Study participants were recruited from the Kidney Transplant Clinic at the Medical University of South Carolina (MUSC), Charleston. Eligible patients were those who had previously received a kidney transplant, were over 18 years of age and spoke English. Between February and April 2012, 103 patients were approached during their usual post-transplant clinic visit, either by their clinical coordinator, clinic nurse or physician. Patients were asked if they were willing to speak to the study coordinator regarding participating in the survey, 99 agreed to participate. Those that declined did so either for lack of time or lack of interest. The demographic and transplant related clinical characteristics of the survey participants are summarized in Table 1. The study was approved by the MUSC institutional review board.

Patients were approached about completing a survey that included questions on their attitudes toward remote monitoring, mobile phones, electronic medication monitors and electronic home blood pressure monitors. Also evaluated were perceived levels of general stress and medication adherence (Table 1). Patients were individually shown to a private clinic space, accompanied by their informal caregivers (if present), where they were provided a description and demonstration of a prototype mHealth system with a presentation of the specific steps that were required to utilize the device (Multimedia Appendix 1).

The prototype system included a smartphone (Motorola Droid X), a wireless (GSM-enabled) medication tray (Maya MedMinder) and a wireless (Bluetooth-enabled) blood pressure monitor (Fora D15b). Patients were required to use the medication tray for all medication dispensing and to measure their resting blood pressure and pulse every third day at both morning and evening. The smartphone automatically transfers the blood pressure and pulse data to computer servers for later analysis. The medication tray is fully programmable and capable of delivering reminders in the form of light, tone, text message or phone call. Adherence is tracked in real time and can trigger the delivery of motivational or positive reinforcement messages to the patient via text, email or phone. A summary of the adherence over time can be generated and delivered via email to the patient and the treating clinician. Blood pressure and pulse readings outside predetermined safe parameters could generate automated alert messages that would be sent to both patient and physician. Participants were informed that a clinical coordinator would contact them in the event that alerts were generated.

Medication adherence was evaluated using a 7 item modified Morisky Medication Adherence Scale with an internal consistency of 0.82 and a sensitivity and specificity of 91% and 50% respectively [39]. Further description and psychometric data on the Morisky scale are described in detail elsewhere [40]. The modified Morisky scale yields a score in the range of 0 to 7 with higher scores reflecting higher adherence to medication. Scores can be categorized into high (=7), moderate (≥6 but <7) and poor (<6) adherence levels based on its criterion validity with blood pressure control among hypertensive patients [39].

Generalized perceived stress was measured using the Perceived Stress Scale in which each of the 10 items is answered using a 5 point Likert item ranging from ‘never’ to ‘very often’. The scale has established psychometric properties including internal consistency of 0.85 [41]. Internal consistency for the present study was 0.85.

The respondents’ awareness of, and attitudes toward, mHealth and telemedicine based remote monitoring were evaluated using a 10 item survey (Table 2), in which 9 of the 10 items were answered using a 5 point Likert item ranging from ‘strongly disagree’ to ‘strongly agree’. The items were adapted from prior studies assessing patients attitudes toward mobile phone based remote monitoring for chronic illness [34,36,42]. Items included questions on their perceptions of remote monitoring and their comfort with using mobile phones. Cronbach’s alpha internal consistency coefficient was 0.92 for the 9 items. The 10^th item queried their a priori awareness of health related remote monitoring technology.

Our sample was analyzed in two ways: by race, blacks versus whites (Table 3) and by attitude toward use of mHealth. Participants who answered either ‘agree’ or ‘strongly agree’ to the question whether they would use the mHealth system if it were free were compared to the participants who chose either ‘disagree’, ‘strongly disagree’ or ‘neutral’ (Table 4). Means and standard deviations for continuous variables and frequency distributions for categorical variables were used to describe the characteristics of the total sample and the racial and mHealth attitude groups. Clinical and demographic features were compared for racial and attitude groups using the pooled t test for continuous variables and the X² test/Fisher exact test for categorical variables.

The results indicate that 85% (83/98) of respondents are presently using devices at home to monitor either their blood pressure or blood sugar. Nearly two thirds of the respondents, 63% (62/99), were using medication dispensing devices (ie. standard non-signaling pillboxes). Respondents reported slightly lower than average levels of perceived stress (Table 1) that were not remarkably higher than the general population (10.0 ± 6.5 out of 40) [43]. Self-reported adherence was also reported to be moderately high (6.1 out of 7) [39]. There were no racial differences in perceived stress (P=.13), but there was a difference in self-reported adherence (P=.03).

Nearly all respondents (90%, 87/97) indicated that they already own a mobile phone and were comfortable utilizing this technology. Over a third of the patients (35%, 35/99) reported that they own a smartphone and over half (52%, 51/99) reported that they had access to a working smartphone in the household other than their own. Most of the patients (82%, 81/99), indicated that there was someone in the household who could assist them with using a mobile phone if needed.

The survey results also indicated that most respondents had a familiarity with using mobile phones for reasons other than phone calls. Amongst these, over half (61%, 60/99) used a mobile phone to send or receive text messages, 38% (38/99) to browse the web, 35% (35/99) to send or receive email and 34% (34/ 99) reported using a mobile phone to download a ringtone or a mobile application.

Only 7% (7/98) of participants had any prior knowledge of mHealth remote monitoring technology before being surveyed (Table 2). However, most of the participants felt that mobile technology would be helpful in reminding them to follow their doctor’s directions (81%, 80/99). The majority also felt that the technology would allow their doctor to make more rapid adjustments to their medication regimen (84%, 83/99). Furthermore, most of the participants, 79% (78/99), indicated that if they were provided the mHealth system at no cost and instructed on its use that they would use it as directed by their health care provider. The addition of free technical support did not significantly increase their willingness to use the devices. On the matter of health information, 80% (79/99) indicated that they were comfortable with a health care provider monitoring their health information using remote monitoring technology and 76% (75/99) felt confident that their privacy could be adequately protected. Almost all participants (95%, 94/99) felt that it was important to follow their doctor’s directions and 87% (86/99) thought that remote monitoring technology would help them effectively communicate with their health care providers about their medical conditions. When asked about how they would prefer to receive instructions from their health care providers, most respondents preferred that communication be done via phone call, with voicemail being the most common second choice. Text messaging was the third most common choice, with only a small fraction of patients indicating that they were interested in receiving instruction primarily via live video conferencing.

As shown in Table 3, when compared to whites, blacks were younger (P=.04), more likely to report hypertension as an etiology of their renal failure (P=.05), more likely to be a first time recipient of a kidney transplant (P=.02) and more likely to live nearer to the transplant center (P<.001). While mobile phone ownership did not differ significantly between races, blacks were more likely than whites to own a smartphone (P=.03). Although it did not reach statistical significance, there was a trend toward more mobile phone based internet usage among blacks (P=.08). Perceived stress levels did not vary by race (P=.13), but there was a significant difference in medication adherence with blacks reporting slightly poorer adherence (P=.03). Blacks had a slightly more positive attitude toward mHealth than whites as gauged by their willingness to use the technology if it came at no cost to them (P=.02). There were no significant differences between blacks and whites in the level of education (P=.62), annual income (P=.16) or employment status (P=.46).

Respondents who answered either ‘agree’ or ’strongly agree’ to the query as to whether they would use the mHealth system, as demonstrated, if it were free, were more likely to be employed (P=.04), the recipient of their first transplant (P=.02), already using a medication tray at home (P=.04) and the owner of a working mobile phone (P=.04). These respondents were also more likely to own a smartphone (P=.01) and to have used a mobile phone to text (P=.02), email (P=.01), browse the internet (P=.002) or download an application or ringtone (P=.03). As can be seen in Table 4, they also reported higher levels of perceived stress (P=.01).

With 90% (87/97) of respondents owning a mobile phone and 35% (35/99) owning a smartphone, this population of kidney transplant recipients closely mirrors the adult American population [46]. This finding is mildly surprising given South Carolina’s historically low household income and underscores the near ubiquitous use of mobile phone technology. Interestingly, in our cohort, while there were no racial differences in overall mobile phone ownership, blacks were significantly more likely to own a smartphone. This reflects national figures that show higher rates of smartphone adoption among racial minority groups [47]. Blacks are significantly more likely than whites to use a wireless device to access the internet [46]. As early adopters and high utilizers, blacks may be uniquely positioned to benefit from improving mHealth technology. The penetrance of mobile phone technology, particularly the rapid ascension of the smartphone [47], bodes well for the continued expansion of the mobile phone’s role in health care delivery.

Few of the kidney transplant recipients had any knowledge of mHealth technology prior to being surveyed. Despite that, the vast majority was receptive to utilizing such technology if the devices were provided at no cost. Respondents felt that having the technology would help them follow their medical regimen and improve communication with their healthcare providers, particularly with regards to the efficiency of regulating or changing their medical regime as the need arises. These findings are consistent with other studies that have evaluated the attitudes toward mHealth technology among patients with various chronic illnesses, including essential hypertension, diabetes and congestive heart failure [27,34,36].

Although there was a high receptivity toward using mHealth technology, there was a cohort of respondents who indicated a less than positive attitude. That these respondents were less likely to own a mobile phone and far less likely to own a smartphone might reflect a lower level of comfort with technology. This potential barrier to use of an mHealth system could be addressed both by making the system easier to use and by providing some skilled assistance and training. The fact that these same respondents were more likely to have had a prior kidney transplant and were less likely to be using a medication tray at home, might indicate a higher comfort level with immunosuppression medications or a lower perceived importance of medication adherence. That this cohort self-reports higher adherence with medications and lower levels of perceived stress may, in part, explain their diminished interest in the technology. Unsurprisingly, this same cohort of patients was less likely to respond positively to the remaining questions regarding comfort with being monitored, comfort with mobile phone technology, privacy protection and various aspects of utility.

These findings must be evaluated within the context of several limitations of the study. First, that all respondents were recruited from a single transplant center, which may call into question the generalizability of the findings. However, it should be noted that this center is the sole transplant service provider for the State of South Carolina and has a catchment population of over 4.6 million persons. Second, those that chose to participate might be predisposed to a positive attitude toward mHealth and thereby introduce a positive bias. The participation of nearly everyone who was approached however, suggests that a significant bias toward mHealth is unlikely. Third, it cannot be assumed that the respondents’ purported interest in mHealth will translate into actual use. Anecdotally, as we have begun to enroll kidney transplant recipients in a mHealth medication adherence trial, as a proof of concept research based on this work, we have experienced high participation and utilization rates.

This is the first study assessing the attitudes of transplant recipients with this technology and the data demonstrates that there is a positive overall attitude towards mHealth technology. Additionally, the data demonstrates that most kidney transplant recipients already own and are comfortable using mobile phones and that many of these participants already own and use smart mobile phones. Results indicate that the participants feel that mHealth offers an opportunity for improved self-efficacy and improved provider driven medical management. Participants are also comfortable with the idea of being monitored using mobile technology and are confident that their privacy can be protected. As a whole, kidney transplant recipients are receptive to the technology and believe in its utility. Further research in this area should include patient centered evaluations of usability and usefulness as well as proof of concept trials to identify areas of concern.