The presented study is a cross-sectional survey with a single evaluation time. Study participants comprised PSP nurses and HCPs who support patients and their families during the initiation of r-hGH treatment administered with the connected Easypod device.

All participating PSP nurses worked as third-party providers who were managed by the respective local affiliates of the health care business of Merck KGaA (Darmstadt, Germany) and offered the Easypod AR mobile app to patients as part of their r-hGH treatment initiation and education. They were invited by email by EK to respond to an online survey. There was no other involvement or influence by local affiliates, and each PSP nurse was asked to provide their individual consent to the survey and to respond independently. The invited nurses were from countries where the Easypod AR mobile app was already integrated into the PSP nurse care routine, including Hong Kong, Taiwan, Germany, Singapore, the United Kingdom, Australia, and South Korea. PSP nurses in Argentina also participated, based on preparation and training they received when the app was launched there in 2022.

Participants anonymously accessed an online form where they evaluated and commented on their experience with the use of the Easypod AR mobile app in their work educating patients in receiving r-hGH treatment. The researchers did not collect the participants’ contact details, as EK distributed the invitation to take part in the study to all eligible participants. The online questionnaire was based on the validated MARS questionnaire, which assesses, mostly using Likert scales (eg, 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, and 5=strongly agree) [23], whether an intervention is perceived as entertaining, interesting, customizable, and interactive [22]. It also addresses usability and perceived impact in terms of self-management. Regarding the association dimension (the self-management behaviors that the app is aiming to impact), and following MARS guidelines, we adapted the questionnaire for the administration of r-hGH using the connected Easypod device (Multimedia Appendix 1 provides more details on the adaptation of this dimension). We did not use the MARS information dimension since the quality of the information within the app was out of the scope of the study. Furthermore, we added a few additional questions on the subjective quality of the mobile app in the context of using it for patient support (eg, the impact of COVID-19 on using the app to support patient education). Finally, the survey included a qualitative feedback element to acquire additional context and understanding of the mobile app using questions such as “Please enter any feedback suggestions for the improvement of Easypod AR” and “Please enter any positive feedback about your experience with Easypod AR.”

The data were analyzed using simple descriptive statistics, and the qualitative feedback received is presented together with these data.

This project follows the ethical and deontological principles marked by the principles of the Declaration of Helsinki and the Convention of the Council of Europe for the protection of human rights and the dignity of the human being regarding the applications of biology and medicine of Oviedo. Special care was taken with respect to informed consent of the PSP nurses, their voluntary participation, and their right to leave the study at any time. The project was approved by the Ethical Review Committee of the University of Valencia, Spain (1807083).

This study took place within the context of treatment with r-hGH (somatropin; Saizen, the health care business of Merck KGaA, Darmstadt, Germany) and the r-hGH digital health ecosystem, comprising the Easypod connected injection device, Easypod Connect for HCPs, the Growlink app for patients and caregivers, the integrated PSP nurses, and the TuiTek adherence support behavior coaching program. This evolving platform of digital health solutions connects HCPs with their patients and their caregivers to support optimal treatment adherence and deliver HCP insights to support clinical decision-making to achieve the best possible growth outcomes. Figure 1 illustrates how patients using the connected Easypod device work with PSP nurses within the context of the r-hGH digital health system.

The participants in this study were r-hGH PSP nurses who worked for the services provided by the health care business of Merck KGaA, Darmstadt, Germany. These nurses provide support and training to patients receiving r-hGH. In addition, the prescribing HCPs had access to a remote dashboard to monitor patient adherence [24] to the Easypod device and facilitate communication between themselves and the patient and their caregiver [9]. Previous studies have shown high levels of adherence in patients using Easypod and also observed clinically significant changes in height and mean growth velocity [25].

The Easypod AR mobile app was specifically developed to help educate and support patients and their families using the connected Easypod device to administer r-hGH. It is a digital and interactive tool that contains the instructions for using the Easypod device to administer r-hGH (Figure 2). The tool aims to help patients better understand the steps of the injection process using AR technology to provide an immersive learning experience. The app is also intended to help HCPs resolve questions that patients or caregivers may have and provide support between visits.

The Easypod AR app was launched in 2020 and had over 1000 users as of December 2021 in the countries where the study was performed (Hong Kong, Taiwan, Germany, Singapore, the United Kingdom, Australia, and South Korea). The average amount of time that these users spent with the app per session (defined as one user opening the mobile app) varied by country but averaged between 8 and 14 minutes, which is a considerable duration for a mobile app [26] and may reflect patient engagement during treatment initiation and PSP-delivered training.

The nurses reported average positive results in all 5 subdimensions of engagement (entertainment, interest, customization, interactivity, and adaptation to the target group). All reported mean scores were ≥3.0 (Table 1; Multimedia Appendix 1 provides details of the specific rating scales for each dimension). The highest mean score reported for engagement (adaptation to the target group) was 4.0 (SD 0.74). The lowest score (3.3, SD 0.97) was reported for entertainment, which aligns with qualitative feedback that suggested adding more engagement features such as gamification elements.

Within the dimension functionality, the highest score (4.1, SD 0.79) was reported for navigation, while the lowest (3.8, SD 1.03) was reported for performance. The qualitative feedback provided by the nurses showed that in some devices, the app was slower than desired, which might reflect the use of mobile devices with fewer technical features; this might have compromised the performance of the app, which has substantial 3D visualizations and AR.

Within the dimension related to aesthetics, the average score was positive for all elements, but the highest score was reported for graphics (4.1, SD 0.67) and the lowest score reported for visual appeal (3.7, SD 0.81).

The MARS questionnaire also includes a perceived association dimension, which in this case was related to the administration of r-hGH using the connected Easypod device. The perceived impact scaled positively across all subdimensions, notably exceeding in knowledge, emotions, and help-seeking (Table 2).

The subjective quality of the mobile app was high, with 70% (16 of 23) of the respondents saying that they would recommend it (Table 3). Also, the average rating was quite positive, with an average of 3.5 on a scale from 1 (worst) to 5 (best).

Fourteen of 23 participants reported that they “especially liked” or “strongly liked” the potential to reduce fear of injections (eg, “Relieving anxiety about injections”). Also, one nurse reported that the app might be useful for training children and parents together (eg, “Easy to use, parents and children can engage training together”).

As explained in the Methods, we included some questions about the impact of COVID-19, because the introduction of Easypod AR occurred at the same time as the global pandemic. Indeed, of the participating nurses, 12 answered that yes, they believed such a mobile solution could improve patient education in the context of such a public health situation.

This study investigated the experiences of nurses who used a mobile app to support patient training and education within a PSP that was mostly virtual (phone-based). The results are quite encouraging in terms of the positive feedback received from the nurses; these results are aligned with previous studies on the use of AR in nursing care [21] and pediatric patient education [18-20]. Furthermore, the average rating of the app was quite positive when compared with examples used in MARS testing [22]. The results also showed areas for improvement in terms of technical aspects that might also be related to the heterogeneity of setups (eg, different smartphone capabilities and internet connections). Qualitative feedback suggested adding gamification elements, which have the potential to support adherence to r-hGH therapy [27]. Our study adds to the previous literature due to its international nature, with nurses participating from different countries who all worked in specialized care (pediatric endocrinology) using telehealth. Importantly, this shows the potential of AR-based approaches to support patient education across different health care systems.

International recommendations state that nursing involvement is needed in the development and application of artificial intelligence–based technologies in nursing [28]. However, research indicates that nurses are traditionally not sufficiently involved in the development of these technologies [29]. This study also shows the potential of involving nurses in the evaluation and assessment of digital health solutions that can, in fact, help increase digital health literacy [30] among those HCPs who are involved in patient education and are consequently also able to advise patients on mobile health solutions. This is especially important in growth-related disorders, where there have been concerns about the quality of some available mobile apps [12].

Our study has some limitations. The use of a survey (MARS) has many inherent limitations (eg, a lack of detailed qualitative feedback). Also, here, a modified version of the survey was used; in particular, we did not address the information dimension in the standard MARS survey, as it was not pertinent to the research objective, and we added a few complementary questions (eg, impact of the COVID-19 pandemic). Furthermore, our study did not address the objective impact on patient education outcomes (eg, reducing errors or promoting adherence), as this would have required a separate study design. Therefore, future research is needed to explore the patient’s perspective.

Our study addresses the acceptability of an AR-based mobile solution to support nurse-led patient education from the nurses’ perspective, but we did not address the quantifiable impact in nursing practice. Although there is evidence supporting the use of AR in nursing [21], few studies have looked into how this mobile solution impacts clinical encounters. An example outside of the domain of pediatric endocrinology is Sisom (from the Norwegian phrase “Si det Som det er,” meaning “Tell it how it is”), a computer-based animated tool that analyzed the impact of a mobile solution in communication between pediatric oncology patients and nurses [31,32]. Future research using an experimental study design could investigate how mobile solutions impact the quality of nursing encounters in patient education for r-hGH therapy.

The Easypod AR mobile app was well-received by nurses involved in the training of patients with GHD for the administration of r-hGH, especially with regard to nurses’ perceptions about the potential to improve patient education, improve self-management, relieve anxiety about injections, and encourage patients and their families to seek further support from PSPs.