither were there differences in wound care knowledge, skills,
state anxiety (STAI), and physiological measures at baseline (Table 2). This study shows beginning evidence for the effectiveness of an
mHealth app on increasing wound care knowledge and skills and
reducing anxiety compared with traditional health education meth-
3.1 | Wound care knowledge ods for patients and/or family caregivers with the responsibility of
changing a wound dressing at hospital discharge. Effective learning
Participants in both intervention and control groups significantly im- or the magnitude of difference between traditional and mHealth
proved their wound care knowledge between their own respective become more apparent at the second post-test time period. Skill ac-
time periods of pre-test T1, post-test T2, and post-test T3 (all t tests quisition of wound care, on the other hand, occurred more quickly
p < .001). There was no notable increase in knowledge between with both groups, but the magnitude was greater for mHealth users.
groups at (T1) and (T2) (B = 1.14, p = .067). However, Table 2 shows Gunter et al. (2018) reported on the use of an image-based mHealth
that the interaction of the groups with time between T1 and T3 was protocol for post-operative wound monitoring; however, its purpose
significant (B = 1.51, p = .025). Figure 3 shows that the magnitude of was the detection of wound complications and participants’ satisfac-
knowledge increased significantly more in the experimental group tion, making comparisons with our study difficult.
than in the control group. Acquiring the requisite psychomotor skills of changing wound
dressing, coupled with increasing access to the mHealth's knowl-
edge bank, bring greater expertise more efficiently to users of the
3.2 | Wound care skills mHealth app than through traditional education methods. Effective
learning requires repeated demonstrations under an expert nurse's
Results of t tests similarly indicated that participants in both inter- guidance who can review the steps of dressing changes (Self-
vention and control groups improved significantly their skill levels in monitoring). Learning is reinforced when patients evaluate their own
wound care between their own respective time periods of pre-test wound photos stored in the mHealth app and can compare them
T1, post-test T2, and post-test T3 (all t tests p < .001). Table 2 shows with optimal healing (Self-judgement).
that the interaction of groups and the time between (T1) and the Repeated viewing of an individual's own wound care process on
first post-test (T2) was significant (B = 2.03, p = .001). Although the an mHealth app deepens the impression of the procedures in wound
level of wound care skills was higher in the experimental group than dressing changes. Increasing both knowledge and skills together,
in the control group, the magnitude of change in the second post- brings a sense of expertise to app users. This affects state anxiety.
test (T3) only approached significance (B = 1.60, p = .056). Sanger et al. (2014) indicated there is a need to reduce a person's
anxiety about wound dressing. We show that an mHealth app can
effectively lower a person's state anxiety about changing wound
3.3 | Wound care state anxiety (STAI) dressings prior to hospital discharge.
State anxiety was affected more than its physiological mea-
Again, results of t tests indicated that participants in both interven- sures. We had expected a correlation between anxiety, heart rate
tion and control groups significantly decreased their state anxiety variability, and other measures (Koenig & Thayer, 2016). Heart rate
between their own respective time periods of pre-test T1, post-test variability is influenced by the main endogenous, exogenous, and
T2, and post-test T3 (all t tests p < .001). Table 2 shows that the constitutional factors, such as age, body weight, sexual hormones,
interactions of groups and the time between the pre-test (T1) and breathing, acute psychological stress, chronic diseases, caffeine use,
the first post-test (T2) and between T1 and the second post-test (T3) and drugs (Sammito & Böckelmann, 2016). We did not consider a
were each significant (B = −8.57, p < .001; B = −10.11, p < .001, re- history of chronic diseases (such as hypertension or diabetes), men-
spectively). Figure 3 shows that the magnitude of decrease in anxi- strual cycle, or numerous lifestyle factors. In clinical settings, pa-
ety in the experimental group was greater than in the control group. tients’ heart rate variability may be affected by their physiological
and psychological condition (such as the white coat effect), resulting
in uncontrolled changes in heart rate variations.
3.4 | Wound care anxiety (physiological measures)

When comparing the first and second post-test data (T2, T3) in both 4.1 | Limitations
groups to their own respective pre-test data (T1), only heart rate,
diastolic BP, low-frequency power, high-frequency power, and LF/ Although a double-blind study might strengthen future research de-
HF ratio reached statistical significance (p < .05). Table 2 shows that signs, it was not practical under the circumstances. Resources did
only the interaction of both groups and the time between pre-test not permit extending the evaluation of learning retention of wound
(T1) and the second post-test (T3) for heart rate variability was sig- care and anxiety reduction after hospital discharge to the home.
nificant (B = 3.69, p = .042). Including only participants familiar with smartphones narrowed the
1054 | CHANG et al.

Wound care knowledge Wound care skills

Score Score

20.00
25.00

15.83
13.60 21.74
15.00
18.86
20.00
9.26
10.00 14.20
12.34
19.34

9.14 15.00
Experimental
5.00 16.03
12.00 Experimental
Control
Control
11.20
0.00 10.00
T1 T2 T3 Time
T1 T2 T3 Time

State-trait anxiety inventory

Heart rate variability
Score Score

50.00 46.54 55.00

Experimental
51.00
Control 49.26
40.34 50.00
46.43
40.00
44.74
34.94 45.00

40.00
30.00 40.51 41.31
40.43
29.97 35.00 Experimental

23.03 Control
20.00 30.00

T1 T2 T3 Time T1 T2 T3 Time

F I G U R E 3 Mean scores of knowledge, skill, and anxiety related to wound care and distribution across 3-time periods for experimental
and control groups

number of participants, although the age spread did not indicate an the wound condition, and self-reaction of wound care accuracy.
age bias. The mHealth app is currently available only for the Android The app enables patients and family caregivers to watch for signs
operating system, albeit the worldwide market shares of Android of infection, learn practical procedures for wound care, and in-
(76.08%) is greater than iOS (22.01%) (Statcounter, 2019). Future crease their self-care ability about wound care. The advantages
studies should consider patient satisfaction (Gunter et al., 2018), ef- of mHealth are that it makes health education accessible without
fects on quality of life, clinical outcomes, and usage rates. barriers of location and time, whereas traditional health education
booklets are easy to set aside, misplace and lack customized adapt-
ability. The content of health education via mHealth app can be ad-
5 | CO N C LU S I O N justed and modified daily according to individual requirements by
patients taking photos of wound dressing changes, attaching tai-
A patient-centric mHealth app can be an individualized tool to lored descriptive text and recording their wounds to observe the
educate patients on wound care before discharge. It supports progress in healing. This is an innovative trend in clinical healthcare
self-monitoring of the wound healing process, self-judgement of education.
CHANG et al. | 1055

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care of emergency traumatic patients. (Unpublished master’s thesis).
Our appreciation is extended to the participants who gave so much
Taichung City, Taiwan, ROC: China Medical University.
of their valuable time and thoughts in this study. We acknowledge Clark, N. M., Gong, M., & Kaciroti, N. (2001). A model of self-regulation
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The authors declare that they have no competing interests.
thesis). Bozeman, USA: Montana State University.
Fearns, N., Heller-Murphy, S., Kelly, J., & Harbour, J. (2017). Placing
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responsibility for appropriate portions of the content. HYC, YPH https​://doi.org/10.1016/s0272-7358(97)00008-1
Foltynski, P. (2018). Ways to increase precision and accuracy of
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wound area measurement using smart devices: Advanced app
tant intellectual content; agreed to be accountable for all aspects Planimator. PLoS ONE, 13, e0192485. https​://doi.org/10.1371/journ​
of the work in ensuring that questions related to the accuracy or al.pone.0192485
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