Views on Mobile Health Apps for Skin Cancer Screening in the General Population

An In-depth Qualitative Exploration of Perceived Barriers and Facilitators

T.E. Sangers; M. Wakkee; E.C. Kramer-Noels; T. Nijsten; M. Lugtenberg


The British Journal of Dermatology. 2021;185(5):961-969. 

In This Article


Description of Participants

Participant characteristics on group level are presented in Table 1. Characteristics of individual participants can be found in Table S1 (see Supporting Information).

Views Towards Using mHealth Apps for Skin Cancer Screening

Six main barriers and five main facilitators for the use of mHealth for skin cancer screening were identified (Table 2). These, including the subthemes identified for the barriers and facilitators, are described below. Illustrative quotations of the results are presented in Table 3 and Table 4. An overview of illustrative quotations of all (sub-)barriers and (sub)facilitators can be found in Table S2 (see Supporting Information).

Barriers to Using mHealth Skin Cancer Screening Apps. Perceived Lack of Value of mHealth Skin Cancer Apps: The first main barrier identified to using mHealth for skin cancer screening was a perceived lack of value. This was first of all related to limited knowledge among participants about mHealth apps for skin cancer screening. Some participants were unaware of the functionality these apps may have to offer, and questioned the added value of these apps. Moreover, a lack of concern regarding skin cancer contributed to a perceived lack of mHealth apps' value. Whereas some participants had a history of skin cancer and indicated vigilance regarding suspicious skin lesions on their skin, others mentioned they had never worried about skin cancer and as such did not see the need to perform self-inspection for suspicious skin lesions. Furthermore, while participants acknowledged the usefulness of performing a skin check at home, a lack of integration with the healthcare system was mentioned as a sub-barrier. One still has to visit a general practitioner (GP) after a high-risk assessment instead of receiving a direct referral to a dermatologist, which was found to reduce such an app's overall value.

Perception of Untrustworthiness: The perception of untrustworthiness was identified as a second main barrier to mHealth for skin cancer screening, consisting of two sub-barriers: a perceived lack of screening accuracy and doubts about the app developer's reliability. First of all, a perceived lack of accuracy was related to a general lack of confidence in mHealth apps to detect skin cancer. The screening accuracy of mHealth apps was questioned as they are based on an image rather than an in-person assessment by a doctor, which was considered a limited source of information on which to base an assessment. Secondly, the perceived lack of confidence was related to a lack of information provided by mHealth developers about screening accuracy. For example, the accuracy of an app in comparison with that of GPs and dermatologists was unclear to participants. When asked about the minimum required level of screening accuracy of such apps, some participants insisted that apps should work flawlessly; others mentioned that they would accept less than 100% accuracy from an app. The absence of an evaluation of the screening accuracy by an independent party (i.e. an academic institution or regulating body) contributed to perceptions that an app was unreliable. Insufficient accuracy in detecting skin cancer was considered a potential health risk for app users, as an incorrect risk advisory may evoke a false sense of reassurance and potentially cause delay in skin cancer treatment. Furthermore, it was mentioned that mHealth apps incorrectly classifying benign skin lesions as skin cancer would cause unnecessary worry and concerns among users. Doubts about the app developer's reliability was identified as a second subtheme in the perception of untrustworthiness of an mHealth app for skin cancer screening. Participants expressed their concerns towards mHealth apps, which are developed for commercial purposes. Moreover, claims about the safety and trustworthiness coming from mHealth app developers with a commercial motive were considered unreliable.

Preference for a Human Doctor Instead of an Algorithm: The preference for visiting a GP or dermatologist for a suspicious skin lesion rather than using an app to perform a risk assessment was identified as a third barrier. While some participants stated that they would use an app for a skin cancer risk assessment, others appeared to prefer an assessment from a physical doctor. The assessment of a doctor was considered more believable than the assessment from an algorithm. Additionally, the possibility of communicating verbally and discussing the possibility of treatment was a reason to prefer a doctor consultation. Furthermore, participants explained that person-specific disease information related to prognosis (e.g. tumour staging) should only be communicated by doctors rather than an app. Lastly, participants mentioned that even if an app were integrated within healthcare systems, patients should always maintain the choice to visit a doctor instead of using an app compulsorily.

Privacy Concerns: Participants expressed concerns about the sharing of personal data with mHealth apps for skin cancer screening. While some participants considered an image of a skin lesion to be nonintrusive personal data, others saw this as a reason not to use an app. Participants reported preferably wanting to fill in as few personal details as possible. The fear of unsolicited data sharing by trackers and spyware was a reason to refrain from using mHealth. The need to create an account and fill out personal details and requests for permission (e.g. to access GPS location) and install cookies was considered a reason to remove the app directly after installation.

Complex and Distracting User Interface: A complex user interface, referring to the inability to quickly navigate to and perform essential tasks, such as the camera function to perform a risk assessment, was identified as a fifth barrier. A lengthy tutorial and the need to perform multiple clicks through the app menu were considered factors contributing to a complex user interface. Moreover, concerns were expressed about the ability to properly use the camera function to make a high-quality photo for a risk assessment, particularly by older people. Participants explained that it might be challenging to take photos of skin lesions located on certain parts of the body (e.g. the face) and worried that the inability to make a high-quality photo may lead to an incorrect assessment by the algorithm. Concerning the user interface, participants viewed commercial in-app advertising during the use of an app as rather distracting.

Costs Associated With Using mHealth: Costs associated with using mHealth apps were identified as a sixth barrier. Consulting a GP in the Netherlands does not involve any costs for the patient, as the health insurer fully reimburses a visit's costs. Therefore, participants indicated they would be reluctant to pay for an mHealth app that provides a similar service.

Facilitators of mHealth use. Perceived High Value of mHealth Apps for Skin Cancer Screening: A perceived high value of mHealth apps was identified as a first facilitator of using mHealth apps for skin cancer screening. Perceptions of high value were related to the ability to perform a skin cancer risk assessment from home, the ability to monitor skin lesions over time, and the possibility of integration with dermatology-related care. First and foremost, participants were generally positive about the idea of receiving instant risk advice for a suspicious skin lesion at home from an app. Participants expressed their difficulty in judging for themselves whether a doctor visit was necessary or not. As a result, the main benefit mentioned from using an app for a skin lesion risk assessment was the avoidance of unnecessary doctor consultations. However, participants mentioned two preconditions regarding the risk assessment provided by an app. Firstly, they indicated that an app should only provide a risk indication but not a diagnosis. Secondly, while an app may provide an advisory suggesting a doctor visit, the advisory should not be binding and should not take away users' freedom to see a doctor. Beside the possibility of instantly screening a skin lesion and receiving a risk indication of skin cancer, participants were positive about the possibility of monitoring skin lesions over time. Moreover, a functionality that sends users a reminder to rephotograph a skin lesion to judge whether it is progressing into malignancy was evaluated as useful. Furthermore, integration of mHealth apps with GP and dermatological care increased the value of such apps to users. Multiple possibilities for integration were stated. Firstly, participants would have liked the option to directly visit a dermatologist after receiving a high-risk rating from an mHealth app, without first having to visit the GP. Secondly, the possibility that an app could provide advice about whether or not to contact a doctor during treatment of skin cancer was thought to be useful. Thirdly, the availability of tailored information related to a photographed skin lesion or skin cancer follow-up care in an app was considered valuable.

Transparent and Trustworthy Identity of app Developer: A transparent and trustworthy identity of the app developer was a second main identified facilitator of using mHealth apps. Participants stressed that they wanted to know the identity and background of the (clinical) team that develops the app as this influences its perceived trustworthiness. Additionally, insight into who performs the assessment (i.e. an algorithm or a teledermatologist) was also considered essential. Participants mentioned that an app ideally should be developed by healthcare providers, a hospital, or a health institution associated with the government instead of a commercial company. App store ratings were named as a factor that could indicate whether an app is trustworthy.

Endorsement by Healthcare Providers (General Practitioners, Dermatologists) and Government Regulating Bodies: Endorsement of mHealth apps for skin cancer screening by healthcare providers and government regulating bodies was identified as a third facilitator of using mHealth in the general population. The endorsement of healthcare providers was considered to increase an mHealth app's trustworthiness, especially if the app is endorsed by an independent group of experts from multiple academic institutions. In addition to endorsement from an expert group, a GP or dermatologist who recommended the app during a consultation was considered an encouraging reason for adoption. Besides endorsement from healthcare providers, government regulation of mHealth apps was regarded as essential to ensure an app's quality and safety, and was thus perceived as a facilitator. They considered assurance of the quality of mHealth apps to be a matter of government regulation.

Ease of use: The ease of use of an mHealth app for skin cancer screening was identified as a fourth facilitator, consisting of four subthemes. Firstly, participants mentioned that to facilitate use, the app should have a simple user interface, and focus on the core feature of taking a photo using the smartphone camera and providing advice on whether a doctor visit is necessary. Secondly, the process of performing a risk assessment should ideally be easy, without requiring users to provide additional information or create an account. Thirdly, through a simple user interface and assessment functionality, the app should be usable by all ages, regardless of technological savvy. Last, participants emphasized the superiority of mHealth apps in terms of usability and portability over alternatives, such as a website or brochure providing information on skin cancer.

Low or no Cost of use: Low, or no cost for the use of a mHealth app was identified as a fifth facilitator. While there was no consensus among participants about how low the costs ideally should be, they indicated that low or no costs would significantly increase their drive to adopt a mHealth app. Reimbursement by one's health insurer was identified as a solution to overcome the resistance of paying for an mHealth app.