Opportunities and Challenges of a Self-Management App to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Qualitative Study

Background Mobile health applications can offer tailored self-management support to individuals living with chronic health conditions. However, there are several challenges to the adoption of these technologies in practice. Co-design is a promising approach to overcoming some of these challenges by enabling the development of solutions that meet the actual needs and preferences of the relevant stakeholder groups. Objective Taking spinal cord injury as a case in point, the overall objectives of this study were to identify the perceived benefits of a co-designed self-management app that could promote its uptake and to explore the factors that may impede adoption. Methods We adopted a qualitative research approach guided by the Technology Acceptance Model. Data were collected through semistructured interviews with individuals with spinal cord injury (n=15) and two focus groups with health care professionals specialized in spinal cord injury (n=7, n=5). Prior to the interviews and focus groups, study participants were given time to explore the app prototype. All interviews were transcribed verbatim and analyzed using inductive thematic analysis. Results Findings of our analysis indicate that study participants perceived the app prototype as potentially useful for supporting individuals with spinal cord injury in preventing pressure injuries. In particular, we identified three concrete use cases highlighting the benefits of the app for different audiences: (1) a companion for newly injured individuals, (2) an emergency kit and motivational support, and 3) a guide for informal caregivers and family members. We also uncovered several challenges that might impede the adoption of the self-management app in practice, including (1) challenges in motivating individuals to use the app, (2) concerns about the misuse and abuse of the app, and (3) organizational and maintenance challenges. Conclusions This study adds to a growing body of research that investigates individuals’ adoption and nonadoption behavior regarding mobile health solutions. Building on earlier work, we make recommendations on how to address the barriers to the adoption of mobile health solutions identified by this study. In particular, there is a need to foster trust in mobile health among prospective users, including both patients and health care professionals. Moreover, increasing personal relevance of mobile health solutions through personalization may be a promising approach to promote uptake. Last but not least, organizational support also plays an instrumental role in mobile health adoption. We conclude that even though co-design is promoted as a promising approach to develop self-management tools, co-design does not guarantee adoption. More research is needed to identify the most promising strategies to promote the adoption of evidence-based mobile health solutions in practice.


Introduction
Mobile health applications promise to provide tailored self-management support to individuals living with chronic health conditions. However, there are several challenges to the adoption of these technologies in practice. First, while there is an abundance of health apps freely available, the majority are not evidence-based [1,2]. This is especially true for apps aimed at individuals with disabilities [3][4][5]. There are also no clear guidelines or quality standards when it comes to mobile health (mHealth) applications. This may, in turn, discourage health care professionals from recommending them to patients [6]. Second, research has shown that individuals' use of health applications often declines over time when the initial phase of curiosity has worn off [7,8]. A potential explanation for this may be that there is a misfit of the technology leading to a lack of integration into the person's life. Third, technologies are evolving at an ever-increasing pace, yet, in health care, moving from development to adoption is a long and complex process [9,10]. This means that once a pilot evaluation is concluded, the application's design and functionalities may already be outdated and may thus fail to reproduce the outcomes of a pilot evaluation in a real-life setting.
Involving relevant stakeholder groups in the early stages of the app development process constitutes a promising approach to address these challenges [11][12][13][14]. First, co-design can ensure an evidence-guided approach to translating different stakeholders' needs and preferences into digital solutions in a meaningful way [12,[15][16][17][18][19]. Moreover, if decisions regarding content, functionality, and design are guided by real-life experiences of prospective users, this helps to ensure the appropriateness and relevance of self-management applications. Involving prospective users also fosters trust and the credibility of the technology, thus increasing the likelihood of system acceptance and, as a result, accelerating adoption into practice [20,21].
This study forms part of a larger co-design research project carried out in Switzerland. The project aimed to develop an evidence-based self-management app to support community-dwelling individuals with spinal cord injury (SCI) in the prevention of pressure injuries. SCI is a complex chronic health condition that makes individuals prone to incurring secondary health conditions. Pressure injuries are among the most common and serious secondary health conditions in people with SCI [22][23][24]. In addition to a number of nonmodifiable risk factors (eg, natural skin aging) [25], self-management plays a key role in the prevention of pressure injuries [26,27]. The overall objectives of this study were to identify the perceived benefits of the self-management app that could promote its uptake and to explore the factors that may impede its adoption.

Study Design
This study forms part of a larger mixed-methods study that combined qualitative research methods (ie, semistructured interviews) into user-centered design approaches (ie, ideation workshop, design sprints, usability tests). Figure 1 illustrates the methodological approach of the overall project. Detailed descriptions of the app development process have been published elsewhere [5,28]. This paper focuses on assessing the perceived utility and acceptance of the app prototype that resulted from the previous phases of this project. The study was approved by the cantonal ethics commission (EKNZ 2017-01787).

Data Collection and Analysis
Following a convenience sampling approach, we conducted 15 semistructured interviews with individuals with SCI and two focus groups with health care professionals specialized in SCI (n=7; n=5). Both individuals with SCI and health care professionals were given time to explore the app prototype (see Multimedia Appendix 1 for screenshots of the app prototype) prior to the interviews/focus groups. People with SCI first took part in a usability test [28] that allowed them to explore the app prototype in more depth. Healthcare professionals received a brief introduction to the main functionalities and elements of the app by the first author (JA). They could then freely explore the app prototype in pairs for 15 minutes before the focus group discussion. The interview and focus group guides were informed by the constructs of the Technology Acceptance Model [29]. In particular, we aimed to capture participants' views regarding usability and perceived usefulness of the app prototype, as well as their attitudes and intentions toward using the app. In this paper, we focused our analysis on identifying concrete benefits of the app that could promote its uptake and exploring the factors that may impede its adoption into practice. Results of a preliminary usability test of the co-designed self-management app are reported elsewhere [28].
All interviews and both focus groups were conducted in German by the first author (JA), who is a native German speaker and communication scholar trained in qualitative research methods. All interviews and both focus groups were audio-recorded. Additionally, a research assistant was present during all interviews and focus groups to take notes. Interviews lasted 33 minutes on average, ranging between 17 and 69 minutes. Focus group 1 (FG1; n=7) lasted 100 minutes, and focus group 2 (FG2; n=5) lasted 97 minutes. In total, 687 minutes of audio material were transcribed verbatim for analysis.
Data were analyzed using inductive thematic analysis [30]. For this purpose, initial line-by-line coding was carried out by the first author (JA). In this initial coding phase, we aimed to identify instances where participants described situations where they either would personally use or could imagine someone else engaging with the self-management app. In the next step, we focused on uncovering the factors that may impede adoption by focusing on those instances where participants voiced concerns or challenges. Starting from the initial coding and in line with our research objectives, we identified preliminary themes and subthemes, which were continuously refined through discussion in regular meetings involving all coauthors.

The App Prototype
The interactive web-based app prototype evaluated in this study is the result of a multistage co-design process [5,28]. It includes five main features: (1) a smart camera, (2) a pressure injury diary, (3) an expert consultation, (4) reminders, and (5) a knowledge repository.
As such, the app prototype comprises features that can be used independently by people with SCI (eg, documenting pressure injuries, setting reminders), as well as a communication component that allows for interaction with Parahelp, a home care service provider specialized in SCI care. (See Multimedia Appendix 1 for screenshots of the app prototype.)

Participants
Within the scope of the overall project, we aimed to involve a balanced sample of participants in terms of age, gender, lesion level for people with SCI, and health care professionals' expertise [28]. Prospective participants were identified through the local rehabilitation center (Swiss Paraplegic Center), patient association (Swiss Paraplegic Association), and home care provider specialized in SCI (Parahelp). Additionally, we launched a call for participants on the Paraplegie Community [31], an online community for people with SCI initiated and funded by the Swiss Paraplegic Foundation. All participants received detailed information on the study and signed a consent form. Study participants' characteristics for the interviews and focus groups are presented in Table 1 and Table 2, respectively.

Overview
Findings of our analysis indicate that both individuals with SCI and health care professionals saw potential value in the self-management app prototype. Study participants acknowledged its usefulness for different life situations and target groups, including newly injured individuals and experienced wheelchair users, as well as informal caregivers. In addition, we also identified some of the key factors that could impede the app's adoption into practice. In the Results section, we illustrate our findings using quotes from the interviews and focus groups, each followed by a participant identifier. With the exception of the theme "Organizational and maintenance challenges" (which was predominantly present in the focus groups with health care professionals), themes occurred fairly equally in both groups. Thus, when we refer to "study participants," this encompasses both individuals with SCI and health care professionals.

A Companion for Newly Injured Individuals
Wheelchair users and health care professionals concurred that individuals who recently suffered a spinal cord injury, for example, those who are completing or have recently completed first rehabilitation, could particularly benefit from the app as a complementary measure to traditional patient education.
The app could be complementary [to traditional patient education], yes. So the nurses could introduce the app to patients, maybe those that are not so much into paper-based information sheets and prefer something more interactive. [B,FG2] One of the participants with SCI underlined how the app could support people who were recently injured in processing information at their own pace and in their own time. In recalling her own experiences from first rehabilitation, the participant described how the app could contribute to fostering patient autonomy and self-determination. Another important aspect that participants noted was that the app could help to lower individuals' inhibition thresholds when in need of medical assistance or advice. In other words, they described the app as a low-key means of getting in touch with evidence-based knowledge and a health care professional at times or in situations where one might otherwise feel uncomfortable. Given that newly injured individuals in particular may not immediately recognize the seriousness of an early-stage pressure injury or may be embarrassed to seek help, participants noted that the app could support these individuals in early detection before the situation worsens. Both individuals with SCI and health care professionals also pointed out that the app could help newly injured individuals to build and adopt new habits to better self-manage. Building these new habits after partial loss of functioning is key to effective self-management. Wheelchair users attributed particular value to the reminder function as a potentially powerful habit-building assistance that can provide structure and introduce new routines into someone's life.

An Emergency Kit and Motivational Support
Individuals with SCI highlighted that the app could be particularly useful under extraordinary conditions (ie, outside of their daily routine). According to them, these were situations where even experienced wheelchair users might be hesitant or unable to use their usual means of contact (ie, telephone call).
Frequently mentioned examples of such extraordinary circumstances were during holidays abroad, where one might not trust the foreign health care system, or when fallen ill. Wheelchair users also described nighttime and weekends as situations where the app could potentially come in handy. These views were shared by the health care professionals. They also noted that the app could support wheelchair users in recognizing skin problems at an early stage. According to them, the app could help to reduce the risk of individuals waiting too long to get in touch by providing them with easy access to health care providers' expertise. In this context, health care professionals emphasized the benefits of being able to receive images (ie, using the smart camera feature), allowing them to get an idea of how serious the situation is. Both wheelchair users and health care professionals described refreshing one's memory and extending knowledge on pressure injury prevention as key benefits that could promote self-management, particularly among more experienced wheelchair users. In addition, being able to learn from one's own experience by reflecting on past experiences or behaviors (ie, through self-documentation in the pressure injury diary) was mentioned as a potential motivational boost to become more self-aware and attentive.

A Guide for Informal Caregivers and Family Members
According to the study participants, informal caregivers could also benefit from using the app as a tool to learn more about spinal cord injury and the risk of pressure injuries. They suggested that the app could allow caregivers to better understand the manifold challenges that individuals with SCI face and propose ways to better support them in their daily life. In this context, both wheelchair users and health care professionals mentioned practical aspects that could help to increase knowledge and skills among caregivers and, as a result, improve support for people with SCI. In their remarks, participants touched upon the importance of shared responsibility of care and the related need to provide caregivers with evidence-based information and practical support. When comparing how information was currently provided to family members (ie, a bulky informational brochure) to the possibilities that the app would offer, health care professionals agreed that it would make information retrieval easier. They argued that an app could easily be used on the go, at any time, even just out of boredom. According to them, this may not only help family members to save time when looking for information but may also incentivize them to do so. Most importantly, the app would provide them with curated, evidence-based information. One study participant with SCI also referred to the potential of the app to address emotional aspects that are of great importance for the psychological well-being of people with SCI and the people around them alike. In his view, the app could help to foster understanding and empathy for individuals with SCI.
Yes, for all those in wheelchairs and this could also be interesting for the family, provide a clear overview, or for people who are not directly but indirectly affected through someone they know. That

Motivating Individuals to Use the App
Established attitudes and behavioral patterns of people with SCI toward pressure injuries constitute potential obstacles. A key challenge we identified relates to onboarding or, in other words, motivating both experienced and newly injured individuals to use the app. Healthcare professionals voiced concerns that wheelchair users may, in fact, only start using the app once they experience skin problems. This raises questions as to how to best engage newly injured individuals in early preventive measures.

I see it very much as an acute approach, "If something happens to me, I have a red spot, uh. I know here [in the app] I might find an answer." [F, FG2]
In line with this, some of the wheelchair users noted that they didn't consider themselves a primary target audience. In this context, some noted that frequent reminders in the form of pop-up messages could easily become annoying. Drawing on their own experiences, wheelchair users explained that they had internalized important preventive behaviors and knowledge. While they could see the potential benefits of the app for others, both newly injured and experienced, they themselves indicated that they would not need the app.

I don't really need reminders as a support, I actually do everything quite independently. Sometimes you notice that it wasn't enough pressure-release and that you have to do something else again -so, no, I don't need something like that [an app to remind me]. [P2]
Similarly, the secure contact function was viewed as beneficial, yet many wheelchair users noted that under ordinary conditions, they would rather see a health professional in person or call them in case of an emergency. A key consideration in case of an emergency was to choose the quickest and simplest way to get professional assistance, and according to some, this may not necessarily be through the app's contact function.

Many people are afraid [to call]. But with me, if I want to know something, I usually call quickly. And I know I can find it somewhere on the website myself, but I don't have time. Just tell me quickly and done. [P4]
If I had a pressure injury, I'd take a picture of it. I had one once and I was told to take a picture of it when I called. My friend took a picture of it quickly.

The question is, how fast will it be handled when I put it into an app or when I call, what is the better or faster way, that's what I'm wondering. [P6]
In relation to behavioral and attitudinal barriers, health care professionals raised another important issue they encountered in their daily work: "regular clients" (ie, patients who regularly have problems and often have to be hospitalized because of these problems). According to them, this group of patients would use pressure injuries as a means of attracting attention, sometimes even consciously manipulating wounds to receive care. They considered it unlikely that these individuals could be motivated to use the app, let alone benefit from the app to prevent pressure injuries.

Concerns About Misuse and Abuse of the App
Study participants expressed concerns that the app could potentially be misused and that both patients and health care professionals could fall victim to such misuse. On the one hand, they worried about privacy and data protection issues that prospective app users would be facing. In particular, participants raised questions regarding the storage, sharing, backup, and deletion of personal data. However, these concerns were not shared by all participants. For instance, one study participant with SCI noted that the stand-alone use of a smartphone with mobile data enabled would already compromise personal privacy. He thus did not consider the collection of data through the self-management app problematic but rather a necessary requirement to provide adequate support. In addition to privacy concerns impacting the user, some study participants were concerned about the potential misuse of the app by patients and the negative impact this could have on health care professionals. In particular, they worried about excessive messaging from people with SCI without actual skin problems. According to the study participants, the fact that it would easier to initiate contact may lower individuals' inhibition thresholds, thus increasing the risk that some people might contact health care professionals for irrelevant information or just to talk to someone.

Organizational and Maintenance Challenges
When discussing what was needed to bring the app into practice, health care professionals also referred to organizational problems, including the difficulty of integrating the app with currently used systems. They feared that the adoption of the app might increase their workload (eg, having to reenter existing information). Healthcare professionals were also unsure of how to securely identify their clientele and worried about managing resources. Here, it is important to note that unlike other home care providers, Parahelp has a specific care mandate, meaning that only individuals meeting predetermined criteria are entitled to receive assistance from Parahelp (ie, persons with spinal cord injury). Determining whether these conditions are met was highlighted as a core challenge by health care professionals.
You have to be able to make a query to determine: does this person belong to our target audience or not. Because if you can't have a professional make the selection, then we'll suddenly have everyone in the chat. And then it [workload] explodes. [F,FG1] With regard to the challenges of integrating the app into practice, some health care professionals also pointed to weaknesses in the app's content. For example, the lack of information on psychological aspects was criticized. The maintenance and further development of the app were also heavily discussed. In particular, health care professionals were concerned about how information would be kept up to date and who would be responsible for ensuring information accuracy. They agreed that the app content should be regularly checked to ensure that it contains the latest evidence-based information. However, it was unclear who would be responsible for this task.

Exactly, so I think the possibility for developments and new innovations -because this is also evolvingthis would need to be included [in the app]. It just has to be taken up somehow. [B, FG2]
A: But then who feeds the whole thing [

Principal Findings
This study identified the perceived benefits of a co-designed self-management app for the prevention of pressure injuries that could promote its uptake and shed light on the factors that may impede its adoption in practice. It is one of the first studies on the perceived opportunities and challenges of a mobile health application to support individuals with spinal cord injury in the prevention of pressure injuries. By capturing both the perspectives of people with spinal cord injury and health care professionals, it complements earlier work, which has predominantly focused on assessing patient views [32] and compliance with app-based interventions [33].
Study participants perceived the app as potentially useful for supporting individuals with SCI in preventing pressure injuries. In particular, we identified three concrete use cases highlighting the benefits of the app: (1) a companion for newly injured individuals, (2) an emergency kit and motivational support, and (3) a guide for informal caregivers and family members. In addition, we also uncovered several challenges that might impede the adoption of the self-management app in practice, including (1) challenges in motivating individuals to use the app, (2) concerns about the misuse and abuse of the app, and (3) organizational and maintenance challenges.

Fostering the Adoption of Self-management Apps
It seems intuitive that a self-management app can be experienced as empowering and motivating by some while being deemed useless or even annoying by others. Similarly, some health care professionals may welcome an app as a promising alternative, while others may worry about increased workload. What can be done to capitalize on the app's perceived benefits and to reduce barriers to uptake? Several studies have addressed this question more generally by developing frameworks aimed at improving the uptake and impact of eHealth technologies [14,34]. Drawing on our findings and Greenhalgh et al's nonadoption, abandonment, scale-up, spread, and sustainability framework [34], we propose three promising strategies to address the barriers to adoption identified by this study ( Figure  2).

Promoting Trust in mHealth Solutions
Findings of this study showed that both participants with SCI and health care professionals had concerns about the data protection and privacy of the app. Individuals with SCI in particular were worried that personal health information might be shared with third parties without their explicit consent. These findings indicate that trust in the app's commitment and adherence to data protection and privacy plays an important role when it comes to adoption. In this context, transparency plays a central role [35,36].
To create trust in an app's commitment and adherence to data protection, users need to be informed about the kind of data being collected, ownership of and control over the data, and their right to have their data deleted. All this information needs to be accessible to prospective users in a clear and concise format, informing them about their rights to access and control their data. However, how personal information is handled by mobile health apps often remains unclear [37][38][39]. Some apps, for example, track and share user data continuously by default, even when the app is not in active use, sometimes without explicitly informing users about these tracking practices in their terms of use [39]. A recent study [36] that investigated end users' opinions on what constitutes a trustworthy mobile health app found that users interpreted lengthy terms of service and privacy policies as an attempt by developers to obscure possible risks. Moreover, the study showed that users perceived apps that request "too much" personal information as untrustworthy.
Tools like the mHealth App Trustworthiness checklist [36] can help to guide developers in creating trustworthy apps to foster the adoption of mHealth solutions. Visualization techniques might be promising approaches to make privacy information more accessible, making it easier for users to understand how apps collect, use, and share data. Also, a privacy by design approach that allows users to opt in for data sharing and enables granular permissions could help to strengthen user privacy [39] and, as a result, foster trust. Last but not least, the credibility of the provider (ie, the organization behind the app) will also likely have an impact on prospective users' trust. To further strengthen prospective users' trust, authors have also proposed to include logos of reputable organizations endorsing the app (eg, universities or hospitals) [40].

Providing a Personalized User Experience
Our findings showed that established attitudes and behavioral patterns of individuals with SCI constitute potential barriers to adoption. "Why use an app to contact a health care professional when I can just WhatsApp them?" "Why would I need a reminder to check my skin after having done it for the past 20 years?" "Why do I need the app? I never had problems with my skin." These are the kind of questions prospective users might ask themselves. All of these questions hint at an important aspect: value. How can we create value for a diverse user group ranging from newly injured individuals to experienced wheelchair users, from those that constantly struggle with pressure injuries to those who have never experienced any problems with their skin? This is where personalization comes in.
Personalization technologies can help to better tailor the self-management app to an individual user's needs and preferences [41] by ensuring that recommendations regarding preventive measures are perceived as relevant and actionable rather than generic advice. In matching an individual's preferences and lifestyle, personalization can lower barriers to act on recommendations. Contextualization can ensure that interventions (eg, in the form of recommendations) are delivered at moments of need (eg, long time with low activity levels) or at an opportune moment when a particular recommendation is easy to follow (eg, when leaving work) [42,43]. While personalization is a familiar concept in health communication, artificial intelligence and machine learning techniques offer unprecedented opportunities to take personalization to the next level [42,44,45]. These techniques can then be used to translate population-level data alongside individual user data to provide a personalized user experience, similar to recommendation systems like Netflix [41,42]. However, for personalization to be realized, users are required to disclose personal information [46]. Such information may include personal information that users actively enter themselves (eg, age, gender) but it may be complemented by information on app usage through tracking (eg, how often or when the app is used).
It is, however, important to acknowledge the limits of personalization. What personalization likely cannot achieve is motivating download and first-time use. This is where health care professionals have to step in to promote and endorse the app. However, in order to encourage health care professionals to endorse the app, it is first important to obtain their buy-in. To this end, it will be important to demonstrate that the app allows health care professionals to better support their patients in effectively reducing pressure injuries (ie, by supporting self-management and early detection). Moreover, it will be essential to show that the app will not impose an additional burden on health care professionals, leading to increased workloads.

Ensuring Organizational Support and Interoperability
It is important to consider that in the case of an app that enables communication between patients and health care providers, there are two prospective user groups: senders and receivers. Even though many of the app's features can be used by people with SCI independently, the communication component requires uptake from health care professionals as well. Findings of our study indicate that health care professionals were particularly concerned about challenges in integrating the proposed solution with currently used systems and worried about additional workload to reenter existing information. Additionally, there were also concerns about inappropriate use of the app that could lead to overburdening of staff.
Given the crucial role of health care professionals' acceptance of new technologies, it is of utmost priority to take these concerns seriously and to respond to them in an adequate manner. In addition to ensuring the technical requirements are met, including issues related to system operability, organizations also need to ensure that new systems can be smoothly integrated into existing workflows [47]. Organizations may also want to establish technical training and support to deal with cases of malfunction or inappropriate use [48]. This would allow health care professionals to feel that support is available and may help to reduce concerns over increased workloads.
Close to the completion of our own project, we realized that we had invested a lot of time and resources to understand what the user interface (ie, the front end of the application that individuals with SCI would interact with) should look like. However, our findings indicated that we had neglected to consider the administrative interface (ie, the back end of the application operated by health care professionals). In other words, we had not collected sufficient information on the internal workflows of the care provider Parahelp to determine whether and how the app could actually be integrated into their daily practice. In the current app prototype, we also did not consider reimbursement aspects, which constitute a relevant factor for adoption but, at the same time, trigger many other organizational questions.

Limitations
This study is subject to some limitations. First, we need to acknowledge that our research was focused on a narrow, specialized health care setting in Switzerland. However, while our findings may not necessarily be directly applicable to other health care settings or health conditions, they have relevant implications for mHealth research more broadly. In particular, the strategies we identified to promote the adoption of evidence-based mHealth solutions lend themselves to inform research on self-management apps in other areas. Second, two focus group participants (both affiliated with Parahelp) had been involved in the co-design process of the app prototype at an earlier stage of the project. This may have led them to hold more favorable attitudes toward the project and possibly steer the focus group discussion in this direction. To account for this potential bias, we made it clear that critical scrutiny would help us to identify potential weaknesses of the app prototype, which would in turn foster improvement. Lastly, we need to acknowledge that the characteristics of the wheelchair users with SCI who participated in this study may have had an impact on our findings. While we aimed for a balanced sample of wheelchair users in terms of age, gender, and lesion level, we cannot rule out the possibility that participating individuals may have had overall more favorable attitudes toward mHealth solutions than those who did not take part. While findings of this study may not reflect the views of the Swiss population with SCI, they provide the basis for further investigations at a population level.

Conclusion
Findings of this study indicate that even though co-design seems to be a promising approach to develop self-management tools that meet the needs of different stakeholder groups, it does not guarantee adoption. To fully harness the potential of a co-designed mHealth self-management solution and to overcome barriers to adoption, further efforts are needed. In particular, there is a need to foster trust in mHealth solutions among prospective users, including both patients and health care professionals. Moreover, increasing the personal relevance of mHealth solutions through personalization may be a promising approach to driving adoption. However, with data-driven approaches, such as machine learning, several ethical questions need to be considered, including but not limited to issues of autonomy, data protection, and privacy. Last but not least, organizational support and financial concepts also play a key role in mHealth adoption, particularly in the clinical context.