Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation





First Advisor

Dr. Chung L. Misook


Consumer-facing mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patient engagement with mHealth apps in real-world settings and the effect of such engagement on HF outcomes, making it challenging to inform decision-making regarding the use of mHealth apps in real-world settings.

The specific aims of this dissertation were to; 1) examine current evidence on measures of engagement with mHealth interventions in patients with HF; 2) examine the patterns of patient engagement with a consumer-facing mHealth app and the predictors of engagement in real-world settings;3) identify factors that predict time-to-attrition from mHealth intervention in real-world settings; 4) to examine the effects of the engagement on medication adherence and incidence of rapid weight gain;5) explore patients’ experiences using a consumer-grade mHealth app for HF self-care in a real-world setting.

Specific aim one was addressed by a scoping review of the literature to synthesize current evidence on measures of patient engagement with mHealth interventions. Patient engagement with mHealth intervention was measured objectively based on frequency, intensity, or duration of intervention use; and subjectively based on data from semi-structured interviews and focus groups. Specific aims two to five were addressed using a retrospective longitudinal mixed-method study that examined engagement with a consumer-grade mHealth app, OnTrack to Health app, in 229 patients with HF. Patient engagement decreased over time. Cost-sharing, attainment of target doses of HF medications, and being a long-term user were positively associated with patient engagement. Increasing medication adherence, the number of staff-initiated and patient-initiated secured Short Message Service (SMS), and attainment of target doses of HF medications were associated with a longer time to attrition from mHealth intervention in a real-world setting. Patient engagement was not significantly associated with the rates of changes in medication adherence over time or incidence of rapid weight gain over time.

Specific aim six was addressed by using a qualitative design approach to describe the experiences of 23 patients with HF who were provided OnTrack to Health app as a part of routine HF management. Patients were satisfied with using Ontrack to Health for self-care. They perceived the features of the app as valuable tools for enhancing self-care ability, facilitating patient-provider communication, and decreasing hospitalization rates.

The findings of this dissertation suggest that patient engagement with mHealth apps in real-world settings decreases over time. Patients would sustain their engagement with mHealth apps that act as an enabler in achieving self-care goals. The findings also show mixed findings on the effects of patient engagement on HF outcomes, which may be explained by the inability of objective measures of patient engagement to capture comprehensive patterns of patient engagement. Additional research is needed to develop objective measures of patient engagement that may effectively capture patterns of patient interactions with features of mHealth apps.

Digital Object Identifier (DOI)

Funding Information

April 2021 College of Nursing Ph.D. Dissertation award

Nov 2019 Delta Psi Chapter, Sigma Theta Tau Research Award

August 2017 - May 2021 University of Kentucky College of Nursing Fellowship

Available for download on Saturday, August 10, 2024