Applied Nursing Research 32 (2016) 182189

Contents lists available at ScienceDirect

Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Evaluation of a smartphone application for self-care performance of

patients with chronic hepatitis B: A randomized controlled trial
Jae Hee Jeon, RN, PhD
Department of Nursing, Semyung University, Jecheon, Chungbuk 390-711, Republic of Korea

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To verify the usefulness of a smartphone application (App) for facilitating self-care in patients with chronic
Received 18 May 2016 hepatitis B (CHB).
Revised 15 July 2016 Background: CHB is a global health problem, and patients with CHB need to routinely perform self-care. Health-
Accepted 26 July 2016 related smartphone apps could help users self-manage their disease.
Methods: Fifty-three CHB patients were assessed in this randomized controlled before-and-after experimental
Keywords:
study. The patients were randomly and equally assigned to groups that did (n = 26) or did not (n = 27) use
Smartphone
Application
the smartphone app for 12 weeks. The experimental and control groups were analyzed for differences in disease
Hepatitis B knowledge, self-efcacy, and self-care before and after use of the smartphone app.
Self-care Results: After intervention, patients who used the app displayed signicantly increased disease knowledge com-
pared with the control group (p = .015). Self-efcacy and self-care also signicantly increased in the experimen-
tal group (p = 0.006 and 0.001, respectively).
Conclusion: The smartphone app can be useful for increasing self-care in CHB patients.
Abbreviations: App: application, CHB: chronic hepatitis B, CVI: content validity
2016 Elsevier Inc. All rights reserved.

1. Introduction
The number of patients with chronic hepatitis B (CHB) is estimated
at 350400 million worldwide (Tseng et al., 2012). Every year, around
1 million patients with CHB die from disease-related complications
such as cirrhosis, liver failure, and hepatocellular carcinoma and ap-
proximately 70% of primary hepatocellular carcinomas are caused by
CHB (Tseng et al., 2012). A nationwide assessment of the hepatitis B in-
fection prevalence in Korea, diagnosed by a positive hepatitis B surface
antigen test, revealed that approximately 2.5%3.1% of the population
is infected with CHB (Statistics Korea, 2013). If not properly treated
and efciently managed, CHB infection can result in death through its
many complications, indicating that CHB is a signicant public health
issue (Cuenca, Corts, Cuenca, & Verdugo, 2014).
Moreover, symptoms such as fatigue, body weakness, nausea,
vomiting, loss of appetite, dyspepsia, abdominal discomfort, bleeding
tendency, swelling, abdominal edema, and jaundice occur as CHB infec-
tion progresses (Korean Association for the Study of the Liver, 2011). In
addition, CHB can cause psychosocial problems, such as anxiety and
withdrawal from interpersonal relationships. Such physical, psycholog-
ical, and socioeconomic problems will consistently affect the everyday
activities and quality of life of patients with CHB (Che et al., 2013).
Department of Nursing, Semyung University, 65 Semyung-ro, Jecheon, Chungbuk 390-
711, Republic of Korea. Tel.: +82 43 649 1356; fax: +82 43 649 1785.
E-mail address: anesjjh@naver.com.
Accordingly, patients with CHB need to manage the symptoms and
prevent severe sequelae (Korean Association for the Study of the Liver,
2011). When a patient with CHB becomes ill, however, clinical symp-
toms are often not clearly manifested until liver damage has consider-
ably progressed (Korean Association for the Study of the Liver, 2011).
Furthermore, many patients do not take disease management seriously
and miss regular follow-up appointments or fail to adhere to treatment,
potentially due to a low level of disease awareness of the patients (Che
et al., 2013).
Thus, it is important for patients with CHB to not only undergo med-
ical treatment but also perform self-care in order to promote their own
health and well-being (Orem, 1985). Self-care is an extensive concept
that includes activities involved in disease prevention, disease and inju-
ry treatment, chronic disease management, rehabilitation, and health
promotion (Orem, 1985). Proper and active self-care of patients with
chronic health conditions positively affects prognosis (Clark, Gong, &
Kaciroti, 2001). Previous reports have indicated that knowledge of a dis-
ease (Che et al., 2013) and self-efcacy (Yang, 2012) are the main fac-
tors that can improve self-care of these patients.
However, previous studies have revealed low levels of disease
knowledge in patients with CHB (Ha et al., 2013), which play a role in
the negligence of self-care in these patients, as well as in the transmis-
sion of hepatitis B virus (Ha et al., 2013; Soto-Salgado et al., 2011). In
order for patients with CHB to effectively perform self-care, in this
study, the model of self-regulation for control of chronic disease pro-
posed by Clark et al. (2001) was used as the conceptual framework.

http://dx.doi.org/10.1016/j.apnr.2016.07.011
0897-1897/ 2016 Elsevier Inc. All rights reserved.
 J.H. Jeon / Applied Nursing Research 32 (2016) 182189
This model suggests that effective self-care can be achieved through
self-regulation using continuous interactive processes.
By 2020, 6.1 billion people, or approximately 70% of the global pop-
ulation, are expected to use smartphones, and at least 50% of
smartphone users will use health-related mobile apps (Miller, Cafazzo,
& Seto, 2014). Approximately 80% of the Korean population currently
uses smartphones (Shin & Lee, 2014). Therefore, smartphones could
represent an effective tool for health-related interventions. Specically,
health-related smartphone apps could help users self-manage their dis-
ease (Miller et al., 2014). It can be hypothesized that patients with CHB
who use a smartphone app focusing on self-care performance would
improve their overall self-care performance (Miller et al., 2014). An
app search in 2013, however, found 23 hepatitis-related apps in the
Google Play and Apple App Stores. Of these, only ve apps were specic
to hepatitis B (Cuenca et al., 2014), and none were developed in Korea.
Moreover, the utilization rate of the already developed hepatitis-related
apps was low, likely owing to a lack of evidence-based knowledge and
limited functionality. Accordingly, based on user demand, a smartphone
app facilitating self-care for patients with CHB was recently developed
(Jeon, 2015).
In this study, this smartphone app, used as a self-regulation strategy
for patients with CHB to perform self-care, is presented, and its effects
and utility with respect to disease knowledge, self-efcacy, and self-
care performance of patients with CHB are analyzed.
2. Materials and methods
2.1. Theoretical basis
This study is based on the conceptual framework model of self-
regulation for control of chronic disease (Clark et al., 2001). Self-
regulation is an interactive feedback in which decisions are made
based on observations, followed by appropriate responses (Clark et al.,
2001). A self-regulation model is a process in which the ultimate goal
is achieved through self-regulation based on continuous interaction
and feedback (Bandura, 1986). In other words, individuals can change
their behavior to manage chronic disease by self-regulation as a result
of continuous interaction and feedback via observations, judgments,
and reactions (Clark et al., 2001).
For patients with CHB, such a self-regulation model consists of intra-
personal and external factors, observations, judgments, reactions, a self-
regulation strategy, and a purpose. The intrapersonal factors in this
study are the knowledge of the disease and attitudes and beliefs about
using a smartphone app for CHB self-care. The external factors are the
healthcare services for health management provided through the
smartphone app. Responses occurring during the interaction feedback
of observations and judgments are dened as the outcome expectations
and expected values of a resource. Accordingly, during the development
of this smartphone app, the attitudes, beliefs, outcome expectations, and
the expected value of the app were assessed and considered (Jeon, 2015).
A self-regulation model strategy is a method that individuals use to
control their current disease. Individuals establish a strategy based on
observations, judgments, and reactions to intrapersonal or external fac-
tors and consequently utilize that strategy during the self-regulation
process (Clark et al., 2001). In this study, the self-regulation strategy
was used for the smartphone app for self-care, and the reaction thereof
was considered the outcome measurement of such use (e.g. the app uti-
lization rate).
The conceptual framework of the study is shown in Fig. 1. In a self-
regulation model, the purpose is achieved through a positive feedback
loop. The smartphone app, provided as an external factor for patients
with CHB, helps the patients acquire disease knowledge and improve
self-efcacy through self-regulation that occurs during continuous in-
teraction and feedback of observations, judgments, and reactions in
order to ultimately improve self-care performance.
183
2.2. Study design and participants
This study was designed as a randomized controlled trial. Pre-tests,
interventions, and post-tests were conducted between April 1 and Au-
gust 20, 2015. The participants were outpatients treated in the Depart-
ment of Gastroenterology of the university hospital where the author
works, which has 800 in-patient beds and an online support group for
patients with CHB with approximately 20,000 members.
For inclusion in the study, participants had to understand the study
objectives, voluntarily agree to participate, and sign a written consent
form. The specic inclusion criteria were: (1) patients diagnosed with
CHB by a physician and with positive hepatitis B surface antigen test re-
sults during the prior 6 months and no CHB comorbidity, such as cirrho-
sis, hepatocellular carcinoma, or liver failure; (2) patients aged between
19 and 60 years and capable of survey self-administration; (3) patients
who were using an Android smartphone at the time; and (4) patients
who understood the study objectives and provided written consent
for study participation.
The sample size was estimated in the following manner: the expect-
ed effect sizes of disease knowledge, self-efcacy, and self-care perfor-
mance were calculated by using a program for patients with CHB
based on previous studies by Yang (2012). In Yangs (2012) study, the
estimated effect sizes were 2.00 for knowledge, 0.83 for self-efcacy,
and 0.88 for self-care performance. Hence, with the assumption of a
two-tailed test, an of 0.05, power (1 ) of 0.80, and a large effect
size of 0.8, the minimum required sample size per group was estimated
to be 26 (Cohen, 1992). With an expected dropout rate of 20%, the re-
quired sample size was thus determined to be 31 per group, for a total
of 62 patients.
2.3. Ethical considerations
This study was approved by the Institutional Review Board of the
hospital where the author works (C2014188 (1385)), and conducted
with permission of the chief of the hospital, the chief of the nursing de-
partment, and a liver specialist in the gastroenterology department. Ad-
ditionally, permission was received from the manager of the online
support group for patients with CHB. All study participants provided
written consent for participation. The study data were stored in a locked
area and will be destroyed 3 years post-study. For ethical purposes, the
control group was provided with the same smartphone app as the one
used by the experimental group after the study was completed, and
all participants were offered a small payment for participating. Permis-
sion was also obtained from the original authors to use the previously
developed instruments in the study.
2.4. Randomization
Participants were assigned to experimental and control groups by a
research assistant using a block randomization method (http://www.r-
bloggers.com/example-2014-2-block-randomization/) (Kleinman,
2014). Specically, group assignments were made so that 31 patients
each were allocated to the experimental and control groups in the
order of enrollment (Fig. 2). The allocation was concealed from the par-
ticipants until the end of the experiment.
2.5. Intervention
2.5.1. Smartphone app
The smartphone app used consists of 8 screens: Self-Care, Disease
Knowledge, Statistics, Record of Liver Lab Data, My Information, Alarms,
Role Practices, and App Information. In the Self-Care menu, the user
can check the daily progress by answering 8 questions regarding 6
topic areas (regular follow-up, medicine, meals, drinking, exercise, and
body weight). The results can be viewed as daily, weekly, and monthly
statistics. Disease knowledge delivers theoretical knowledge based on
184 J.H. Jeon / Applied Nursing Research 32 (2016) 182189
Fig. 1. Study conceptual framework.
evidence, including anatomical information relevant to CHB, causes of
the disease, pathological physiology, symptoms, infection pathways, di-
agnosis, treatment, everyday activities and diet habits, and vaccinations.
Record of Liver Lab Data allows the user to track their liver function
test results in a calendar. The results and trends in the changes in the re-
sults can be viewed on the Statistics screen. My Information displays
the user's history related to liver disease, and through Alarms, the user
can set alarms as reminders to take medication, of regular follow-up ap-
pointments, and of self-care performance. Role Practices provides a
message board and space for the community of registered app users. Fi-
nally, the App Information screen describes the app and also displays a
list of references for Disease Knowledge (Jeon, 2015).
Moreover, a manager app that was created separately from the hep-
atitis B self-care app was designed to control some parts of the app from
a server. A research assistant that served as the app manager was re-
sponsible for providing the service. For example, the manager app
could manage the Role Practices board within the hepatitis B self-
care app and send group push messages to the registered users (Fig. 3).
3. Experimental procedure
We recruited participants through postings in an outpatient clinic at
a university hospital that serves patients with CHB and through online
study announcements on a CHB support group site. Contact was made
with individuals interested in voluntarily participating in the study. A
member of the research team contacted each interested participant
and explained the objectives and methods of the study, and received
written consent from each patient. The participants were allocated to ei-
ther the experimental or the control group upon enrollment and com-
pleted a pre-intervention paper survey. Patients assigned to the
experimental group were provided with an apk le for installing the
smartphone app and an instruction manual that explained how to use
the app. The experimental group was instructed to immediately install
and use the app. The manager app was installed on the research
assistant's smartphone to enable group push messages to be sent once
or twice a week. The control group was instructed to perform everyday
activities and follow the treatment prescribed by the hospital, as usual.
To evaluate the effect of the app, a post-intervention paper survey was
administered to the participants after 12 weeks.
4. Measurements
4.1. Smartphone app utilization rate
Some contents of the smartphone app, such as the data from the
Self-Care menu, were scored or summarized in the main server of
the app developer. Although the exact numbers that users input could
not be viewed, the daily and monthly utilization of the Self-Care
menu was analyzed.
4.2. Disease knowledge
Disease knowledge is the most essential factor in the self-
management of health (Orem, 1985). To assess the disease knowledge
 J.H. Jeon / Applied Nursing Research 32 (2016) 182189 185

Fig. 2. Participant CONSORT ow diagram.

of patients with CHB, an instrument developed by Jeon and Kim (2015)
was used; this instrument includes 5 items regarding the anatomical
structure and functions of the liver, 10 items regarding the infection
pathways, 4 items regarding pathological physiology, 5 items regarding
symptoms, 6 items regarding diagnosis, 4 items regarding treatment, 9
items regarding everyday activities and diet habits, and 6 items regard-
ing vaccinations, for a total of 49 items. Each item had three response
options: yes, no, and don't know. Correct answers were given a
score of 1, and incorrect or don't know answers were given a score
of 0. The total score ranged from 0 to 49, and a higher score indicated
a higher level of disease knowledge. The KuderRichardson Formula
20, a measure for internal consistency reliability, was 0.877 in the
study by Jeon and Kim (2015) and 0.849 in this study.
4.3. Self-efcacy
Self-efcacy is one's belief that he or she can successfully perform ac-
tivities necessary to achieve a specic goal (Bandura, 1986). To measure
self-efcacy, the 14-item instrument from Kang (2003) for cirrhosis pa-
tients, was modied in order to make the items suitable for the disease-
related characteristics of the current participants. The modied instru-
ment was reviewed by a total of 5 experts, including a nursing professor,
2 gastroenterologists, and 2 nurses more than 5 years' experience work-
ing with patients with liver disease, to measure the content validity
(CVI). The CVI values were 0.80 or higher for all 14 items. Of the 14
items, 3, 1, 2, 1, 3, and 4 were related to medical instructions and med-
ication adherence, management of symptoms and complications,
186 J.H. Jeon / Applied Nursing Research 32 (2016) 182189
(a)
(d)
Fig. 3. Intervention smartphone application screens for users: (a) Main screen; (b) Self-care screen; c) Knowledge of disease screen; (d) Lab data record screen; (e) Statistics screen.
exercise and rest, diet management, health management and the pre-
vention of infection transmission, and preferred foods and stress man-
agement, respectively. Each item was measured on a 5-point Likert
scale where 5 indicated I am very condent and 1 indicated I am
not very condent. The total score ranged from 14 to 70, and a higher
score meant a higher level of self-efcacy. The Cronbach's alpha values
for this instrument were 0.845 in Kangs (2003) study and 0.837 in
this study.
4.4. Self-care performance
Self-care performance includes the everyday activities an individual
performs to maintain his or her health, life, integrated functioning, or
well-being (Orem, 1985). To measure self-care performance, a 23-
item instrument, which was developed by revising the 13-item instru-
ment originally developed by Park (2002), was used. To measure CVI,
the revised 23-item instrument was reviewed by the same 5 experts
mentioned above. The CVI values were 0.80 or higher for all 23 items.
The instrument included 4, 1, 4, 4, 6, and 4 items related to medical in-
structions and medication taking, management of symptoms and com-
plications, exercise and rest, diet management, health management and
the prevention of infection transmission, and preferred foods and stress
management, respectively. The items were measured on a 5-point
Likert scale where a score of 5 indicated I am doing it very well and
1 meant I never do it. The total score ranged from 23 to 115, and a
higher score meant a higher level of self-care performance. The
(b) (c)
(e)
Cronbach's alpha values for this instrument were 0.850 in Parks
(2002) study and 0.876 in this study.
4.4.1. Statistical analysis
Data were analyzed using SPSS 21.0 (SPSS Inc., Chicago, IL). For anal-
ysis of the participants' general characteristics, the frequencies, percen-
tiles, means, and standard deviations were computed. Chi-squared and
Fisher's exact tests were used to test the homogeneity between the ex-
perimental and control groups with respect to the general characteris-
tics and pre-intervention dependent variables. Descriptive statistics
were used to analyze the smartphone app utilization rate in the exper-
imental group. To test the between-group differences in disease knowl-
edge, self-efcacy, and self-care performance before and after the use of
the smartphone app, t-tests were used after normality was conrmed
by the KolmogorovSmirnov normality test. The signicance level for
all tests was set at 5%.
5. Results
5.1. General participant characteristics and homogeneity testing
Data from 53 participants (experimental group: n = 27; control
group: n = 26) were analyzed (Fig. 2). In the homogeneity tests, there
were no signicant differences between the groups in any of the general
participant characteristics, conrming homogeneity of the dependent
variables between the groups (Table 1).
 J.H. Jeon / Applied Nursing Research 32 (2016) 182189 187

Table 1
Baseline characteristics of the experimental and control groups.

Experimental Control
Characteristics Categories (n = 27) (n = 26) 2 p
n (%) n (%)

Male 24 (88.9) 24 (92.3)

Sex 0.670a 1.000
Female 3 (11.1) 2 (7.7)
2039 15 (55.6) 9 (34.6)
2.344 .126
Age (years) 40 12 (44.4) 17 (65.4)
Mean SD 39.44 10.15 44.69 9.57
Married and living together 21 (77.8) 23 (88.5)
Marital status 1.072a .467
Other 6 (22.2) 3 (11.5)
Yes 26 (96.3) 24 (92.3) a
Working 0.395 .610
No 1 (3.7) 2 (7.7)
High school 3 (11.1) 4 (15.3)
Education level 1.795a .719
University 24 (88.9) 22 (84.6)
Good 3 (11.1) 4 (15.4)
Economic status Moderate 20 (74.1) 18 (69.2) 0.347a .911
Poor 4 (14.8) 4 (15.4)
Seoul/Gyeonggi/Incheon 10 (37.0) 12 (46.2)
Gangwon/Chungcheong 5 (18.5) 2 (7.7)
Area of residence 1.729a .701
Jeolla/Gyeongsang 9 (33.3) 10 (38.5)
Jeju/Country other than Korea 3 (11.1) 2 (7.7)
10 4 (14.8) 5 (19.2)
Duration of CHB (years) 1120 17 (63.0) 12 (46.7) 1.581a .493
21 6 (22.2) 9 (34.6)
Yes (once) 6 (22.2) 8 (30.8)
Hospital admission due to CHB Yes (N 1 time) 1 (3.7) 1 (3.8) 1.922a 1.000
No 20 (74.1) 17 (65.4)
Yes 23 (85.2) 20 (76.9)
Remembers last liver blood test result GOT, GPT) 0.593a .501
No 4 (14.8) 6 (23.1)
Yes 1 (3.7) 2 (7.7) a
Other hepatitis treatment besides HME 2.977 .430
No 26 (96.3) 23 (88.5)
Once a month 4 (14.8) 4 (15.4)
Regular follow-up for HME Every three months 19 (70.4) 15 (57.7) 0.438 .663
Every six months 4 (14.8) 7 (26.9)
Yes 23 (85.2) 19 (73.1)
Treated with AVHD 1.277a .503
No 4 (14.8) 7 (26.9)

SD = standard deviation; CHB = chronic hepatitis B; GOT = glutamic oxaloacetic transaminase; GPT = glutamic pyruvic transaminase; HME = hospital medical examination;
AVHD = anti-viral hepatitis drugs.
a
Fisher's exact test.

5.2. Homogeneity testing on pre-intervention dependent variables
As determined by t-tests, the experimental and control groups were
not signicantly different with respect to any of the pre-intervention de-
pendent variables, conrming between-group homogeneity (Table 2).
5.3. Smartphone app utilization rate
The utilization rate of the Self-Care menu was examined 12 weeks
after initiation of the experiment. The utilization rates of the experimen-
tal group were 69.3%, 74.6%, 74.6%, and 82.0% at weeks 3, 6, 9, and 12,
respectively, with a mean monthly utilization rate of 75.1%.
5.4. Testing effects of the smartphone app (Table 3)
for the experimental group was signicantly higher than that for the
control group (t = 2.530, p = .015).
The self-efcacy score of the experimental group increased by 1.59
points, from 56.56 points pre-intervention to 58.15 points post-
intervention. On the other hand, the control group score decreased by
0.73 points, from 58.15 points pre-intervention to 57.42 points post-
intervention. The change in the self-efcacy score was signicantly dif-
ferent between the groups (t = 2.867, p = .006).
The self-care performance score of the experimental group in-
creased by 5.22 points, from 85.89 points pre-intervention to 91.11
points post-intervention, while the score of the control group decreased
by 3.19 points, from 89.77 points pre-intervention to 86.58 points post-
intervention. The change in the self-care performance score was signif-
icantly different between groups (t = 3.597, p = .001).

The mean disease knowledge score increased between pre- 6. Discussion

intervention and post-intervention for both the experimental (33.15
vs. 37.93 points; mean change: 4.78 points) and control groups (32.00, The present study used a randomized controlled trial design to eval-
vs. 33.11 points; mean change: 1.11 points). However, the score change uate the effects and utility of a smartphone app developed to facilitate

Table 2
Homogeneity of dependent variables pre-intervention.

Experimental (n = 27) Control (n = 26)

Variables t p
M SD M SD

Disease knowledge 33.15 7.15 32.00 8.58 0.530 .598

Self-efcacy 56.56 4.92 58.15 5.08 1.142 .259
Self-care performance 85.89 7.00 89.77 8.96 1.760 .084

M SD = Mean Standard Deviation.

188 J.H. Jeon / Applied Nursing Research 32 (2016) 182189
Table 3
Comparison of disease knowledge, self-efcacy, and self-care performance pre- and post-intervention.
Pre-test
Variables Group
M SD
Experimental (n = 27) 33.15
Disease knowledge
Control (n = 26) 32.00
Experimental (n = 27) 56.56
Self-efcacy
Control (n = 26) 58.15
Experimental (n = 27) 85.89
Self-care performance
Control (n = 26) 89.77
M SD = Mean Standard Deviation.
self-care for patients with CHB. The results showed that the disease
knowledge, self-efcacy, and self-care performance increased signi-
cantly in the experimental group compared to in the control group, sug-
gesting that the smartphone app was useful for patients with CHB
performing self-care.
The pre-intervention mean disease knowledge scores were 33.15
and 32.00 points (out of 49 points) for the experimental and control
groups, respectively. The mean score reported by Jeon and Kim
(2015), in which the same instrument was used, was 31.15 points,
and the score in Yangs (2012) study was 17.44 points out of a maxi-
mum score of 28 points, although the instrument used was not identical
to that used herein and in the study by Jeon and Kim (2015). However,
when all scores were converted to a 100-point scale, they were similar
(experimental: 67 points, control: 65 points; Jeon and Kim: 63 points;
and Yang: 62 points). Disease knowledge in various areas, including eti-
ology, vaccination, prevention of infection transmission, and everyday
activities, is necessary for patients with CHB to perform self-care (Jeon
& Kim, 2015). Thus, these relatively low knowledge scores may indicate
poor self-care performance. However, in the present study, there was a
statistically signicant difference in the change in knowledge scores be-
tween the control and experimental groups post-intervention, indicat-
ing that the smartphone app may be effective in partially improving
the disease knowledge and thereby the self-care of the patients.
Signicant differences were also noted in the changes in the self-
efcacy scores between the experimental and control groups. There
are numerous ways to increase self-efcacy, including by past experi-
ences of achievement, vicarious experience, verbal persuasion, and sup-
port from others (Bandura, 1986). In this study, a Role Practices board
was used as one of the app menus to improve self-efcacy; this board
is believed to have actively contributed to improved participant self-
efcacy through understanding of other patients' experiences of
achievement. In addition, once or twice a week, the research assistant
used the manager app to send encouraging messages to those registered
with the self-care app. Thus, it can be speculated that verbal persuasion
from specialists and knowledge gained through vicarious experiences
contributed to the improvement of self-efcacy in self-care perfor-
mance in the experimental group. In previous studies, the disease
knowledge and self-efcacy of the subjects were found to relate to the
hepatitis virus infection rate, with a high infection rate associated with
poor disease knowledge and self-efcacy of the patients (Ha et al.,
2013; Kuwabara & Ching, 2014; Soto-Salgado et al., 2011). Therefore,
improving the disease knowledge and self-efcacy is important to im-
prove the self-care of CHB patients.
There was also a signicant difference in the self-care performance
score between the experimental and control groups in this study. The
pre-intervention scores of self-care performance were 85.89 and 89.77
out of a maximum score of 115 points for the experimental and control
groups, respectively. Using a similar instrument to measure self-care
performance, Yang (2012) reported a score of 59.75 out of a maximum
score of 75 points, which is in the range of 7580 points when converted
to a 100-point scale. In these two previous studies, as well as in the pres-
ent study, many participants were recruited from a clinical setting, such
as a hospital. Most of these CHB patients receive regular follow-up from
the hospital, as well as information and education from the medical staff
Post-test Difference
t p
M SD M SD
7.15 37.93 6.99 4.78 4.23
2.530 .015
8.58 33.11 8.62 1.11 6.16
4.92 58.15 5.08 1.59 2.80
2.867 .006
5.27 57.42 4.44 0.73 3.09
7.00 91.11 8.27 5.22 10.42
3.597 .001
8.96 86.58 7.06 3.19 5.92
regarding the disease prognosis and management (Yang, 2012). There-
fore, the level of self-care is expected to be relatively high. Previous
studies have reported that the degree of self-care and management in
patients with hepatitis B infection affects the chronicity of the disease
(Mohamed et al., 2012; Nkonge, Mayabi, Kithinji, & Magambo, 2012),
further conrming the importance of self-care. However, in Korea,
only about 25% of patients with CHB are aware that they are infected,
and less than 20% of those who are aware reportedly care for their
health and consistently receive follow-up and disease management
from a hospital (Korean Association for the Study of the Liver, 2011). Ac-
cordingly, a smartphone app that anyone can easily use may be an effec-
tive medium to improve self-care performance in patients with CHB.
Indeed, in a variety of other diseases such as chronic heart disease, diabetes
mellitus, obesity and stroke, smartphone apps have been reported to im-
prove the self-care of the subjects (Jo & Park, 2016; Miller et al., 2014;
Sureshkumar et al., 2016), supporting the results of the present study.
The smartphone app developed in this study had an effect similar to
that reported in a previous study of a self-management program for pa-
tients with CHB (Yang, 2012). In that previous study, the experimental
group, who underwent the self-management program, showed greater
improvements in disease knowledge, self-efcacy, coping behavior, and
self-management performance than the control group, and the effects
persisted over time. However, a large proportion of patients with CHB
are at an economically active age, and may not have time to attend a
program outside of their home on a predetermined schedule (Che
et al., 2013). Thus, since there are no specied time or location require-
ments, a smartphone app is expected to have a stronger effect, because
it can effectively deliver an intervention to a high number of patients
(Cuenca et al., 2014).
As the number of patients with chronic diseases is rapidly increasing
worldwide, demands for a healthcare system centered around hospital-
provided disease management, prevention, and patient-customized
services are increasing (Sureshkumar et al., 2016). In particular, the u-
Health Service is a healthcare service in a ubiquitous computing envi-
ronment that enables patient-customized services by combining
healthcare and information technology. For patients with chronic dis-
eases, the u-Health Service should be based on medical services and
guidelines provided by hospitals and aim to improve patient health
through self-management (Miller et al., 2014). If the smartphone app
developed in this study can be linked to hospitals and be used to provide
patient-customized services, it would represent a cost-effective mecha-
nism for improving the self-care performance of patients with CHB and
could potentially improve their overall health.
Evaluation and discussion about the continuity and interaction feed-
back of the self-regulation process are necessary. In a survey conducted
during the analytic phase of the development of this smartphone app,
positive values for attitudes, beliefs, outcome expectations, and expect-
ed values of a smartphone app for the target population were identied
(Jeon, 2015). The outcome expectation with the highest response rate
for use of the app was, I am curious about how to manage CHB
(Jeon, 2015). Consistent with this expectation, the participant utiliza-
tion rate of the Self-Care menu gradually increased over time. This be-
havior was also reected in the analyses of the effects of the smartphone
app in the present study. In the experimental group, the disease
 J.H. Jeon / Applied Nursing Research 32 (2016) 182189
knowledge, self-efcacy, and self-care performance signicantly in-
creased from the pre-intervention levels, indicating that the use of the
smartphone app, for as little as 12 weeks, positively affected the users
through interactions with intrapersonal and external factors, and, to a cer-
tain degree, helped them achieve step-wise responses and purpose
through continuous observations and judgments (Clark et al., 2001).
However, managing a chronic disease requires both short-term and con-
tinuous self-management (Sureshkumar et al., 2016). Therefore, a long-
term study is needed in the future to evaluate the interaction feedback
and continuity in patients with CHB who use this smartphone app and
to identify factors impeding the interaction feedback and continuity.
There were some limitations to this study. The psychological aspects
and quality of life of patients with CHB were not considered in the
smartphone app. Patients with CHB commonly complain of fatigue, re-
duced work ability, depression, and anxiety, and these symptoms have
negative impacts on their quality of life, as well as mental and physical
well-being (Che et al., 2013). For patients with CHB, the quality of life
is often negatively affected early in the disease course, not only because
the patients may be withdrawn from interpersonal relationships due to
anxiety accompanied with the possibility of transmitting the disease to
others, but also because the disease could ultimately progress to cirrho-
sis or hepatocellular carcinoma, for which curative treatment ap-
proaches are limited (Park et al., 2003). Nonetheless, the medical
providers focus mainly on the treatment of the symptoms, and often do
not consider the psychological aspects and quality of life while treating
the patients (Che et al., 2013). In addition, little research has been con-
ducted on the quality of life of patients with CHB (Park et al., 2003).
Hence, when the app used in this study is updated in the future, functions
related to psychological aspects and quality of life should be added.
7. Conclusions
Herein, it was conrmed that a recently developed smartphone app
for patients with CHB had positive effects on self-care performance. The
results of this randomized controlled trial demonstrated that the dis-
ease knowledge, self-efcacy, and self-care performance improved in
the experimental group compared to in the control group, indicating
the effectiveness of the app for CHB patients.
Conicts of interest
None
Acknowledgments
This article is based on the rst author's doctoral dissertation from
Chung-Ang University in Korea (unpublished). This research did not re-
ceive any specic grant from funding agencies in the public, commer-
cial, or not-for-prot sectors.
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