139 6 Better Stoma Care using the Stoma App – does it help? resolved in further development scaling-up the app, including migration of the app and choosing a different app developer. This needed to be done in order to futureproof and sustain the app, fitting current and future technical and legal requirements and operational stability. Building an app and researching it -even after committing to a pilot testing phase for technical issues- is a journey in itself. New insights are bound to be derived and are generated by actual use and implementation research itself. It is important to acknowledge this phenomenon, be transparent about it and act accordingly. It is encouraging that despite the technical issues, on the primary outcome measurement significant difference was noted. This strengthens our belief that with optimal functionality, the value of personalization and peer-support is likely to be higher than now visible. The need for peer contact is frequently reported in literature by patients having a stoma.11,13,14,22. However, only one out of five patients in the intervention group used the peer contact function. This may indicate that, when asked, patients may have responded socially desirable to the question of whether peer support is important for them. It seems that for the majority of patients in our study, the opportunity to have peer contact via an app is not a ‘need to have’ feature, but rather a ‘nice to have’. That said, one out of five patients used this feature, being either curious or in need of the support or opinion of a peer. It would be interesting to know, if these patients have a weaker social network than the ones who did not use it, but that could not be retrieved from data. And one may argue that one- out –of five is relevant number in itself to support the need for this feature. Although the app is freely available in the app stores and publicized by patient associations, the involvement of local stoma nurses proved to be key in the process and success of the Stoma App.30 The stoma nurses recruited and onboarded the patients for the trial, which took approximately 15 minutes. In addition, stoma nurses helped patients not familiar with app installation, and with overcoming some digital literacy issues using the app. We consider this to be a best-fit in the normal work routine, as patients in both groups needed a code to access the app. Of course, we needed to ensure that there were only patients having or getting a stoma as users in the app. Throughout the study, the participating stoma nurses were updated about course of the study and new app insights. Also, non-participating stoma nurses were informed about the trial and the app on national stoma congresses, many of them expressing interest in the app. In our study, as in many multicentre trials, patient recruitment varied between the study sites. That can be explained because some nurses actively integrated the app into the standard care pathway, while others did not and sometimes forgot about the app. This study has several limitations. Mostly importantly, it is highly likely that the results were significantly and negatively influenced by technical issues within the intervention version of the app. When developing a mobile app, careful consideration should be given to selecting a qualified app developer. But one should also clearly agree on what is
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