Mobile educational follow-up application for patients with peripheral arterial disease

ABSTRACT Objective: to describe the development of a prototype mobile educational application for nursing follow-up aimed at patients diagnosed with peripheral arterial disease. Method: a prototype-based technological production study. The construction followed the contextualized instructional design model using two steps: analysis and design and development. Results: the pedagogical content of the application was based on a survey of needs of patients with Peripheral Arterial Disease and treatments recommended in the literature. The prototype developed contained concepts, risk factors, signs and symptoms, treatment, importance of medications and their side effects, frequent doubts, necessary health care, and follow-up of patients by monitoring the evolution of the cicatricial process of lesions and possible complications, clarification of doubts and stimulus for continuation of treatment. Conclusion: the use of health applications is a technological tool with the potential to improve the follow-up of patients regarding the progress of the disease and self-care, monitoring of risk factors, co-participation of the patient in the treatment, family participation, as well as planning of individualized care, and cost reduction for the health system.


Introduction
Mobile web or mobile connection entered the market in the year 2000 and is defined as wireless technology to access information and applications anywhere and anytime through mobile devices such as cellphones, smartphones and tablets (1) .
Mobile computing can be used in many health care areas such as support to medical and nursing diagnosis, decision making, electronic medical record of the history of medical examinations, diagnoses and consultations, assessment of nursing workload, drug stock control, bed management, besides the focus on patient support with consultation/return reminders via Short Message Service (SMS), remote monitoring, pain management, post-discharge follow-up, reduction of ambulatory consultations in long-term treatments, stimulation to adherence to treatments and healthy life (2)(3) .
In this context, there are studies that highlight the use of mobile applications via smartphones for postoperative follow-up in order to identify possible surgical complications. These follow-up takes place through photos, guidance and clarification of doubts regarding the use of medications, monitoring of potential adverse events such as postoperative pain and complications (3)(4) .
Monitoring patients with chronic diseases is especially important to reduce costs with surgical interventions and complications that can be avoided. One example is Peripheral Arterial Disease (PAD), a chronic obstructive process mainly caused by atherosclerosis.
The regions of the body most affected by PAD are the lower limbs. However vascular disease is responsible for cardiovascular and cerebrovascular complications.
The reduced blood supply in peripheral arteries is responsible for symptoms of intermittent claudication (IC) and resting ischemic pain (5)(6) .
In Brazil, the annual estimate of PAD is 0.053% of the population of men aged 55-74 years and women aged 65-74 years (7) . The asymptomatic evolution of PAD can reach up to 70 to 80% of patients. This delays and hinders early diagnosis. Early diagnosis, in turn, is essential for the identification of risk factors and changes in lifestyle in order to improve the effectiveness of treatment, reduce the risk of complications such as ulcers and early amputations, and ensure the quality of life of patients (8) .
Many PAD patients are often observed to make telephone calls to the inpatient unit to resolve their doubts, to confirm that the guidelines received are correct, or they go to the inpatient unit to seek help.

Communication and information via Web 3.0 and
Mobile Applications (Apps) in the health area can be a facilitator of the health services' functioning dynamics.
They can reduce or avoid displacement, reduce demands on the health network, minimize aggravation due to lack of therapeutic support, and facilitate referral and counter-referral, thus improving the link with the Health System and with a care planning focused on the patient's need.
Web 3.0 consists in the generation that allows the organization, reuse and replication of data about the user at any time and anywhere, being able to interact through the analysis of information provided by the user (9) .
Health education aims to increase people's autonomy and ability to intervene in their own lives.
Information and Communication Technologies (ICTs), in turn, have the potential to contribute significantly to improving access to quality services and at the same time, reduce costs (10)

Method
This is a prototypying technology production aimed at building an educational mobile application by scientific rigor. The nursing treatment provided in a teaching hospital in southern Brazil in a surgical clinic unit that serves patients with peripheral arterial disease was used as reference for this study, from May to November 2017.
The development of the study was organized and guided according to the Contextualized Instructional Design (CID) model (11) , which consits in providing tools and resources to reach learning needs. This model to the contents, didactic resources, interface of the environment, and maintenance (11).
In turn, the application was developed in two stages: 1) analysis and 2) design and development.
They are described below: Stage I -analysis: in this stage, the needs of patients with PAD were identified (12) , particularly those Catarina under the number 76825717.8.0000.0121, and authorization was requested from the author (12) to use the unpublished data of her study.

Results
The results are presented according to the construction steps: Stage I: doubts of PAD patients were identified based on a previous study (12) . The doubts were related to knowledge about the disease, life habits, difficulties    (22)(23)(24)(25)(26)(27) .
Other studies present the contribution of physical exercise as a therapy to improve walking distance without presenting intermittent claudication and an increase in the Ankle-Brachial Index (ABI) in the short-and medium-term associated with pharmacological treatment and/or intervention (28)(29)(30)(31) .
As for therapies recommended for the treatment of PAD, we evaluated the association of eight therapies: antiplatelet agents, statins, angiotensin converting enzyme inhibitors, blood pressure control, lipid control, diabetic glycemic control, cessation of smoking, and body mass index. It was also evidenced that the involvement of vascular surgeons, family physicians, and patients with PAD favored a positive result for reduction of cardiovascular risk and lower limb complications (25) .
At this stage, we also sought to carry out technological prospecting by analyzing similar Apps aimed at the pursuit of a healthy life for patients and/ or individuals. We evaluated 30 Apps aimed at several segments ( Figure 2).

Area of influence Applications
Practice of physical exercise Daily tips, intensity-organized training, calorie counters, weight assessment, cycling routes, online personal trainer Nutrition Recipes, guidance on food substitution, calorie control, stimulus to water intake Wellness Improvement of sleep quality (amount of hours, use of alarms to signal the moment of falling asleep and waking up and music), relaxation (movements, breathing)

Medications
Medication-time-intake alarm system, dose, guidance on side effects, drug interaction, history, maps indicating the nearest private and/or popular pharmacy Diseases Prevention of skin cancer with the possibility of identifying sites that have spots and photographic registration, medical information of dermatological diseases; support for women with breast cancer; follow-up for patients with rheumatoid diseases with measurement of mood, pain, morning stiffness, daily functionality and fatigue, interaction with health professionals, glycemic control and blood pressure monitoring; registration with health data such as chronic diseases and allergies that may be useful in emergencies; stimulus for cessation of smoking, informing how many days the patient has been free from the addiction

Women's health
Gestational follow-up, with tips, descriptions of the baby's evolution, menstrual calendar, schedules for organization of baby/child care such as immunization and growth control through recording measures, breastfeeding     (32) . In this sense, the follow-up and the idea of knowing the patients better, smoking, and lack of medication and dressing materials in the Basic Unit.
Abstinence from smoking is seen as a fundamental pillar in the treatment of PAD, since smoking influences the development of cardiovascular complications in three different levels: fat plaque progression, inhibition of endothelial repair processes and inhibition of angiogenesis (33) .
Low purchasing power was listed as a justification for not maintaining a healthy diet, interrupting medication use, and difficulties in hiring a caregiver (12) .
A study (34) shows the difficulties patients face to adhere to a healthy diet, including their preference for carbohydrates and sugars instead of fruits and vegetables, the ease of acquiring processed foods, which are of low cost, the lack of time to prepare foods, not to mention the wrong idea that healthy eating is not tasty and diet is a sacrifice.
Other studies (35)(36)  The follow-up was carried out by telephone for 28 days and provided clarification of doubts, benefiting the recovery of patients at their homes, as well as increasing safety for family members and caregivers (37) .
In another study with 136 patients diagnosed with asthma and allergic rhinitis using a mobile platform as a tool for rapid patient-professional interaction through message exchange, health status recording and drug use monitoring demonstrated a considerable impact on outcomes of health and quality of life; there was a decrease in the number of hospital admissions, frequency of medical consultations, and loss of productivity (38).
In this sense, nurses are clearly important in the health education of patients, to improve adherence to treatment. Thus, mobile technologies for follow-up are currently useful, easy-to-access, wide-ranging, real-time and low-cost tools.
Advances in the development of mobile technology and health communication have been considered an effective strategy to encourage patients to adopt healthy lifestyles, to provide counseling on the disease, to stimulate self-care, to strengthen conditions for chronic diseases, and to reduce time and cost for patients and for the health system (39) .
A study on the use of mobile applications to stimulate behavior changes such as healthy eating, with increased consumption of fruits and vegetables, and realization of physical exercise, showed a positive association with life habits. However, the study pointed out that the main users of the applications are young people of high socioeconomic power and educational level (40) . In line with these findings, a study with an App for young adults with idiopathic juvenile arthritis encouraged self-management and increased the involvement with health care, besides high levels of acceptability and usability (41) .
A study about the efficacy of cellphone and tablet applications in self-management of symptoms of chronic diseases made it possible to show an improvement in the health status of patients living with symptoms of diabetes mellitus, cardiovascular diseases and pulmonary diseases (42) .
Discussing the application of mobile services, a study (43)