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Background: Mental health disorders affect 1 in 10 people globally, of whom approximately 300 million are affected by depression. At least half of the people affected by depression remain untreated. Although cognitive behavioral therapy (CBT) is an effective treatment, access to mental health specialists, habitually challenging, has worsened because of the COVID-19 pandemic. Internet-based CBT is an effective and feasible strategy to increase access to treatment for people with depression. Mental health apps may further assist in facilitating self-management for people affected by depression; however, accessing the correct app may be cumbersome given the large number and wide variety of apps offered by public app marketplaces. Objective: This study aims to systematically assess the features, functionality, data security, and congruence with evidence of self-guided CBT-based apps targeting users affected by depression that are available in major app stores. Methods: We conducted a systematic assessment of self-guided CBT-based apps available in Google Play and the Apple App Store. Apps launched or updated since August 2018 were identified through a systematic search in the 42matters database using CBT-related terms. Apps meeting the inclusion criteria were downloaded and assessed using a Samsung Galaxy J7 Pro (Android 9) and iPhone 7 (iOS 13.3.1). Apps were appraised using a 182-question checklist developed by the research team, assessing their general characteristics, technical aspects and quality assurance, and CBT-related features, including 6 evidence-based CBT techniques (ie, psychoeducation, behavioral activation, cognitive restructuring, problem solving, relaxation, and exposure for comorbid anxiety) as informed by a CBT manual, CBT competence framework, and a literature review of internet-based CBT clinical trial protocols. The results were reported as a narrative review using descriptive statistics. Results: The initial search yielded 3006 apps, of which 98 met the inclusion criteria and were systematically assessed. There were 20 well-being apps; 65 mental health apps, targeting two or more common mental health disorders, including depression; and 13 depression apps. A total of 28 apps offered at least four evidence-based CBT techniques, particularly depression apps. Cognitive restructuring was the most common technique, offered by 79% (77/98) of the apps. Only one-third of the apps offered suicide risk management resources, whereas 17% (17/98) of the apps offered COVID-19-related information. Although most apps included a privacy policy, only a third of the apps presented it before account creation. In total, 82% (74/90) of privacy policies stated sharing data with third-party service providers. Half of the app development teams included academic institutions or health care providers. Conclusions: Only a few self-guided CBT-based apps offer comprehensive CBT programs or suicide risk management resources. Sharing of users' data is widespread, highlighting shortcomings in health app market governance. To fulfill their potential, self-guided CBT-based apps should follow evidence-based clinical guidelines, be patient centered, and enhance users' data security., Journal of Medical Internet Research, 23 (7), ISSN:1438-8871

Background Diabetic retinopathy (DR), a common complication of diabetes mellitus, is the leading cause of impaired vision in adults worldwide. Smartphone ophthalmoscopy involves using a smartphone camera for digital retinal imaging. Utilizing smartphones to detect DR is potentially more affordable, accessible, and easier to use than conventional methods. Objective This study aimed to determine the diagnostic accuracy of various smartphone ophthalmoscopy approaches for detecting DR in diabetic patients. Methods We performed an electronic search on the Medical Literature Analysis and Retrieval System Online (MEDLINE), EMBASE, and Cochrane Library for literature published from January 2000 to November 2018. We included studies involving diabetic patients, which compared the diagnostic accuracy of smartphone ophthalmoscopy for detecting DR to an accurate or commonly employed reference standard, such as indirect ophthalmoscopy, slit-lamp biomicroscopy, and tabletop fundus photography. Two reviewers independently screened studies against the inclusion criteria, extracted data, and assessed the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies–2 tool, with disagreements resolved via consensus. Sensitivity and specificity were pooled using the random effects model. A summary receiver operating characteristic (SROC) curve was constructed. This review is reported in line with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines. Results In all, nine studies involving 1430 participants were included. Most studies were of high quality, except one study with limited applicability because of its reference standard. The pooled sensitivity and specificity for detecting any DR was 87% (95% CI 74%-94%) and 94% (95% CI 81%-98%); mild nonproliferative DR (NPDR) was 39% (95% CI 10%-79%) and 95% (95% CI 91%-98%); moderate NPDR was 71% (95% CI 57%-81%) and 95% (95% CI 88%-98%); severe NPDR was 80% (95% CI 49%-94%) and 97% (95% CI 88%-99%); proliferative DR (PDR) was 92% (95% CI 79%-97%) and 99% (95% CI 96%-99%); diabetic macular edema was 79% (95% CI 63%-89%) and 93% (95% CI 82%-97%); and referral-warranted DR was 91% (95% CI 86%-94%) and 89% (95% CI 56%-98%). The area under SROC curve ranged from 0.879 to 0.979. The diagnostic odds ratio ranged from 11.3 to 1225. Conclusions We found heterogeneous evidence showing that smartphone ophthalmoscopy performs well in detecting DR. The diagnostic accuracy for PDR was highest. Future studies should standardize reference criteria and classification criteria and evaluate other available forms of smartphone ophthalmoscopy in primary care settings.

Background Social media platforms have numerous potential benefits and drawbacks on public health, which have been described in the literature. The COVID-19 pandemic has exposed our limited knowledge regarding the potential health impact of these platforms, which have been detrimental to public health responses in many regions. Objective This review aims to highlight a brief history of social media in health care and report its potential negative and positive public health impacts, which have been characterized in the literature. Methods We searched electronic bibliographic databases including PubMed, including Medline and Institute of Electrical and Electronics Engineers Xplore, from December 10, 2015, to December 10, 2020. We screened the title and abstracts and selected relevant reports for review of full text and reference lists. These were analyzed thematically and consolidated into applications of social media platforms for public health. Results The positive and negative impact of social media platforms on public health are catalogued on the basis of recent research in this report. These findings are discussed in the context of improving future public health responses and incorporating other emerging digital technology domains such as artificial intelligence. However, there is a need for more research with pragmatic methodology that evaluates the impact of specific digital interventions to inform future health policy. Conclusions Recent research has highlighted the potential negative impact of social media platforms on population health, as well as potentially useful applications for public health communication, monitoring, and predictions. More research is needed to objectively investigate measures to mitigate against its negative impact while harnessing effective applications for the benefit of public health.

Background Inappropriate antibiotic prescription is one of the key contributors to antibiotic resistance, which is managed with a range of interventions including education. Objective We aimed to summarize evidence on the effectiveness of digital education of antibiotic management compared to traditional education for improving health care professionals’ knowledge, skills, attitudes, and clinical practice. Methods Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990, and September 20, 2018. There were no language restrictions. We also searched the International Clinical Trials Registry Platform Search Portal and metaRegister of Controlled Trials to identify unpublished trials and checked the reference lists of included studies and relevant systematic reviews for study eligibility. We followed Cochrane methods to select studies, extract data, and appraise and synthesize eligible studies. We used random-effect models for the pooled analysis and assessed statistical heterogeneity by visual inspection of a forest plot and calculation of the I2 statistic. Results Six cluster RCTs and two RCTs with 655 primary care practices, 1392 primary care physicians, and 485,632 patients were included. The interventions included personal digital assistants; short text messages; online digital education including emails and websites; and online blended education, which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed postintervention change in clinical practice. The majority of the studies (4/6) reported greater reduction in antibiotic prescription or dispensing rate with digital education than with traditional education. Two studies showed significant differences in postintervention knowledge scores in favor of mobile education over traditional education (standardized mean difference=1.09, 95% CI 0.90-1.28; I2=0%; large effect size; 491 participants [2 studies]). The findings for health care professionals’ attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction, or potential adverse effects. Conclusions Findings from studies deploying mobile or online modalities of digital education on antibiotic management were complementary and found to be more cost-effective than traditional education in improving clinical practice and postintervention knowledge, particularly in postregistration settings. There is a lack of evidence on the effectiveness of other digital education modalities such as virtual reality or serious games. Future studies should also include health care professionals working in settings other than primary care and low- and middle-income countries. Clinical Trial PROSPERO CRD42018109742; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=109742

Background People from underserved communities such as those from lower socioeconomic positions or racial and ethnic minority groups are often disproportionately targeted by the tobacco industry, through the relatively high levels of tobacco retail outlets (TROs) located in their neighborhood or protobacco marketing and promotional strategies. It is difficult to capture the smoking behaviors of individuals in actual locations as well as the extent of exposure to tobacco promotional efforts. With the high ownership of smartphones in the United States—when used alongside data sources on TRO locations—apps could potentially improve tobacco control efforts. Health apps could be used to assess individual-level exposure to tobacco marketing, particularly in relation to the locations of TROs as well as locations where they were most likely to smoke. To date, it remains unclear how health apps could be used practically by health promotion organizations to better reach underserved communities in their tobacco control efforts. Objective This study aimed to demonstrate how smartphone apps could augment existing data on locations of TROs within underserved communities in Massachusetts and Texas to help inform tobacco control efforts. Methods Data for this study were collected from 2 sources: (1) geolocations of TROs from the North American Industry Classification System 2016 and (2) 95 participants (aged 18 to 34 years) from underserved communities who resided in Massachusetts and Texas and took part in an 8-week study using location tracking on their smartphones. We analyzed the data using spatial autocorrelation, optimized hot spot analysis, and fitted power-law distribution to identify the TROs that attracted the most human traffic using mobility data. Results Participants reported encountering protobacco messages mostly from store signs and displays and antitobacco messages predominantly through television. In Massachusetts, clusters of TROs (Dorchester Center and Jamaica Plain) and reported smoking behaviors (Dorchester Center, Roxbury Crossing, Lawrence) were found in economically disadvantaged neighborhoods. Despite the widespread distribution of TROs throughout the communities, participants overwhelmingly visited a relatively small number of TROs in Roxbury and Methuen. In Texas, clusters of TROs (Spring, Jersey Village, Bunker Hill Village, Sugar Land, and Missouri City) were found primarily in Houston, whereas clusters of reported smoking behaviors were concentrated in West University Place, Aldine, Jersey Village, Spring, and Baytown. Conclusions Smartphone apps could be used to pair geolocation data with self-reported smoking behavior in order to gain a better understanding of how tobacco product marketing and promotion influence smoking behavior within vulnerable communities. Public health officials could take advantage of smartphone data collection capabilities to implement targeted tobacco control efforts in these strategic locations to reach underserved communities in their built environment.

Background: The use of digital education in problem-based learning, or digital problem-based learning (DPBL), is increasingly employed in health professions education. DPBL includes purely digitally delivered as well as blended problem-based learning, wherein digital and face-to-face learning are combined. Objective: The aim of this review is to evaluate the effectiveness of DPBL in improving health professionals’ knowledge, skills, attitudes, and satisfaction. Methods: We used the gold-standard Cochrane methods to conduct a systematic review of randomized controlled trials (RCTs). We included studies that compared the effectiveness of DPBL with traditional learning methods or other forms of digital education in improving health professionals’ knowledge, skills, attitudes, and satisfaction. Two authors independently screened studies, extracted data, and assessed the risk of bias. We contacted study authors for additional information, if necessary. We used the random-effects model in the meta-analyses. Results: Nine RCTs involving 890 preregistration health professionals were included. Digital technology was mostly employed for presentation of problems. In three studies, PBL was delivered fully online. Digital technology modalities spanned online learning, offline learning, virtual reality, and virtual patients. The control groups consisted of traditional PBL and traditional learning. The pooled analysis of seven studies comparing the effect of DPBL and traditional PBL reported little or no difference in postintervention knowledge outcomes (standardized mean difference [SMD] 0.19, 95% CI 0.00-0.38). The pooled analysis of three studies comparing the effect of DPBL to traditional learning on postintervention knowledge outcomes favored DPBL (SMD 0.67, 95% CI 0.14-1.19). For skill development, the pooled analysis of two studies comparing DPBL to traditional PBL favored DPBL (SMD 0.30, 95% CI 0.07-0.54). Findings on attitudes and satisfaction outcomes were mixed. The included studies mostly had an unclear risk of bias. Conclusions: Our findings suggest that DPBL is as effective as traditional PBL and more effective than traditional learning in improving knowledge. DPBL may be more effective than traditional learning or traditional PBL in improving skills. Further studies should evaluate the use of digital technology for the delivery of other PBL components as well as PBL overall. Published version

Background Effective communication skills are essential in diagnosis and treatment processes and in building the doctor-patient relationship. Objective Our aim was to evaluate the effectiveness of digital education in medical students for communication skills development. Broadly, we assessed whether digital education could improve the quality of future doctors’ communication skills. Methods We performed a systematic review and searched seven electronic databases and two trial registries for randomized controlled trials (RCTs) and cluster RCTs (cRCTs) published between January 1990 and September 2018. Two reviewers independently screened the citations, extracted data from the included studies, and assessed the risk of bias. We also assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations assessment (GRADE). Results We included 12 studies with 2101 medical students, of which 10 were RCTs and two were cRCTs. The digital education included online modules, virtual patient simulations, and video-assisted oral feedback. The control groups included didactic lectures, oral feedback, standard curriculum, role play, and no intervention as well as less interactive forms of digital education. The overall risk of bias was high, and the quality of evidence ranged from moderate to very low. For skills outcome, meta-analysis of three studies comparing digital education to traditional learning showed no statistically significant difference in postintervention skills scores between the groups (standardized mean difference [SMD]=–0.19; 95% CI –0.9 to 0.52; I2=86%, N=3 studies [304 students]; small effect size; low-quality evidence). Similarly, a meta-analysis of four studies comparing the effectiveness of blended digital education (ie, online or offline digital education plus traditional learning) and traditional learning showed no statistically significant difference in postintervention skills between the groups (SMD=0.15; 95% CI –0.26 to 0.56; I2=86%; N=4 studies [762 students]; small effect size; low-quality evidence). The additional meta-analysis of four studies comparing more interactive and less interactive forms of digital education also showed little or no difference in postintervention skills scores between the two groups (SMD=0.12; 95% CI: –0.09 to 0.33; I2=40%; N=4 studies [893 students]; small effect size; moderate-quality evidence). For knowledge outcome, two studies comparing the effectiveness of blended online digital education and traditional learning reported no difference in postintervention knowledge scores between the groups (SMD=0.18; 95% CI: –0.2 to 0.55; I2=61%; N=2 studies [292 students]; small effect size; low-quality evidence). The findings on attitudes, satisfaction, and patient-related outcomes were limited or mixed. None of the included studies reported adverse outcomes or economic evaluation of the interventions. Conclusions We found low-quality evidence showing that digital education is as effective as traditional learning in medical students’ communication skills training. Blended digital education seems to be at least as effective as and potentially more effective than traditional learning for communication skills and knowledge. We also found no difference in postintervention skills between more and less interactive forms of digital education. There is a need for further research to evaluate the effectiveness of other forms of digital education such as virtual reality, serious gaming, and mobile learning on medical students’ attitude, satisfaction, and patient-related outcomes as well as the adverse effects and cost-effectiveness of digital education.

Background Reducing childhood morbidity and mortality is challenging, particularly in countries with a shortage of qualified health care workers. Lack of trainers makes it difficult to provide the necessary continuing education in pediatrics for postregistration health professionals. Digital education, teaching and learning by means of digital technologies, has the potential to deliver medical education to a large audience while limiting the number of trainers needed. Objective The goal of the research was to evaluate whether digital education can replace traditional learning to improve postregistration health professionals’ knowledge, skills, attitudes, and satisfaction and foster behavior change in the field of pediatrics. Methods We completed a systematic review of the literature by following the Cochrane methodology. We searched 7 major electronic databases for articles published from January 1990 to August 2017. No language restrictions were applied. We independently selected studies, extracted data, and assessed risk of bias, and pairs of authors compared information. We contacted authors of studies for additional information if necessary. All pooled analyses were based on random effects models. We included individually or cluster randomized controlled trials that compared digital education with traditional learning, no intervention, or other forms of digital education. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. Results Twenty studies (1382 participants) were included. Participants included pediatricians, physicians, nurses, and midwives. Digital education technologies were assessed including high-fidelity mannequins (6 studies), computer-based education (12 studies), mobile learning (1 study), and virtual reality (1 study). Most studies reported that digital education was either as effective as or more effective than the control intervention for outcomes including skill, knowledge, attitude, and satisfaction. High-fidelity mannequins were associated with higher postintervention skill scores compared with low-fidelity mannequins (standardized mean difference 0.62; 95% CI 0.17-1.06; moderate effect size, low-quality evidence). One study reported physician change in practicing behavior and found similar effects between offline plus online digital education and no intervention. The only study that assessed impact on patient outcome found no difference between intervention and control groups. None of the included studies reported adverse or untoward effects or economic outcomes of the digital education interventions. The risk of bias was mainly unclear or high. The quality of evidence was low due to study inconsistencies, limitations, or imprecision across the studies. Conclusions Digital education for postregistration health professions education in pediatrics is at least as effective as traditional learning and more effective than no learning. High-fidelity mannequins were found to be more effective at improving skills than traditional learning with low-fidelity mannequins. Computer-based offline/online digital education was better than no intervention for knowledge and skill outcomes and as good as traditional face-to-face learning. This review highlights evidence gaps calling for more methodologically rigorous randomized controlled trials on the topic. Trial Registration PROSPERO CRD42017057793; https://tinyurl.com/y5q9q5o6

Background: Learning theory is an essential component for designing an effective educational curriculum. Reviews of existing literature consistently lack sufficient evidence to support the effectiveness of digital interventions for health professions’ education, which may reflect disconnections among learning theories, curriculum design, use of technology, and outcome evaluation. Objective: The aim of this review was to identify, map, and evaluate the use of learning theories in designing and implementing intervention trials of health professions’ digital education, as well as highlight areas for future research on technology-enhanced education via the establishment of a development framework for practice and research. Methods: We performed a systematic search of Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register of Controlled Trials (Cochrane Library), PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Education Resources Information Center, and Web of Science for randomized controlled trials (RCTs) published between 2007 and 2016. Results: A total of 874 RCTs on digital health education were identified and categorized into online-offline, mobile digital education, and simulation-based modalities for pre and postregistration health professions’ education. Of these, 242 studies were randomly selected for methodological review and thematic analysis. Data were extracted by one author using a standardized form, with a (48/242, 20%) random sample extracted by a second author, in duplicate. One-third (81/242, 33.4%) of the studies reported single or multiple learning theories in design, assessment, conceptualization, or interpretation of outcomes of the digital education interventions. Commonly reported learning theories were problem-based learning (16/81, 20%), social learning theory (11/81, 14%), and cognitive theory of multimedia learning (10/81, 12%). Most of these studies assessed knowledge (118/242, 48.8%), skills (62/242, 25.6%), and performance (59/242, 24.3%) as primary outcomes with nonvalidated assessment tools (151/242, 62.4%). Studies with reported learning theories (χ21=8.2; P=.002) and validated instruments (χ21=12.6; P=.006) have shown effective acquisition of learning outcomes. Conclusions: We proposed a Theory-Technology Alignment Framework to safeguard the robustness and integrity of the design and implementation of future digital education programs for the training of health professionals. Published version

Background: Globally, online and local area network–based (LAN) digital education (ODE) has grown in popularity. Blended learning is used by ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors; however, the evidence for its effectiveness and cost-effectiveness is unclear. Objective: This systematic review evaluated the effectiveness of online and LAN-based ODE in improving practicing medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes, and cost-effectiveness (secondary outcomes). Methods: We searched seven electronic databased for randomized controlled trials, cluster-randomized trials, and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. We have presented the findings narratively. We mainly compared ODE with self-directed/face-to-face learning and blended learning with self-directed/face-to-face learning. Results: A total of 93 studies (N=16,895) were included, of which 76 compared ODE (including blended) and self-directed/face-to-face learning. Overall, the effect of ODE (including blended) on postintervention knowledge, skills, attitude, satisfaction, practice or behavior change, and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher postintervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge scores (small to large effect size and very low quality) for the intervention, while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size and low quality), while 13 studies reported no difference in the skill scores between the groups. One study reported a higher attitude score for the intervention (very low quality), while four studies reported no difference in the attitude score between the groups. Four studies reported higher postintervention physician satisfaction with the intervention (large effect size and low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher postintervention practice or behavior change for the ODE group (small to moderate effect size and low quality), while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects or cost-effectiveness of the interventions. Conclusions: Empiric evidence showed that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training practicing physicians. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings. Published version

Background: There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown. Objective: The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior. Methods: We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors. Results: A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias. Conclusions: Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries. Published version

Background:\ud There is a pressing need to implement efficient and cost-effective training to address the worldwide shortage of health professionals. Mobile digital education (mLearning) has been mooted as a potential solution to increase the delivery of health professions education as it offers the opportunity for wide access at low cost and flexibility with the portability of mobile devices. To better inform policy making, we need to determine the effectiveness of mLearning.\ud \ud Objective:\ud The primary objective of this review was to evaluate the effectiveness of mLearning interventions for delivering health professions education in terms of learners’ knowledge, skills, attitudes, and satisfaction.\ud \ud Methods:\ud We performed a systematic review of the effectiveness of mLearning in health professions education using standard Cochrane methodology. We searched 7 major bibliographic databases from January 1990 to August 2017 and included randomized controlled trials (RCTs) or cluster RCTs.\ud \ud Results:\ud A total of 29 studies, including 3175 learners, met the inclusion criteria. A total of 25 studies were RCTs and 4 were cluster RCTs. Interventions comprised tablet or smartphone apps, personal digital assistants, basic mobile phones, iPods, and Moving Picture Experts Group-1 audio layer 3 player devices to deliver learning content. A total of 20 studies assessed knowledge (n=2469) and compared mLearning or blended learning to traditional learning or another form of digital education. The pooled estimate of studies favored mLearning over traditional learning for knowledge (standardized mean difference [SMD]=0.43, 95% CI 0.05-0.80, N=11 studies, low-quality evidence). There was no difference between blended learning and traditional learning for knowledge (SMD=0.20, 95% CI –0.47 to 0.86, N=6 studies, low-quality evidence). A total of 14 studies assessed skills (n=1097) and compared mLearning or blended learning to traditional learning or another form of digital education. The pooled estimate of studies favored mLearning (SMD=1.12, 95% CI 0.56-1.69, N=5 studies, moderate quality evidence) and blended learning (SMD=1.06, 95% CI 0.09-2.03, N=7 studies, low-quality evidence) over traditional learning for skills. A total of 5 and 4 studies assessed attitudes (n=440) and satisfaction (n=327), respectively, with inconclusive findings reported for each outcome. The risk of bias was judged as high in 16 studies.\ud \ud Conclusions:\ud The evidence base suggests that mLearning is as effective as traditional learning or possibly more so. Although acknowledging the heterogeneity among the studies, this synthesis provides encouraging early evidence to strengthen efforts aimed at expanding health professions education using mobile devices in order to help tackle the global shortage of health professionals.

Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice.\ud \ud Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction.\ud \ud Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence.\ud \ud Results: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals’ cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency.\ud \ud Conclusions: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change.