Use of Mobile Health Applications and the Self-Management of Cancer: A Gendered Approach

The growing use of mobile health applications for health purposes increased the expectations about their effectiveness. The study examines the effectiveness of mobile health applications on the self-management behaviors of 168 individuals diagnosed with cancer. The results of a secondary analysis indicate that using extensively mobile health applications significantly increases women’s health empowerment attitudes—reaching health decisions, changing their approach to health concerns, seeking additional health consultation. However, the use of mobile health applications does not increase the likelihood of adopting self-management behaviors. The study indicates that the effectiveness of mobile health applications in self-management practices is contingent upon a set of personal characteristics and the level of technology skills.


Introduction
The rapid development of communication technologies and the widespread dissemination of information has affected individuals and the health sector. The internet has increased individuals' possibilities providing quick access to online health information and online health services and offered them a better perspective on a particular health condition, treatment or medication [1] [2] [3]. Approximately 81% of US adults use the internet, 59% admit to searching online for health information and 35% have gone online to determine what medical condition they or someone else may have. In Europe, some 7.4% of the population reported contacting a family doctor, specialist or other health professionals tion needs and preferences [29], the "masculine" technology restrains women from fully capitalizing on Mapps.
In this study, we examine the importance of gender differences in the use and effectiveness of Mapps in the self-management of cancer. We consider the possibility that women diagnosed with cancer who need to access health-related information and address daily functions, are less likely to capitalize on the use of Mapps to address their condition. As a result, the benefits of preventive online and offline medical health support [30] [31] for women are reduced lowering the likelihood for effective self-management of cancer [9] [24] [32].

Background
The rise of the information society and the adoption of the internet have the capacity to reduce existing health inequalities [33] because technology devices have become a significant means of health self-management because they serve many health goals [34]. This is especially evident in the growing use of mobile technology supporting eHealth and mHealth platform for health purposes narrowing gaps in access to information and services [1].
Technology skills enable individuals to capitalize on technology-based applications [6] such as those available in Mapps help people access relevant information on health concerns and health services [7], provided and that socio-demographic characteristics such as age [4], cultural variations [1] and gender [9] [35] do not limit the extent of Mapps use. The literature discussing the use of technology makes two alternative and contradictory predictions.
According to the normalization hypothesis, these skills help individuals with chronic diseases to search for more information [9], consult online rankings or reviews [36], engage in online health-related activity [37] and exchange information with others who have similar health concerns. Thus, the use of Mapps decreases gaps in health information and services [30] [38]. In contrast, the techno-feminism approach suggests that technology may increase the discrepancies between those who do and do not possess the skills necessary to capitalize on technology. In this case, Mapps will not necessarily provide greater health empowerment and improved self-management for individuals who lack the necessary skills or place less trust in virtual health sources [30] [38] [39]. As a result women with cancer may not be able to overcome the technology barrier and will therefore be less willing to rely upon this medium to address the self-management of cancer [9] [40].

Technology Use and Chronic Disease
Empirical evidence regarding the effect of Mapps on individuals diagnosed with chronic diseases (hereafter CDs) is limited and contradictory [9]. On the one hand, individuals with chronic disease use digital technologies to search for updated and innovative solutions to their health conditions. Nevertheless, their use of digital health services is limited [30] [31]. As a result, individuals with chronic disease are less likely to adopt self-management behaviors, after using Mapps [32]. Indeed, evidence of the direct effect of Mapps on health behaviors remains inconclusive, raising concerns regarding the extent to which Mapps adequately serve the health concerns of specific chronic disease groups [30] [31]. The Health Belief Model offers an important theoretical approach for understanding these contradictory findings.
The Health Belief Model (HBM) uses a set of constructs to consider the impact of perceived threat [40] and perceived benefits associated with the probability of adopting a particular behavior [41]. Perceived threat refers to a situation in which individuals assess they are at risk of some threat to their health [42]. Items used to measure this construct include evaluations that you or someone in your close circle is vulnerable (e.g., a history of disease in the family or the likelihood that your close partner will contract a disease) [40]. The association between HBM constructs and health outcomes was assessed for gender-mixed samples, but the evidence for individuals diagnosed with chronic conditions is contradictory [43].
On the positive side, ample evidence indicates that individuals with a medical condition are more motivated to search for health and medical information about their condition, its symptoms and their meaning, medication side effects and effectiveness, and even alternative treatments. This motivation increases the odds of monitoring a health problem in time or providing timely access to lab test results [18] [33]. Existing studies show, that a heart condition [44], diabetes [45], cancer [46] [47] and other long-term conditions are more likely to use Mapps to communicate with health care providers so they can receive feedback and social support and tracking (e.g., graphical displays of uploaded personal data). On the negative side, other studies indicate that the use of technology devices to provide health services falls short of their intended purposes and fails to provide effective health services [30] [38] [39]. Indeed, for specific chronic disease such as cancer [46] [47], heart conditions [44], diabetes [45] and other long-term conditions [48] [49], lower medication adherence and less health care utilization have been observed [50]. Hence, we hypothesize that: H1: A cancer diagnosis will increase the likelihood of Mapps use.

Gendered Effects on Mapps Use
The issue of gender in health-related internet use is a main area of studies in the fields of internet sociology and public health, with ample evidence indicating that female users are more likely to search for health information than male users [1]. The odds of men using virtual sources of health and consulting online rankings are lower than for women [36], and consistent findings indicate that women use the internet for health purposes more than men [1] [18]. These consistent findings on gender effects derive from assumptions regarding women's traditional role when it comes to health-related issues both within and outside the family [9] [25]. Women are indeed more likely to engage in selective processing of information and carefully weight advantages and disadvantages of technology use [1] [28] [51]. In fact, it is important to understand the influence of technology-embedded communication in terms of "friendly" or "unfriendly" means of communication.
First, gender is a central parameter that affects the digital divide because women are more likely to prefer face-to-face communications. Second, gender has been associated with how people evaluate information and determine the extent to which it is practical, costly or effective in daily activities [9] [19].
Gender may sustain or block health information included in Mapps [22]. Studies show that women seek a higher level of "gratification" regarding health concerns [26] [27], as explained by women's unique internal mental workings and communication style. Women are highly discerning about the scope of their internet use. They are likely to search different sites to use information in different ways [30] [34] and for several persons at once including family and community members [34]. These gender-based differences in communication uses may affect the "perceived functionality" of Mapps. Hence, we hypothesize that: H2: Gender differences will manifest in the extent of Mapps use.
Virtual sources of health are apparently an efficient means for attaining health information (best process), although not necessarily the most effective means (best outcome). According to the functionality assumption, women who use traditional information sources-newspapers, physicians' advice, and books-can also use the internet to expand their knowledge. In fact, the internet is a complementary source of health information rather than as a substitute for more traditional media sources [1]. Thus, a state of "critical consciousness" regarding the existing health situation prevails which combined with the evaluation of available resources activates the process of health related search and use of technology. Women's willingness to use Mapps to access health services may indeed reflect the perceived risks because beliefs about health risks and benefits are a strong predictor of an individual's potential to exercise control over health practices, especially when health concerns are present. As a result, women "comply" with the source of health information only when the benefits outweigh the barriers [51] [52] [53] [54]. It is due to these contradictory reports that some recent studies suggest that Mapps overlook or misunderstand the specific needs of individuals with chronic diseases [30]. Women's cancer conditions may affect their willingness to use Mapps to access health services since knowledge about health risks and benefits for different health issues is a strong predictor of the need to exercise control over health practices, especially in the presence of health concerns. Thus, gender can moderate the perceived functionality of Mapps, necessitating selective processing [1] [28] in order to reach a higher level of gratification regarding health concerns [26] [27]. Hence, we hypothesize that: H3: Women will be less likely to use Mapps for cancer self-management.

Methods
Sample: This study is a secondary analysis of data released by Princeton [5]. or condition may serve as a motivational factor for health-related technology use [18]. Education. Improved cognitive skills attributed to highly educated individuals lead to better evaluation of health information [18], causing these individuals to want to use social media for health more than less educated individuals. Marital status: Having a steady life partner means that one has social control over one's health. Married persons make more use of online health services [55] and consult online rankings or reviews [36] more frequently than those who are not married.

Statistics Analysis
First, we present the proportions of use of mobile health applications for health management among individuals diagnosed with cancer. Second, we examine gender differences in use of Mobile health applications and health management; third, we use logistic regression analyses to predict gender effect on 1) health empowering attitudes and 2) lifestyle and healthcare management.

Findings
In Table 1 we present a general description of Mapps use among cancer patients.
The findings in Table 1  The findings in Table 3  The findings in Table 4 Table 3. Predicting health empowering attitudes.  More importantly, after controlling for age effects, being a woman has a negative effect on lifestyle (B = −1.03, Exp. B = 0.354) and no effect whatsoever on healthcare self-management.

Discussion and Conclusions
The use of mobile health applications in promoting lifestyle and healthcare self-management has enhanced the health empowerment of many individuals. ceived threats and benefits associated with the probability of adopting self-management behaviors are higher among women [41], and 2) gaps between motivations and actual behaviors need further examination [21].
All these indications moderate the perceived functionality of mobile health applications among women with cancer because women are more selective in information gathering processes seeking a higher level of gratification regarding health concerns [26] [27]. Thus, while hypotheses drawn from the Health Belief Model and the normalization hypothesis [1] remain valid, we still must address the theoretical premises that will assist in delineating the link between gender, chronic conditions and self-management.

Limitations and Recommendation for Future Studies
The sample used in this study is small, precluding generalization of the results.
Yet, it is clear that introducing the use of technology devices in health and promoting their use at all costs should be carefully assessed, because such devices are helpful only to a certain extent and are apparently less suitable to the self-management needs of cancer among women. Moreover, cross-sectional studies examining women with different chronic conditions should assess the extent to which gendered technology has an equal effect on all types of chronic conditions.

Funding
This study was not funded by any funding source.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.