The Far-Reaching Telehealth and Telemedicine on Health Education, Consultation and Monitoring

#### **Chapter 1**

## Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping Dependency Therapy Scenarios for Future Telehealth

*Maria Cecilia Vega-Corredor, Simon Hoermann, Alison Watkins and Melanie Tomintz*

#### **Abstract**

Vaping, or the use of electronic nicotine delivery systems (ENDS), has grown rapidly worldwide and is becoming an epidemic among youth in many countries. Invented as a method to help to quit smoking, ENDS are very popular, reaching increasing numbers of users and becoming a health concern. Virtual reality technology (VRT) represents an important tool for conducting addiction-associated interventions, including telemedicine. The design and quality of virtual reality scenarios (VRS) used for VR interventions are fundamental. How well VRS can replicate real-world scenarios has an impact on how realistic the VR immersion experiences are. Thus, VRS development influences therapeutic outcomes. VRT is used for interventions and treatments for smoking-related nicotine addiction but has yet to be validated for vaping-related disorders. Since vaping represents a technological step forward in nicotine consumption, the accurate contextualization of environments surrounding vapers is fundamental for developing advanced VR tools for the prevention and treatment of vaping disorders. Here, we present the results of focus group discussion with young vapers in New Zealand. The knowledge gained from this study will be used to design VRS for cue exposure and reactivity as a first step toward developing effective solutions for vaping disorders using VR interventions and telemedicine.

**Keywords:** virtual reality (VR), electronic nicotine delivery systems (ENDS), vaping, nicotine dependence, interventions, VR in telemedicine

#### **1. Introduction**

Vaping, which refers to the use of electronic nicotine delivery systems (ENDS, e-cigarettes, vapes, or nicotine vaping devices), has grown rapidly worldwide [1, 2], and is currently considered to be an epidemic among teens and young adults in

countries, such as the United States [3]. From an initial cig-a-like device, developed to help to quit smoking, ENDS evolved rapidly into a wide spectrum of gadgets that are used either as tobacco cigarette replacements or for recreational purposes, transforming vaping into a paradigm of its own. Despite being relatively new, ENDS have been subjected to extensive study, with research topics ranging from vaping demographics to their latest technological developments. Nonetheless, as the number of vapers grows, many gaps exist in what is known about vaping, especially in fundamental issues such as those related to long-term health effects [4] and addiction. However, vaping has been shown to be a multifactorial practice that not only relates to a physiological need for nicotine but also responds to different cultural, socio-economic, and psychological aspects that are yet to be fully understood. In order to characterize vaping contexts, some consumers' features, such as ENDS or smoking habit (tobacco cigarettes, hookah, or waterpipe tobacco), use history and status may be of help by providing some evidence in the effort to achieve a better understanding of this trend. Thus, vaper status, such as if they are ex-smokers, dual users, or vape only, has been identified [5]. According to the user status, the context surrounding vaping, preferences, habits, and behavior may change. Therefore, the approach to study vapingrelated problems should be adjusted accordingly.

Aside from conventional methods used in interventions and treatment of behavioral and health disorders, virtual reality technology (VRT) represents a reliable and more personalized technique that can be used under well-developed and lifelike controllable settings [6]. VRT has already been used satisfactorily for craving assessments, cue exposure, and cue reactivity therapy for smoking-associated interventions and treatments [7]. As vaping is associated with smoking and mainly with nicotine use, VRT may be suitable for the study of vaping-related disorders. Nevertheless, a key factor in the implementation of VRT for the study of behavioral and substance use disorders depends on how well real-life situations, locations, and features associated with the targeted condition are identified and characterized. Realistic representations are fundamental to inform the development of virtual reality scenarios (VRS) in which the VR studies take place. These technical systems provide a 3D vision, 360-degree range, and head tracking where the recreated real-life situations are presented [8]. The design and technical development of the VRS will determine how inclusive, extensive, and vivid the resemblances that the system generates are. Thus, it determines how good the VR immersion experience can be and influences the perceptions and reactions experienced by each patient. Recently VR and telehealth have effectively been used to provide different types of interventions, which not only can help improve health conditions but also enable social connectedness and psychological support. For many, in-person consultations may be difficult and costly. VR in telehealth allows the interactive use of online scenarios that represent a cost-effective solution for those who need treatment but for some reason are unable to visit their therapist or doctor's office [9].

As vaping is relatively new but growing at a rapid rate, the situations, locations, and reasons why people vape may be dynamic and changing according to time and geographical location. In New Zealand (NZ), nicotine e-liquids started being sold legally in 2018 [10]. Since then, the country's policies have been changing, and more recently, additional regulations toward vaping products have been put in place [11]. In recent years, NZ has experienced a sharp increase in ENDS use, mostly in teens [12]. In parallel, tobacco cigarette taxes were increased under a plan to achieve a smoke-free country by 2025. This plan included campaigns to switch to vaping as a way to stop smoking tobacco cigarettes [13]. As ENDS evolved rapidly, vaping represents a technological step forward into a new way of nicotine use and dependence [14], which although presented as a less harmful

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

and disruptive way to use nicotine, may signify an underlying cause of long-term health issues. Understanding and accurately characterizing the environments and contexts in which people vape, and the reasons why is fundamental for developing strategies and advanced aid tools in the current and future health issues associated with vaping.

This qualitative study was part of a wider project that aimed to develop and test VRS associated with vaping. The aim of this study was to perform focus group discussions to inform our research about real environments where young people vape in NZ. Thus, we interviewed a diverse sample of university students who had experimented with ENDS, to learn about their vaping experiences. The final VRS will be used for the study of vaping cue exposure and reactivity in VR and telehealth interventions and treatments.

#### **2. Methods**

Focus group discussions were conducted to gain knowledge directly from young adults about their motivations, habits, behavior, contexts, and views associated with vaping. Grounded theory was used as the conceptual research approach [15] since at the time of the study, vaping characteristics and contexts in NZ were not fully identified and a better understanding of the concepts surrounding this practice was necessary to inform the development of realistic vaping VRS. Four focus group sessions were conducted from September to November 2019 at the University of Canterbury (UC - Christchurch, NZ). Recruitment of participants was conducted via an advertisement on UC's social media, TV media, and an event management website. The theoretical sampling method [15], a qualitative method for data collection based on obtaining concepts from data, was used to gain insights into NZ's vaping contexts. We recruited university students that have previously used ENDS.

#### **2.1 Recruitment**

Inclusion criteria: being 18+ years having vaped in the past or at the study's time. Exclusion criteria: having addictions different from smoking or vaping, suffering from mental illness, being associated with a vaping company, and using other nicotine replacement products (nicotine patches, chewing gum, or lozenges). At first contact, all prospective candidates were informed about the project and the focus group aims and checked for inclusion and exclusion criteria.

#### **2.2 Participants**

Nine students were selected to participate in the focus group discussions, from whom 7 were males (M) and 2 females (F). The groups composition was: group 1: n = 3 (M); group 2: n = 3 (1F, 2 M); group 3: n = 1 (M); group 4: n = 2 (1F, 1 M). The groups were not arranged by any specific participant characteristics related to vaping habits or views.

#### **2.3 Focus groups procedure**

All sessions were scheduled to last up to 2 hours. Before each session, consent forms and questionnaires regarding demographics were distributed and completed by all participants. At the beginning of each session, the moderator gave an introduction, informing each group about the project aim and explaining the focus group objectives, procedures, and ground rules. Verbal consent was requested for video and audio recording. Additionally, participants were assured of anonymity and data confidentiality. Everyone chooses a nickname to be addressed during the discussions. All participants were informed that nicknames will be replaced by codes during the transcription process. The raw recorded data can only be used as material for publications related to the research project.

While any assumptions about users' views, experiences, and behavior associated with vaping were not pre-established, semi-structured interviews [16] were conducted throughout the focus group sessions. Thus, with the aim to cover the study's objectives, an interview guide was developed. Four main topics were considered: background, current context, triggers, and reactions. For each topic, questions were elaborated, aiming to prompt each participant to provide open, free, and in-depth answers. The semi-structured interview scheme helped to steer the discussions while allowing for flexibility [16]. Questions were not necessarily asked in the same order and the moderator was free to follow digressions or asked for clarification if required. Probes were used in some questions to facilitate the process. All participants were free to give any personal opinions. At the end of each session, a small financial token was given to the participants to compensate them for their time. The UC Human Ethics Committee approved this study.

#### **2.4 Transcriptions and coding**

All focus group interviews were transcribed into text documents and coded using NVIVO software. At first, using the interview guide, all participants' answers were grouped by related questions. Next, codes were created by finding and grouping similar responses, as well as individual/uniquely relevant answers. Once the data search was exhausted and all possible codes were defined, codes were grouped by theme/topic.

#### **3. Results**

#### **3.1 Demographics**

The total number of participants was nine (2F and 7 M). The mean age was 24 years; hence, most participants were considered as young adults, from which four were New Zealanders, four Indians, and one German. All participants were students at UC (3 undergraduate and 6 postgraduate) (**Table 1**).

#### **3.2 Participants' vaping profile**

In this study, for data analysis, all participants were classified according to their vaping profile:


*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*


#### **Table 1.**

*Demographics of ENDS users who participate in vaping focus group discussions (UC, Christchurch NZ, 2019).*

• *Current frequency of use*: frequent (few times per week/daily), occasional (sometimes per month), and rare. Thus, according to the habit type, there were five dual users (tobacco and e-cigarettes), two ENDS users only and two hookah users. One of the dual users (FG1M1) presented himself as a predominantly tobacco cigarette smoker (occasional e-cigarette user), and one hookah user (FG3M1) stated that he rarely used tobacco cigarettes, therefore, he was classified as a hookah user (**Table 2**).

#### **3.3 Background: length of use, vaping factors associated with start and continuing vaping**

The earliest and latest first use of ENDS by participants were reported around 2009 (FG1M1) and 2018 (FG2M1). Reasons to start vaping were not necessarily associated with one aspect only. Instead, they were a combination of different factors, for six participants the financial aspect was the main reason to start vaping. All five dual users associated high prices of tobacco cigarettes and how ENDS prices help them save money. Other main reasons were: ENDS are more socially acceptable (4 participants), peer pressure (3 participants), and out of curiosity (2 participants). Moreover, only two dual users mentioned quitting smoking as an additional reason to start vaping and one dual user mentioned the need to reduce the intake of tobacco cigarettes. In particular, one participant mentioned a personal relationship: *"I wanted to switch because my girlfriend was like really piss off at me smoking and then so it didn't* 


*\* Hookah classification was based on the mechanism to heat and deliver the tobacco smoke used by the hookah, in which the tobacco is heated with charcoal and the smoke is cooled by passing it through water.*

#### **Table 2.**

*Code and classification of ENDS users who participated in vaping focus group discussions (UC, Christchurch NZ, 2019).*

*really come from me"* (FG1M2)*.* Another mentioned the technological convenience of it, and smell: "*The fact that you don't have to carry a lighter where you go, it seems like a technology advance which was interesting […] smells good"* (FG3F1). Only one participant mentioned health as an important reason to start vaping. Among dual users, three participants experienced an intermittent pattern of ENDS use, for example, "*Yeah, so I probably have been vaping for about 263 days but, before that, I had probably vaped half a year before and then stopped after a party sort of went out of track. [I] started smoking cigarettes with friends and then sort of went back to rolling cigarettes for about 3–4 months and just went back to vaping because I've had a bit of breakdown about it. I don't want to be wasting money and the fact that I had a lot at stake…"* (FG1M3). In relation to factors associated with continuing vaping, after the initial onset, these included: nicotine (3 dual users), flavor (2 hookah users and 1 dual user), hanging out with friends or socializing (2), convenience and enjoyment (1 dual user): *"It's more convenient than sitting down to have a cigarette because you can vape in the car […] without like, stinking like tobacco smoke, so that's probably the main reason why I'm still using […]. Like it's fun so I mean I use it for enjoyment"* (FG4M1). In addition, two participants had already stopped vaping.

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

#### **3.4 Vaping context: frequency of vaping (currently or at the time of ENDS use), e-liquids preferences, nicotine awareness and relevance, devices used, and common places where participants vape**

In general, the participants did not manifest having clear patterns of vaping, their use seemed to be irregular and related to their personal needs or convenience. Keeping this in mind, at the time of the discussions, four participants considered their ENDS use as frequent (3 active and 1 stopped), three occasional, two rare, and two had stopped vaping (**Table 2**). In relation to e-liquid preferences, fruit flavors were the most popular (4 participants). Strawberry, apple, grape, watermelon, and guava were the most commonly used. Three persons indicated menthol and mint as their favorites. For hookah users, bay leaves, and "chilly ice" flavors were preferred. Tobacco flavor was not chosen by anyone, for example, "*I have tried it, like I don't like the tobacco flavor, I like the taste of tobacco I don't like the taste of tobacco vape*" (FG4M1). *"I tried tobacco [vape] [I] absolutely hated it […], smells like tobacco but it doesn't taste like tobacco, not sure at all*" (FG1M2). In addition, for one dual user fruit flavors have helped him to reduce smoking tobacco cigarettes: *"… I changed to grape flavor and it was quite different to the actual cigarette flavor, because the tobacco vape doesn't taste like a cigarette at all […] when I started using the grape flavor […] my mind can separate the two, vaping/smoking, so it's sort of why I think it helped me move away from that*" (FG1M3).

Concerning awareness of nicotine presence in e-liquids and related relevance, five participants were aware of it (4 dual users and 1 ENDS user) and four were not (2 hookah users, 1 ENDS user, and 1 dual user). Notably, one hookah user was not aware of nicotine presence in tobacco used in hookahs: "*Because, when I used to smoke, that was like free of nicotine, just the flavor thing so […] that was like ok, not much harm that I'm doing."* Moreover, when asked about the importance of nicotine presence in e-liquids, most of the participants (7) found nicotine critical, for example, "*I mean for the most part doesn't matter the flavor, there is no vape purpose if there is not nicotine, […]. There's not really much point doing it, without the nicotine*" (FG1M3). Nevertheless, for some participants nicotine was a matter of concern, for example, "*I usually try to get non-nicotine*. *I'm just trying to not get addicted to nicotine*" (FG2M1). In addition, for the second hookah, user nicotine content was not as important as it was flavor.

The levels of nicotine more frequently used by participants varied between low (0–3 mg/ml) to very high (salts) >18 mg/ml. One dual user compared his nicotine addiction to caffeine addiction: "*I would most often buy the lowest, which is 3 mg/ ml, and that's down to like I am addicted to nicotine but in the same way that someone is addicted to caffeine. Like you would not go in the morning without a cup of coffee just because you do not want to and so I choose the nicotine option*" (FG4M1). Another dual user associated levels of nicotine used to circumstance: "*I usually use 6 mg/ml, I also use 50 mg or 30 mg […], because [I] jump onto the top occasionally if I'm just stressed out, but because I do that I don't know the exact amount when I do that*" (FG1M3). In addition, two dual users were taken by surprise when they learned about different levels of nicotine in e-liquids: "*I never considered that, because I never thought that there would be different levels of nicotine, or that you can get it free of nicotine. I picked fruity flavors because I like them, but if I knew, I'd prefer the ones with lower nicotine*" (FG3F1); "*Even the mint ones will have nicotine on it? oh"* (FG1M1). In addition, two participants

indicated not having a vaping device, adducing that when needed they could just use their friend's, for example, "*If I wanted to use, I could use somebody else's"* (FG2M1).

When asked about places for vaping, more than actual locations, answers related to a situation: hanging out with friends (7 participants), for example, "*If you are doing it alone, that's sad"* (FG3M2). Associated locations were at home (2), in a bar (2) outside (2), shisha bar (2), anywhere (2), and in the car (1). Some relevant statements included: "*In the car mostly***.** *Because then you don't have to take time out of your day. […]. It's quite fun to take to parties and stuff, stops you from smoking cigarettes at a party. If I'm like out drinking and smoking cigarettes I can [go] through like 5 or 6 [cigarettes] and it's quite expensive*" (FG4M1). "*If I'm just walking down the street then I would have had a smoke or if I'm waiting somewhere, vaping is […] quick, you just sort of do it, wherever. If you got a cigarette, it's a time constraint as well because you're like burn it, it takes a couple of minutes, the vape is two seconds*" (FG1M3). Additionally, some frustrations about current bar smoking/vaping rules and settings were stated: "*Lots of bars I don't quite like because if somebody is trying to vape exclusively and [don't want] to come back to the cigarette, you are sort of forced into the cigarette area […]*" (FG1M2). Interestedly, some participants (5) found sharing devices, a commonly accepted practice, for example, "*I mean sometimes, if I'm at a party, somehow it gets around […] I really don't have a problem with that as long as it returns to me, no one breaks it"* (FG1M3).

#### **3.5 Triggers: situations or feelings that triggered cravings for vaping**

Regarding visual stimuli acting as a vaping trigger (e.g., seeing others vaping), four dual users answered that it does not. Conversely, seeing others smoking tobacco cigarettes can be a trigger for smoking, for example, "*Vaping does not really trigger me, smoking does trigger me for smoking*" (FG1M2). Two participants found some association, for example, "… *If I see other people vape, I feel more inclined to do it*" (FG2M1); "*I think that depends on the situation and where I am. The other day [in] a bar there were people vaping, I felt the temptation of vaping, but when I'm walking to the university and I see other people vaping I do not feel the need, because I'm coming here to study so my focus is on the studies I don't feel tempted then"* (FG3F1). Moreover, one dual user indicated that the ENDS "artificial" look causes him to have a mental block *"… For me, it's so robotic, the vape, it doesn't have the organic, I mean the cigarettes are still a plant, still lights, but vape, just feel like you are taking a machine into your body, like in a hospital kind of thing, you're check in for the machine. Maybe for me, that's part of the mental block: sure, you got the nicotine hit, but it looks too artificial. I feel, no men no*" (FG1M1). Concerning the smell of e-liquids acting as cravings triggers, only three participants (1 dual user, 1 hookah user, and 1 ENDS user) were positive, for example, "*I prefer the smell of fruit, so, when I smell cigarettes, I don't feel tempted, but with fruity vapes, I do feel the temptation to try again"* (FG3F1). In addition, vaping advertising or vaping shops did not trigger vaping cravings.

To the question of stressful situations acting as vaping triggers, three participants found some association to unspecified stressful situations, for example, *"If things are not great, I probably will be vaping a lot more. It's a coping response. Again, and then it becomes this point there's bigger things to worry about yeah, right?*" (FG1M2). Moreover, two participants may use either, under highly stressful situations, for example, *"It kind of depends on how I feel like at the time, but also like the severity of it. So, if I just had like a really traumatic event I probably just go straight and have a cigarette but like I mean, the same effect from vaping, but cigarettes are just quicker and stronger"* (FG4M1). Two participants also found studying a stress-related vaping trigger. The remaining participants did not find any relation.

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

When exploring deeper, views regarding the role of social contexts as vaping triggers, four participants' (3 dual users and 1 ENDS user) answers were affirmative, for example, "*It's like the worst, being the [odd] one out […] everyone is smoking and you are not smoking. For sure if anyone is passing around a machine, I want a piece of the machine*" (FG1M1). On the other hand, one dual user who previously lived overseas noted that, since he moved to NZ, smoking and vaping has changed from a very socially driven practice to a very lonely experience: "*now it has become like the completely solitary thing it used to be a very special thing, very social thing … but that doesn't happen that often [now]*" (FG1M2). The fact that vaping can be seen as a solitary practice was also shared by another dual user. In addition, one dual user found that social situations might not necessarily represent a trigger factor or a reason to vape: "*Probably [socializing] doesn't really make a difference. So, I just got a vape when I feel like it and sometimes, I might be around a crowd of friends, that none of them vape or smoke, so to that event I wouldn't bring my vape, but other times yeah, [I will] be going out maybe [with] people that I'm going with vape or smokes, and so I bring my vape along*" (FG4M1). For the hookah users, rather being than a trigger, socializing was a situation in which, in order to hang out, vaping was compulsory: "*being in a party, I used to do it. If I didn't do it, it would be like turned down from the group […] So we have to participate, even if you have only one drag, you have to, it's the kind of thing"* (FG3M2).

#### **3.6 Reactions and views associated with vaping: Moods, benefits, harms to health, smoking vs. vaping, quitting smoking, participants' plans to quit vaping**

Seven participants indicated feeling relaxed, as the mood most associated with vaping, followed by: happy (4 participants), focused (2), and stimulated (1). Some participants indicated more than one mood associated with vaping, for example, "*All of the time it's relaxing. Some of the time it can cheer you up, if you are just a bit moody that day or whatever, go for really nice vape [and] you're happier because of it*" (FG4M1). The same participant voiced some concern: "*In terms of vaping you don't seem to have that finish point [as] with a cigarette […], with vaping it's not. [Instead it's] 'give me another hit, give me another hit', kind of thing. That is a big negative of vaping for me because I can see myself just sitting [vaping]*" (FG1M1). Nevertheless, in relation to the benefits found with vaping, several reasons stand out: making friends, a feeling of belonging, peace, fun, it helps work better, psychological control, and it does not interfere with daily activities, such as working out as much as cigarettes can do.

The perceptions associated with harm to health from vaping vs. harm caused by smoking tobacco cigarettes were as follows: six participants found vaping less harmful than smoking cigarettes, and for two others more data/research is needed to determine vaping's long-term health risk. One believed that vaping is as harmful as smoking tobacco cigarettes and for other, vaping represented a risk due to the e-liquid intake: "*For me, that would be a big risk of vaping, you seem to be a seat in a trap, you seat there a lot more, take a lot more on*" (FG1M1). In addition, when asked about their opinion on whether using both (ENDS and tobacco cigarettes) was healthier than only smoking tobacco cigarettes, four dual users answer yes, and one (dual user) said that using both, although it may help regulating and cutting down smoking and use of tobacco cigarettes, may have a nicotine addictive effect. One hookah user indicated that using both is less healthy than smoking only, and two more participants considered the opposite.

Dual users were asked about how ENDS helped them to quit smoking tobacco cigarettes. For this, two participants re-stated their relapses. In one case, the participant had recently managed to quit smoking for 3 months before relapsing. Another had managed to exclusively vape for several months, after earlier relapses. A third one acknowledged a failure in this regard: "*Nah, failed [I] started 10 years ago, it didn't work. Now I thought about trying again, [but] it hasn't work[ed]."* For some others, quitting smoking by using ENDS can only happen with discipline: "*It alleviates the cravings pretty quick. Like, you only need to do like one puff really, to stop smoking a cigarette, so it's quite effective in that regard. It feels like, if you were trying to cut out the smoking, then you need to be quite disciplined with the vaping because it's pretty easy to pick up the vape and vape more than you should."* Moreover, when asked about how satisfying vaping was, six participants felt satisfied, from which two (dual users) commented: "*To save a lot of money, exactly. Yeah, like I said before, I love it. I feel a little bit less tired. Like the stomach upset wise, my throat feels a little bit better than when I was smoking [only] and again comes down to right now I just don't care enough, I think you really need to care about your health at some point if you want to quit smoking*" (FG1M2). "*For me, it's been a financial benefit […] I guess it has brought a social benefit in the sense that I don't feel the need to [smoke]. So, [it's] mainly financially better for me, and obviously, some health benefit, because there was a period when I was heavily smoking for a while but I just can't taste anything…"* (FG1M3). Despite being positive, another dual user voiced concerns: "*I think that it's a good alternative, and especially as there's more research into it. I think that the ban on the nice flavors is probably a good idea because I don't like the idea, myself included, that people just vape for fun, because it's just a good way to get really addicted to nicotine […], so if you are using it to cut out the cigarettes, I think it's a good alternative.*" On the contrary, one person did not find it satisfactory: "*I don't know, it just feels like, a waste of money you don't get much for it […]. I don't enjoy it as much …"* (FG2M1).

In regards to recommending vaping as a way to quit smoking tobacco cigarettes, mixed opinions were given: for three participants it was an option, for example, "*I think it's a good alternative because it gets you a lot more control over exactly how much nicotine you get.*" Three other participants had doubts, for example, "*I do n't know about it because I've got so many mates, including myself, who tried to quit that way they bought it and they haven't. So, for me to recommend that to someone seems a bit disingenuous."* Moreover, one participant would recommend it as a way to help reduce the tobacco cigarettes intake. Another one recommended it with warnings: "*I feel like if somebody is at the point where they start really caring, then I'll tell you to use a vape to try to quit. For me it [has been] such a rollercoaster […] you need to know a lot of things before you start this and if you pick wrong on the nicotine level, you might hit your tolerance like crazy it's very tempting to always do it […] like I've gone to hell and back with my tolerance based on vaping*" (FG1M2).

The final question asked, was related to plans to quit vaping, to which only one participant considered quitting a possibility: "*Yeah, probably. I don't do it much at the moment […]. Well, likely to do it […] my friends are stopping doing it […] I'll see*" (FG2M1). Four participants were not considering quitting in the foreseeable future, for different reasons, such as occasional use (1 hookah user) and intermittent use (1 dual user), do not consider nicotine addiction as a bad thing (1 dual user): "*I mean, probably not [quitting], just because I don't really see having a nicotine addiction as a bad thing […]. I enjoy it, and I think probably right now it brings me more benefits to my life than the negatives […], the whole reason for vaping in the first place is for the nicotine*" (FG1M3). The final related statement was: "*Now, like I said that's one of the things I would really need to [quit], and I know that, but that doesn't mean that [it] can change for the foreseeable future I don't think so*. *When I get off the nicotine, I'm not functional at all, and that's the big issue right now*" (FG1M2).

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

After finishing covering all focus groups' topics, the recording systems were turned off and all participants were thanked for their participation and were asked any further questions about the project and the focus groups discussions.

#### **4. Discussion**

Analyzing the participants' demographics, the cultural and ethnic diversity of the group was evident. Their diverse backgrounds allowed us to have a glimpse into different geographical and cultural contexts surrounding ENDS use. Cultural and geographical contexts should be considered when working toward the development of more targeted and personalized VRT and telehealth services, since they may influence the subject's level of immersion and sense of presence during a VR intervention and, therefore, their physiological and psychological responses [17]. While the resulting information from the number of participants interviewed does not provide a comprehensive representation of the vaping community in NZ, it shows some of the varied factors influencing vaping in our universities. A limited number of participants has not been an impediment to carry out similar qualitative studies in the past [18]. In our study, despite a comprehensive recruitment campaign, only a small turnout of candidates was obtained. Nevertheless, the information acquired not only has provided valuable insights from the participants' perspectives but also has contributed toward gaining a better understanding of how students from diverse backgrounds adapt their vaping habits for NZ university contexts. Statements gathered in these focus group discussions will contribute toward VRS development that resembles more accurately situations and environments related to vaping among young people.

The financial benefit when compared to smoking tobacco cigarettes was the main reason why the participants started vaping. It is remarkable how the lower prices of vaping products influenced the participants' transition toward a more affordable source of nicotine. While higher taxes on tobacco products may be associated with a decline in tobacco smoking, conversely, it may have also influenced the increase in ENDS use [19]. In this regard, before making any assumptions, it is important to consider that, although ENDS have been promoted as a less harmful option than conventional tobacco, there are increasing concerns regarding their long-term health risks, which are already a matter of public health debate [20]. Advance long-term studies are needed to come to definitive conclusions [21]. Furthermore, our findings about the reasons why the participants continued using ENDS were associated mainly with two factors: nicotine and flavor. Together with the perception that ENDS are less harmful to health, these have been identified previously as some of the main reasons why vaping are so popular among teens and young adults [22, 23].

While vaping has become a viable nicotine alternative to many, for some of our dual users, ENDS did not satisfy completely their needs, and stopping smoking tobacco cigarettes was not seen as an option in the foreseeable future. Compared to tobacco cigarettes, ENDS deliver lower levels of plasma nicotine, which can produce an unsatisfied feeling in dual users, inducing them to increase their nicotine intake, either by smoking, vaping, or using more of both [24]. Thus, some dual users may face not only nicotine dependency issues but also potential health problems, such as respiratory and heart conditions [24]. Noticeably, quitting smoking was not found to be one of the main reasons to start vaping, similar to other studies [25, 26], where health, curiosity, or financial reasons had a more relevant role in making the decision. In addition, some dual users in our study indicated having a recurrent pattern of intermittent phases between tobacco cigarettes and vaping and/or using both during the same period. In a recent study [23], similar transitions from single to dual or from dual to single-use were described in one out of three study participants, who were all adolescents (13–18 years old). In our study, the majority of participants were young adults and the pattern described here was spontaneously stated by them rather than being a pre-established assessment.

In regards to e-liquids of choice, as previously established among youth, young adults, and adult vapers [5, 27], flavored products were the most popular ones, among our study's participants. Moreover, in relation to flavors, fruit e-liquids were preferred, followed by menthol, as has been reported previously [28]. Similar to the findings of a recent survey carried out in North America [29], tobacco flavor was not popular, but rather was considered unpleasant. As indicated, flavored e-liquids have become topics of research and discussion since they are determinant factors for vaping initiation and may act as a gateway to smoking cigarettes and nicotine dependency [30–32]. Regardless of the source, nicotine dependency has been associated with disturbances of cognitive development in teens and young adults [33]. In addition, recent studies have reported the presence of toxic substances in vape aerosols [34] and the findings of traces of some chemicals in menthol mint and fruit-flavored e-liquids that increase the risk of cancer [22]. Nevertheless, in some cases, flavored e-liquids have been reported to help some users to cut down on tobacco smoking [35], as was reported by one of our participants. In this regard, the use of flavored e-liquids has been suggested for use in self-help for smoking cessation, alongside other intervention types, such as educational videogames [36, 37], which may be further developed toward targeted VR and telehealth.

In this study, nicotine (the presence and level of) was a determining factor for vaping among some participants (mainly dual users). Notably, other participants manifested a lack of awareness about nicotine information in the e-liquid that they have used. Moreover, in some cases, the participants stated a lack of knowledge on whether or not the products they tried contained nicotine. Neither did they know about the nicotine levels of their preferred products, similar to previous findings [38]. Although consumer awareness is required in many countries, limitations in users' knowledge about vaping products may be associated with the lack of proper warning labels for e-liquids and even mislabeling in some cases [38]. This should be a matter of concern, particularly since the population at higher risk to start using ENDS are teens and young adults. Not only should correct labeling be mandatory but also educational tools for information and guidance should be available for all current and potential users. In this regard, the NZ government is making an effort to regulate all vaping and smokeless tobacco through the Smokefree Environments and Regulated Products Act, 1990 [11]. VRT and telehealth can be used as platforms for prevention and education for all potential health risks associated with vaping.

Hanging out with friends was a situation highly linked to vaping for our focus group participants. Notably for the hookah users interviewed, when hanging out with friends back in their country of origin, at times when vaping took place, this was considered a must-do activity among them. Thus, similar to the findings of previous studies [14, 39], it appears that among our participants, vaping is predominantly a social practice and is increasingly more socially accepted. Moreover, for some participants, it may be part of their socio-cultural practices. In some cases, as a social practice, sharing ENDS devices among friends was considered acceptable, and because of this, some participants did not consider it necessary to acquire their own devices, as long as sharing was an option. Conversely, in a study developed with students of the

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

University of Edinburgh, sharing ENDS was considered socially unacceptable [40], depending on temporal and geographical contexts. In addition, it was notable how vaping, unlike smoking cigarettes, was perceived as a more flexible practice that conveniently can be integrated into different situations or places, such as being in a bar, at home, studying, walking, or driving, either within social or individual contexts. Similar findings were reported by Keane et al. [14]. Nevertheless, the culture shock experienced by some of our international students seemed to have influenced their vaping behavior and attitudes toward it, since either the social context or the physical settings experienced in NZ do not match what they were familiar with, in their country of origin. This reinforces the idea that ENDS contexts and characteristics vary according to culture and geographical location.

In relation to vaping triggers, unlike previous reports [41], in our study, neither passive exposure to vaping nor vaping advertisement appeared to trigger a desire for vaping or smoking. This applies mainly to dual users, who also indicated that, when seeing others smoking tobacco cigarettes, this may trigger their desire for smoking, which sometimes, maybe mitigated with vaping [42]. In terms of olfactory triggers, only fruit e-liquids were found to have some effect. With respect to the role of stressful situations as vaping craving triggers, it seems that regardless of the nature of it, for some of our participants, vaping may be used as a coping mechanism for stress. Similar findings were observed by tobacco cigarette users, which may be associated with nicotine [43]. Moreover, some of our participants related vaping to feeling relaxed, happier, focused, stimulated, and responses that have been linked previously to the effect of nicotine [44]. In addition, a highlighted concern raised by some participants was related to a perception of losing control over vape intake and "endless" vaping. Similar remarks have been observed in for dual users and young adults [40]. This may be associated to previous user's sense of having control over their own smoking, given by the knowledge of time taken to smoke a conventional tobacco cigarette. Nevertheless, uninhibited vaping may induce to higher consumption of nicotine, which given the ever-growing popularity of vaping, may contribute to an overall increase in nicotine dependency, therefore, higher health risks.

In general, our participants perceived vaping as a less harmful practice than smoking conventional cigarettes. Even though the long-term health effects of vaping are under investigation, the same impression seems to be shared by many [36, 45, 46]. The majority of participants considered the use of both ENDS and smoking conventional cigarettes healthier than to smoke tobacco cigarettes only. Although there is insufficient scientific evidence to support this statement, the perception may be associated with the idea that cigarette consumption may be reduced, despite its continued use of it [46, 47]. It is important to remember that vaping and its potential harmful effects depend on many factors, such as frequency of use, the quantity of nicotine consumed, flavors of preference, and type of devices used, together with socioeconomic and associated demographic factors. In particular vaping practice has been associated with youth in socioeconomic disadvantage, who have never smoked [46], which may serve as a gateway to nicotine dependency and consequently, associated health issues. An integrated analysis of contexts and factors influencing vaping is needed to advance effective future interventions and treatments for vaping disorders. As for the lack of success in trying to quit smoking by vaping, it appears to be a common situation among college students and adults [36, 48], who either fail, relapse, or become dual users. It appears that for some participants of our study, relapsing may be a common situation and for others, quitting smoking seems to be a challenge only achievable by being extremely disciplined. As the effectiveness of using vaping

to quit smoking appears to be debatable [46], vaping may be of better use as a tool to help reduce smoking. Some attributes associated with vaping, such as being more socially accepted, the variety of e-liquids flavors as well as different levels of nicotine concentration, may be of help in the effort to reduce smoking [39], nevertheless, the potential effect caused by these attributes should be carefully considered.

In general, our participants seemed to be satisfied with vaping. This feeling was primarily linked to its financial benefit compared to smoking, followed by health and social acceptance. As mentioned by some of our participants, due to high taxation on cigarettes it is possible that, in NZ, conventional cigarette smokers are switching to vaping, a situation that may have been further enhanced by health marketing campaigns [13]. How this may have affected the use of vaping by non-smokers and possibly influenced the increase in nicotine dependency is yet to be understood and is critical to be quantified. The questions about recommending vaping as a way to quit smoking conventional cigarettes, varied opinions were obtained in our focus groups. Our participants' views agree with other studies' report, in which vapers did not recommend it due to their own or their friends' failed attempts [40], or even their own difficulties and struggles with self-controlling nicotine intake. In addition, regarding plans to quit vaping, there was not a clear position about it. Whether it is because of the benefits seen by using it (when compared to smoking conventional cigarettes), nicotine dependency, or their occasional use, quitting vaping does not appear to be considered a priority in the foreseeable future for most of our participants.

As observed in this study, vaping is a dynamic practice. The discussions that took place throughout our focus group sessions, provided important information that has helped us to identify some key social, cultural, and economic components in the vaping contexts of a diverse group of young adults. This material will contribute to the development of a more realistic and immersive VRS. The current technological advances achieved in the development of online VRS can enable better integration with telehealth for the future delivery of interventions and treatments as well as prevention and education campaigns for vaping-related disorders. This would build on recent developments using VRT in telemental health services, in areas, such as social anxiety, obsessive-compulsive and substance use disorders [49], and smoking interventions [50]. As yet, the knowledge of vaping-related disorders is limited and still a work in progress. Nevertheless, the use of VRT for cue exposure treatments could represent an alternative to help patients suffering from nicotine dependence caused by vaping. Moreover, in order to help achieve better results, previous studies developed in smoking cue exposure therapy using VRT have recommended, including mechanisms that help patients to improve their coping skills [7, 51]. In addition, studies indicate a potential need to modulate negative effects and stress during cue exposure [7]. These recommendations are worth being considered and testing in future vaping treatments using VRT.

#### **5. Limitations**

The limitations of the study were primarily related to the number of vapers interviewed in the focus groups and how representative the sample could be in relation to different types of vapers, given demographic factors and geographic location. Thus, we acknowledge that our findings are limited to the views, background, behavior, and environments surrounding a sample of local and international university students in

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

NZ. Nevertheless, despite how dynamic and rapidly growing vaping is, in our study, we found similarities with some perceptions and behaviors described in previous studies carried out worldwide [5, 14, 22, 23, 27, 38, 39], which help to support our findings and will contribute toward vaping-related VRS development.

#### **6. Conclusion**

In this study, the accessible price of vaping products was a key reason for starting and continuing vaping. In most cases, vaping was associated with nicotine dependency by the participants, particularly for dual users. In our sample, flavored e-liquids were popular, especially fruit and menthol, but not tobacco flavor. Flavored e-liquids may be seen to help with the transition from smoking conventional tobacco into vaping, but they are also a concern for potential nicotine dependency. Furthermore, in this group, vaping appears to be mostly seen as a social practice, linked to hanging out with friends, regardless of the location (party, bar, house, car, etc.). On the other hand, for some international students, their current settings for vaping are dissimilar to what they were used to in their countries of origin, which, in some cases, has led to a change in vaping behaviors from a social context into a solitary practice.

In our study, passive exposure to vaping or vaping advertisements appears not to be a trigger for vaping or smoking but for dual users, seeing others smoking conventional cigarettes does trigger their desire for smoking conventional cigarettes, which may not always be mitigated by vaping. When compared to smoking, vaping is perceived as more socially accepted, healthier, more beneficial, and in general satisfying. Moreover, while vaping was not perceived as a way to quit smoking, it may be of help to reduce smoking conventional cigarettes, but concerns remained regarding a tendency toward loss of control of nicotine intake that can occur when vaping, which may induce nicotine dependence. Nevertheless, quitting vaping does not seem to be a concern or priority among our participants, and this may lead to continued or even increased nicotine dependency as well as increasing the risk of health disorders associated with vaping. Further studies are needed to clarify and test these matters.

Vaping is an ever-changing global practice with rapid technological and social growth, which may be taking nicotine dependency to a new level, reaching all sociocultural contexts and age groups. The socio-cultural and economic background of the target population should become a key component to be considered when developing new technological tools toward enabling more inclusive and personalized online VRT and telehealth services for prevention, intervention, and treatment of vaping and its potential associated disorders. The dynamic and multifactorial character of vaping together with its potential associated health risks makes it a key challenge for future VRT and telehealth developments. Furthermore, as adolescents and young adults are at higher risk, the use of online VRT for telehealth represents an attractive and accessible technological platform that can be used to engage this age group to be better informed about vaping. Further technological advancements should facilitate interactive access to online environments developed under more realistic and contextualized settings, in which prevention, control, and treatment focused telehealth programs can tackle commonly associated issues, such as nicotine dependence, ENDS misuse, health harms linked to e-liquids flavors and chemical components. Thus, further developments in online VRS are needed to enhance and facilitate telehealth services in the growing field of vaping-related disorders.

#### **Acknowledgements**

We thank the Health Research Council of New Zealand (HRC), for the explorer grant number 17/738 that funded this project.

We would like to thank Nawan Karki who contributed with technical support to carry out the focus group sessions by looking after the video and audio settings. We are grateful to M.D. Wilson for proofreading the manuscript.

#### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Maria Cecilia Vega-Corredor1 \*, Simon Hoermann2,3, Alison Watkins1 and Melanie Tomintz1

1 Geospatial Research Institute, University of Canterbury, Christchurch, New Zealand

2 School of Product Design, University of Canterbury, Christchurch, New Zealand

3 HIT Lab NZ, University of Canterbury, Christchurch, New Zealand

\*Address all correspondence to: maria.vegacorredor@canterbury.ac.nz

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

#### **References**

[1] Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong H, et al. Electronic nicotine delivery systems. American Journal of Preventive Medicine. 2013;**44**(3):207-215. DOI: 10.1016/j.amepre.2012.10.018

[2] Olonoff M, Niaura R, Hitsman B. Electronic cigarettes are not cigarettes, and why that matters. Nicotine & Tobacco Research. 2019;**21**(10):1441- 1444. DOI: 10.1093/ntr/nty205

[3] Chadi N, Hadland SE, Harris SK. Understanding the implications of the vaping epidemic among adolescents and young adults: A call for action. Substance Abuse. 2019;**40**(1):7-10

[4] Oriakhi M. Vaping: An emerging health hazard. Cureus. 2020;**12**:3. DOI: 10.7759/cureus.7421

[5] Zare S, Nemati M, Zheng Y. A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type. PLoS One. 2018;**133**:e0194145. DOI: 10.1371/ journal.pone.0194145

[6] Kisker J, Gruber T, Schöne B. Behavioral realism and lifelike psychophysiological responses in virtual reality by the example of a height exposure. Psychological Research Psychologische Forschung. 2019;**85**(1):68- 81. DOI: 10.1007/s00426-019-01244-9

[7] Pericot-Valverde I, Secades-Villa R, Gutiérrez-Maldonado J. A randomized clinical trial of cue exposure treatment through virtual reality for smoking cessation. Journal of Substance Abuse Treatment. 2019;**96**:26-32. DOI: 10.1016/j.jsat.2018.10.003

[8] Kamińska D, Sapiński T, Wiak S, Tikk T, Haamer R, Avots E, et al. Virtual reality and its Alications in education: Survey. Information (Basel). 2019;**10**(10):318. DOI: 10.3390/ info10100318

[9] Tamplin J, Loveridge B, Clarke K, Li Y, Berlowitz D. Development and feasibility testing of an online virtual reality platform for delivering therapeutic group singing interventions for people living with spinal cord injury. Journal of Telemedicine and Telecare. 2020;**26**(6):365-375. DOI: 10.1177/1357633X19828463

[10] Gurram N. Electronic cigarette online marketing by New Zealand vendors. New Zealand Medical Journal. 2019;**132**(1506):20-33

[11] Ministry of Health, New Zealand. Regulation of vaping and smokeless tobacco products [internet]. 2022. Available from: https://www.health.govt. nz/our-work/regulation-health-anddisability-system/regulation-vapingand-smokeless-tobacco-products. [Accessed: April 07, 2022]

[12] Ministry of Health, New Zealand. Daily youth smoking rates at all time low in Aotearoa Media release 28 February 2022 [Internet]. 2022. Available from: https://www.health.govt.nz/newsmedia/media-releases/daily-youthsmoking-rates-all-time-low-aotearoa. [Accessed: April 07, 2022]

[13] Health Promotion Agency NZ. Vaping facts: Vape to Quit campaign coming [Internet]. 2021. Available from: https://newsletter.hpa.org.nz/campaigns/ reports/viewCampaignaspx?d=r&c=BA E1E0C2C9F2C8BA&ID=FF7430872482 511B2540EF23F30FEDED&temp=False &tx=0&source=Report [Accessed: April 07, 2022]

[14] Keane H, Weier M, Fraser D, Gartner C. 'Anytime, anywhere': Vaping as social practice. Critical Public Health. 2017;**27**(4):465-476. DOI: 10.1080/09581596.2016.1250867

[15] Corbin JM, Strauss AL. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 4th ed. Thousand Oaks: SAGE; 2015. p. 456

[16] Lopez D, Whitehead D. Sampling data and data collection in qualitative research. In: Schneider Z, Whitehead D, Lobiondo-Wood G, Haber J, editors. Nursing and Midwifery Research Methods and Appraisal for Evidence Practice. 4th ed. Sydney: Elsevier; 2013. pp. 123-140

[17] Gorini A, Mosso JL, Mosso D, Pineda E, Ruíz NL, Ramíez M, et al. Emotional response to virtual reality exposure across different cultures: The role of the attribution process. Cyberpsychology & Behaviour. 2009;**2**(6):699-705. DOI: 10.1089/cpb.2009.0192

[18] Barbeau AM, Burda J, Siegel M. Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: A qualitative approach. Addiction Science & Clinical Practice. 2013;**8**(1):5-5. DOI: 10.1186/1940-0640-8-5

[19] Pesko MF, Courtemanche CJ, Maclean J. The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. Journal of Risk and Uncertainty. 2020;**60**(3):229- 258. DOI: 10.1007/s11166-020-09330-9

[20] Prochaska JJ. The public health consequences of e-cigarettes: A review by the National Academies of sciences a call for more research, a need for regulatory action. Addiction. 2019;**114**(4):587-589. DOI: 10.1111/add.14478

[21] National Academies of Sciences Engineering and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice. Committee on the review of the health effects of electronic nicotine delivery systems. In: Eaton DL, Kwan LY, Stratton K, editors. Public Health Consequences of E-Cigarettes. Washington: National Academies Press; 2018. p. 774. DOI: 10.17226/24952

[22] Dinardo P, Rome ES. Vaping: The new wave of nicotine addiction. Cleveland Clinic Journal of Medicine. 2019;**861**(2):789-798. DOI: 10.3949/ ccjm.86a.19118

[23] Vogel EA, Prochaska JJ, Ramo DE, Rubinstein AJ, ML. Adolescents' E-cigarette use: Increases in frequency, dependence, and nicotine exposure over 12 months. Journal of Adolescent Health. 2019;**64**(6):770-775. DOI: 10.1016/j. jadohealth.2019.02.019

[24] Wang JB, Olgin JE, Nah G, Vittinghoff E, Cataldo JK, Pletcher MJ, et al. Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart study. PLoS One. 2018;**13**(7):e0198681-e0198681. DOI: 10.1371/journal.pone.0198681

[25] Cooper M, Harrell MB, Perry CL. Comparing young adults to older adults in e-cigarette perceptions and motivations for use: Implications for health communication. Health Education Research. 2016;**31**(4):429-438. DOI: 10.1093/her/cyw030

[26] Lewek P, Woźniak B, Maludzińska P, Śmigielski J, Kardas P. Polish e-cigarettes: Users reasons to start vaping – A survey of 1142 polish vapers. Family Medicine & Primary Care Review. 2018;**20**(3):232- 235. DOI: 10.5114/FMPCR.2018.78257

[27] Harrel MC, Bradley MA. Data Collection Methods: Semi-Structured *Design Insights to Support the Development of Effective Virtual Reality Nicotine and Vaping… DOI: http://dx.doi.org/10.5772/intechopen.106958*

Interviews and Focus Groups. Santa Monica: RAND; 2009. p. 140

[28] Groom AL, Vu TT, Kesh A, Hart JL, Walker KL, Giachello AL, et al. Correlates of youth vaping flavor preferences. Preventive Medicine Reports. 2020;**18**:01094-101094. DOI: 10.1016/j.pmedr.2020.101094

[29] Gravely S, Cummings KM, Hammond D, et al. The association of E-cigarette Flavors with satisfaction, enjoyment, and trying to quit or stay abstinent from smoking among regular adult vapers from Canada and the United States: Findings from the 2018 ITC four country smoking and vaping survey. Nicotine & Tobacco Research. 2020;**22**:1831-1841. DOI: 10.1093/ntr/ ntaa095

[30] Gendall P, Hoek J. Role of flavours in vaping uptake and cessation among New Zealand smokers and non-smokers: A cross-sectional study. Tobacco Control. 2021;**30**:108-110

[31] Dai H, Hao J. Flavored electronic cigarette use and smoking among youth. Pediatrics (Evanston). 2016;**138**(6):e20162513. DOI: 10.1542/ peds.2016-2513

[32] Hoffman AC, Salgado RV, Dresler C, Faller RW, Bartlett C. Flavour preferences in youth versus adults: A review. Tobacco Control. 2016;**25**:ii32-ii39

[33] Sindelar JL. Regulating vaping — Policies, possibilities, and perils. The New England Journal of Medicine. 2020;**382**:e54-e54. DOI: 10.1056/ NEJMp1917065

[34] Rawlinson C, Martin S, Frosina J, Wright C. Chemical characterisation of aerosols emitted by electronic cigarettes using thermal desorption– gas chromatography–time of flight

mass spectrometry. Journal of Chromatography A. 2017;**1497**:144-154. DOI: 10.1016/j.chroma.2017.02.050

[35] McRobbie H, Bullen C, Hartmann-Boyce J, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systematic Reviews. 2014;**12**:CD010216

[36] Camenga DR, Fiellin LE, Pendergrass T, Miller E, Pentz MA, Hieftje K. Adolescents' perceptions of flavored tobacco products, including E-cigarettes: A qualitative study to inform FDA tobacco education efforts through videogames. Addictive Behaviors. 2018;**82**:189-194. DOI: 10.1016/j.addbeh.2018.03.021

[37] Meltzer LR, Simmons VN, Piñeiro B, et al. Development of a self-help smoking cessation intervention for dual users of tobacco cigarettes and E-cigarettes. International Journal of Environmental Research and Public Health. 2021;**18**(5):2328. DOI: 10.3390/ ijerph18052328

[38] Sontag JM, Wackowski OA, Hammond D. Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall. Preventive Medicine Reports. 2019;**16**:100966-100966. DOI: 10.1016/j. pmedr.2019.100966

[39] Soule EK, Maloney SF, Guy MC, Eissenberg T, Fagan P. User-identified electronic cigarette behavioral strategies and device characteristics for cigarette smoking reduction. Addictive Behaviors. 2018;**79**:93-101. DOI: 10.1016/j. addbeh.2017.12.010

[40] Lucherini M, Rooke C, Amos A. They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so…: Maturity, control, and socializing: Negotiating identities in relation to smoking and vaping-a qualitative study of young adults in Scotland. Nicotine & Tobacco Research. 2019;**2017**(21):81-87. DOI: 10.1093/ntr/ntx245

[41] King AC, Smith LJ, Fridberg DJ, Matthews AK, McNamara PJ, Cao D. Exposure to electronic nicotine delivery systems (ENDS) visual imagery increases smoking urge and desire. Psychology of Addictive Behaviors. 2016;**30**:106-112. DOI: 10.1037/adb0000123

[42] Keijsers M, Vega-Corredor MC, Hoermann S, Tomintz M. Cue reactivity to electronic cigarettes: A systematic review. Substance Abuse: Research and Treatment. 2022;**16**:1-20. DOI: 11782218221114971

[43] Siqueira LM, Rolnitzky LM, Rickert VI. Smoking cessation in adolescents: The role of nicotine dependence, stress, and coping methods. Archives of Pediatrics & Adolescent Medicine. 2001;**155**(4):489-495. DOI: 10.1001/archpedi.155.4.489

[44] Evans DE, Drobes DJ. Nicotine self-medication of cognitive-attentional processing. Addiction Biology. 2009;**14**:32-42. DOI: 10.1111/ j.1369-1600.2008.00130.x

[45] Baweja R, Curci KM, Yingst J, et al. Views of experienced electronic cigarette users. Addiction Research & Theory. 2016;**2015**(24):80-88. DOI: 10.3109/16066359.2015.1077947

[46] Green MJ, Gray L, Sweeting H, Benzeval M. Socioeconomic patterning of vaping by smoking status among UK adults and youth. BMC Public Health. 2020;**20**:183-183. DOI: 10.1186/ s12889-020-8270-3

[47] Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, carcinogen, and toxin exposure in long-term E-cigarette and nicotine replacement therapy users: A cross-sectional study. Annals of Internal Medicine. 2017;**166**:390-400. DOI: 10.7326/M16-1107

[48] Foulds J, Veldheer S, Berg A. Electronic cigarettes (e-cigs): Views of aficionados and clinical/public health perspectives. International Journal of Clinical Practice (Esher). 2011;**65**:1037. DOI: 10.1111/j.1742-1241.2011.02751.x

[49] Aboujaoude E, Salame W, Naim L. Telemental health: A status update. World Psychiatry. 2015;**14**:223-230. DOI: 10.1002/wps.20218

[50] Keijsers M, Vega-Corredor MC, Tomintz M, Hoermann S. Virtual reality technology use in cigarette craving and smoking interventions (I "Virtually" quit): Systematic review. Journal of Medical Internet Research. 2021;**23**(9):e24307. DOI: 10.2196/24307

[51] Budney AJ, Brown PC, Stanger C. Behavioral treatments. In: McCrady S, Epstein EE, editors. Addictions: A Comprehensive Guidebook. 2nd ed. New York: Oxford University Press; 2013. pp. 411-433

### **Chapter 2**

## Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare Services to a Research Implementation

*Idar Mappangara and Andriany Qanitha*

#### **Abstract**

The fundamental principle for telemedicine implementation in the real world is to address the basic needs of healthcare services. The utilization of telemedicine naturally aimed to overcome distance, time, and financial constraints. Remote areas that are far from the cities and healthcare centers are the main regions that would mostly get benefit from the telemedicine program, for instance, in Indonesia, a country with a big archipelago area in South-East Asia. The primary healthcare center in this country is commonly available, however, the facilities and health workers are still limited. The health services are being centralized in big cities, and thus, the rural areas are far left in the context of healthcare services. Telemedicine could bring both standardized and specialized healthcare services nearer to the patients, irrespective of distance and location constraints. After receiving professional cardiology advice, implementation of telemedicine program, such as tele-electrocardiography (tele-ECG) at the primary care level, may be a financially advantageous way to identify cardiovascular disease in the general population and avoid overtreating patients. This is our first time adopting tele-ECG consultations in East Indonesia under the Makassar Telemedicine Program. This program allows us to maintain a big database of cohorts and connect its implementation to real-world clinical practices, and at the end, could guiding the health workers to improve patient's outcomes.

**Keywords:** tele-ECG, telemedicine, low bandwidth, click point to point, database

#### **1. Introduction**

Telemedicine, a term that appeared in the 1970s, literally means "healing at a distance" [1]. In order to improve the health of people and communities, the WHO defines telemedicine as "the delivery of healthcare services, where distance is a critical factor, by all healthcare professionals, using information and communications technologies for the exchange of valid information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and the continuing education of healthcare workers" [2]. As defined by the WHO, telemedicine is a system utilized to assist the healthcare functioning, especially healthcare services, education, research, and even training. The need for telemedicine is basically due to obstacles in optimizing the function of healthcare, particularly in poor-resource populations; either due to the large costs, long-distance barriers, limited human resources, the need for immediate or 24-hour services, as well as the nature of wide-spread coverage area of telemedicine [3].

The fundamental rule for managing a telemedicine program in a low- and middleincome country (LMIC) like Indonesia is whether the system can address the unmet needs for primary care services, how to deal with budgetary issues, how to empower the locals to use telemedicine, and most importantly, how to maintain and sustain the utilization for a long period of time [3]. This is often seen to be a problem or miscommunication between telemedicine-service providers who generally rely on the sophistication and completeness of the equipment, while the users on the other hand, simply ask for user-friendly devices. Unsurprisingly, the mismatch between providers' capability, supporting infrastructure, and user needs, not rarely ends up with suboptimal function, and even worse, telemedicine is not working at all [4].

#### **2. Tele-electrocardiography in low- and middle-income countries**

Electrocardiography (ECG) is one of the daily needs of healthcare services, guiding the healthcare providers such as general practitioners (GPs), nurses, and even specialists to advance their diagnosis for patients with cardiovascular complaints [5]. The use and interpretation of ECG could be challenging, especially for health workers in suburban and rural areas such as Indonesia. Moreover, the need for real-time and quick decision-making for diagnosis and treatment for patients with acute cardiovascular disease (CVD) will enforce the use of tele-ECG in limited-resource LMICs. However, the available experts to interpret the ECG, the obligation for 24/7 service and quick answers are inevitable aspects of tele-ECG, and thus, considering these important aspects is crucial to implementing tele-ECG programs in LMICs.

Tele-ECG has evolved before, during, and after this pandemic era. The tele-ECG has been instrumental in reducing the un-need patients referral and has allowed better allocation of resources through early triage of patients with acute CVD, based on their symptoms and examinations. Our previous study showed that 100% of ECG recordings were transmitted successfully and qualified for analysis; and thus, we suggest that tele-ECG can be implemented in Indonesian primary care settings with limited resources [6]. In traditional manner, when tele-ECG program was not applied, the ECG solely interpreted by the GP in the primary care center; or even worse, the ECG are not available as a basis healthcare service in several primary centers. By implementing this tele-ECG program, the consultation to the expert cardiologists may assist the GPs for immediate triage, resulting in a higher rate of early hospitalization for indicated patients, and eventually could reduce the mortality rate of acute CVD in Indonesia [6]. The flowchart of utilization and final purpose of tele-ECG is shown in **Figure 1**.

The implementation of telemedicine in LMICs may not encounter many obstacles as long as it is correlated with the needs of healthcare services, as it is fundamental to healthcare function. The first implementation of this tele-ECG program was

*Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

#### **Figure 1.**

*The utilization and final purpose of tele-ECG program.*

commenced before the Covid-19 pandemic. At that time, all patients with cardiovascular risk factors who came up to the primary care centers were screened using the tele-ECG. During this pandemic era, this tele-ECG is even more useful and practical to screen and stratify the patients with cardiac symptoms. This tele-ECG guides the GPs to determine which patients need a referral to the cardiac center, and which ones need enough observation and therapy in the primary level.

What about the research aspect? Is telemedicine program appropriate to be carried out in that direction? We agree that clinical research is important to get a big picture of the current situation of cardiology clinical practice, valuable to help analyze the real health problems and offer possible solutions to those problems. This is an interesting challenge in finding a way to implement and couple the telemedicine program with a research function.

The main principle in clinical research is that we get as much data as possible that represented the real population. The wide coverage of tele-ECG and the capability of providing big data allows the tele-ECG program as a preferable platform for conducting research. Based on our experience, conducting clinical research in LMICs is rather "exhausting." Local researchers are forced to start everything from the scratch. Unavailable standard systems for reliable databases as well as limited resources and infrastructure also contribute to the low interest and awareness of carrying out

**Figure 2.** *Tele-ECG consultation from the primary care center.*

clinical research in LMICs. **Figure 2** presents the primary care nurse performing tele-ECG consultation and contributing to a cornerstone database of tele-ECG in Indonesia.

With 17,508 islands and a population of more than 260 million, Indonesia is the most populous country in South-East Asia and the biggest archipelago in the world [7]. Java is home to more than half of Indonesia's population, with the remaining residents dispersed throughout 6000 islands [7, 8]. About 11% of the Indonesian population living in a poor socio-economic level [9]. The leading cause of mortality in this lower-middle-income country, accounting for ~37% of all fatalities, is cardiovascular disease (CVD) [9]. Despite the high burden of CVD in this country, there were only 1.5 cardiologists available per 1,000,000 people in 2016 [9] and only ~30 cardiac facilities (half of which located in Java) were available in 2013 to treat the >2.6 million prevalent cases of CAD [10, 11].

Especially in remote areas, including in some peripheral areas in Indonesia, where human resources, i.e. nurses, general practitioners, and specialist doctors are rarely available, health equipment and medical facilities are also generally inadequate and not evenly distributed. As is well known, the remote island is an area with very minimal use of technology and with all its limitations, which becomes a challenge in implementing telemedicine in archipelagic areas [12]. On this occasion, the author used the tele-ECG program as a platform to answer the challenges of implementing telemedicine in archipelagic areas, and more specifically to obtain a reliable database in terms of research function.

#### **3. Implementing telemedicine in the archipelago region: what's the problem?**

Remote islands in archipelago countries are areas that are suitable for the concept and purpose of the telemedicine program. These areas commonly live *Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

in poverty with poor health services, and urgently need assistance in solving the local health problems. To this end, telemedicine services should be utilized as routine healthcare services and function in daily practice. However, there may be challenges to run this program. In most remote areas, the healthcare officers are those with a lack knowledge and are not used to using modern technology. Mostly, medical devices in remote areas are also less modern and do not support modern application systems. In addition, in terms of infrastructure, internet signals in archipelagic areas are below average, using a low bandwidth category, and thus, a complex and sophisticated computer application in implementing telemedicine should be avoided [12].

In most LMICs, particularly in rural areas, the healthcare infrastructure is generally minimal or even unavailable, and local residents not rarely used traditional, instead of evidence-based medicine. Healthcare facilities for both diagnosis and treatment are almost blunted [13]. Based on the Speedtest Global Index, Indonesia is a country with the slowest average internet speed in Southeast Asia. As of December 2021, the average speed of mobile internet in Indonesia is only 15.44 Mbps, with the upload speed of about 9.16 Mbps, and the latency is 28 ms.

#### **4. Telemedicine and research**

The Makassar Cardiac Center launched the first telemedicine initiative in Eastern Indonesia in response to the dearth of cardiologists and the obvious demand for competence in cardiovascular treatment. With the use of this service, primary care centers can send electrocardiogram (ECG) data to Hasanuddin University Hospital. In this program, primary care GPs immediately received expertise from cardiologists when dealing with patients with CVD symptoms or risk factors. Despite the fact that Indonesia began implementing the telemedicine program in 2012, reporting on the initiative's effectiveness and results has not received as much attention.

Although telemedicine system is also developed for research functions, it is realized that research stuff is merely invaluable for the users. Primary healthcare centers and sub-health centers will certainly not be interested at all in the research objectives, especially for health workers who work on remote islands. Research appropriation is not the main issue in healthcare services in remote areas. The first and foremost is, whether the large and extensive data can be obtained through telemedicine services to improve the quality of care and clinical outcomes of patients in remote areas.

#### **5. Telemedicine in archipelago countries: the concept of solutions**

Looking at the telemedicine systems that are currently being run and developed, on average, the telemedicine system needs sophisticated technology, such as teleradiology that uses DICOM-based PACS. The telemedicine system requires modern equipment and high-speed internet with high bandwidth, which is expensive. On the other hand, to maximize telemedicine utilization, the users also should be familiar with high-tech applications. Unfortunately, these requirements are incompatible and difficult to be fulfilled in archipelagic or remote areas. Encountering these challenges and limitations, innovation and creativity are

needed in designing and making an ideal and compatible telemedicine model in the archipelagic area [4, 14, 15].

The author hypothesizes that technology is flexible and can be customed to meet the local field conditions, including in extremely difficult archipelagic areas. The concept design of archipelagic telemedicine should be cheap, user-friendly and transmittable, and feasible. The design of the telemedicine system design is also should be easily utilized for the research purpose by providing reliable big data, altogether with appropriate data processing facilities, thus could be used for research and educational purposes.



#### **Figure 3.**

*Tele-ECG application used in Makassar Telemedicine Program that provides services for 46 primary care centers in Indonesia.*

*Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

#### **6. Role model of tele-ECG in Eastern Indonesia**

Electrocardiography examination requires an electronic medical device called an "electrocardiogram" [5]. There are various types of tools based on the development of the system: some have DICOM-based-high-technology which is easily integrated with the current developed modern application systems, and some others are less modern and still based on non-DICOM and difficult to be integrated directly with tele-applications [4, 16–18].

In LMICs, including in Indonesia, the majority of available ECG tools is a non-DICOM-based devices. The developed tele-ECG application model will take the ECG image indirectly from the machine, and then will be stored in pdf format, as long as the ECG device has a program that could produce the output that is connectable to the computer storage, with the average size of files is less than 2 MB. This small file size is very suitable and easy to be transmitted in unstable internet speed or low-bandwidth conditions in LMICs, particularly in remote archipelagic areas. An application model with a display of the ECG image equipped with the result description on one screen will make the interpretation process by expert doctors easier.

The results and description of the ECG were made in a form of multiple choice with a point-to-point-click checklist, and thus the users will no longer need to type descriptions and conclusions of those ECG recordings. The users just need to choose the description that had been provided. The available description patterns are made by default for normal results. For example, for normal ECG results, the expert doctors only need to fill the heart rate column, to optimize the data storage. Each selected description will be ready as the standardized data that have been completed with the description with the smallest file size and will be directly stored in the database that could be easily recognized by the system. **Figure 3** shows the tele-ECG application that has been used for Makassar Telemedicine Program that provides services for 46 primary care centers distributed in urban, rural, including remote islands in East Indonesia.

#### **7. Implementation of tele-ECG model in Makassar, Indonesia**

The implementation of tele-ECG at more than 46 primary care centers in Indonesia has started in 2015, mainly in the South Sulawesi Province. Each primary care center provides tele-ECG services, not only for outpatient clinics but also for Emergency Department. The tele-ECG consultations were carried out for all patients with suspicion of heart disease, including acute coronary syndrome.

Makassar tele-ECG service runs routinely every day, with around 10,000 cardiac records have been transmitted in 4 years since its commencement. During the operation, every transmitted ECG record would get a quick response from the cardiology consultant. For the clinic services in primary care centers, on average, the ECG recordings were sent from morning to afternoon, and subsequently, the response and answers by the consultants would be delivered within 2–4 hours. In the case of acute or emergency settings, the operator will immediately notify the consultant for an immediate response. For normal ECG, the consultant only took 15 seconds to make the description of ECG. Meanwhile, for an abnormal ECG, the average time needed to describe the ECG was about 30–45 seconds. The tele-ECG answers can be immediately seen by the sender, i.e., nurse or GP at the primary care center, with available printable reading results when needed.

#### **8. Data collection and measurement**

Using an automated ECG equipment—the BTL-08 SD ECG (BTL Industries Ltd., Hertfordshire, United Kingdom)—trained primary care nurses collected patients' ECGs. The Hasanuddin University Hospital's analysis service center received the ECG files through the internet and stored them in the hospital's database. All of the ECG recordings were reviewed and examined by two cardiologists. Between August 2015 and February 2018, Makassar Telemedicine Service (MTS) received ~10,000 12-lead ECG recordings from patients in primary care.

In order to gather information on sociodemographic and clinical profiles (such as symptom, onset, prior disease, prior medication, anthropometric status, vital signs, and cardiovascular risk factors: hypertension, diabetes mellitus, current smoking, and family history of CVD), management and medications after tele-ECG, and GP's reasons for and satisfaction with tele-ECG consulting, a thorough questionnaire was developed. All participants had vital sign assessments, including blood pressure, heart rate, respiration rate, and axillary temperature, as well as anthropometrics, a routine physical examination, and ECG analysis. Manual measurements were taken


*\*More than one ECG diagnosis per patient is possible.*

*Values are n (%).res.*

*ECG = electrocardiogram; MI = myocardial infarction.*

#### **Table 1.**

*Interpretation of ECG recordings from Makassar telemedicine service.*

#### *Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

for height, waist circumference, and body weight. Since these tests are typically not accessible at the primary care level, none of the laboratory tests—such as fasting plasma glucose, lipid profiles, and creatinine—was carried out. All these data were collected in a standardized database. The data were then converted into Excel format for further analysis in the SPSS statistical program for research purposes.

**Figure 4.** *Distribution of ECG abnormalities based on gender and age.*

#### **9. Implementation results: the first report from the tele-ECG program in Indonesia**

A total of 10,001 ECG recordings were transferred to telemedicine program's analysis center at Hasanuddin University Hospital between 2015 and 2018. All ECG recordings were eligible for analysis. Around 73% of the overall ECG recordings were classified as normal. After ECG categorization, ischemia was discovered in 13% of cases, arrhythmia in 18%, and structural abnormalities in 5%. **Table 1** displays the analysis and distribution of all ECGs from the Makassar Telemedicine Program (n = 1001), while **Figure 4** shows the ECG abnormalities based on gender and age.

Our previous study shows that tele-ECG consulting was helpful to support GPs in primary care in making a quick decisions on patient management. Of 10,001 ECG screenings transmitted to the analysis center, 100% qualified for analysis.

Implementation of the tele-ECG program during these 4 years showed that the delivery process run smoothly, as there were always 5–10 tele-ECG recordings transmitted from several primary healthcare centers every working day. The succession of this implementation is supported by the local government provided the infrastructure; trained nurses and GPs who made the first screening and risk stratification; and immediate response of the expert, cardiologists to read and answer the teleconsultation. This fact showed a piece of robust evidence that the design and model of the tele-ECG program that prioritized the easiness for both the senders and readers and smooth internet connection had been successfully implemented in the archipelagic areas.

In view of cardiology services, 88 patients for whom hospital admission was advised, 72 (81.8%) were immediately referred within 48 hours following the tele-ECG consultation. Thus far, this tele-ECG program has been successfully carried out with two main purposes, healthcare services, and research, that ultimately help in improving patient outcomes.

SVT, supraventricular tachycardia; AF, atrial fibrillation; Aflut, Atrial Flutter; AES, atrial extra systole; VES, ventricular extra systole; S-A block, sinoatrial block; A-V block, atrioventricular block; RBBB, right bundle branch block; LBBB, left bundle branch block; STEMI, ST-elevation myocardial infarction; Old MI, old myocardial infarction; LAE, left atrial enlargement; RAE, right atrial enlargement; LVH, left ventricular hypertrophy; RVH, right ventricular hypertrophy.

#### **10. Conclusions: philosophy of tele-ECG implementation**


*Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

#### **Acknowledgements**

The participants in Makassar's primary care centers are warmly acknowledged for their willingness to take part in this tele-ECG program. We also thank the patients' advisors and family members for their participation and support. We appreciate Makassar City's municipal government's assistance in putting tele-ECG into daily practice. We also thank the employees and residents at Pusat Jantung Terpadu Makassar Cardiac Center for their contributions to the accomplishment of this telemedicine project. We acknowledge all research assistants, primary care nurses, cadres, and personnel that helped with data administration for this study.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Idar Mappangara1 \* and Andriany Qanitha2

1 Faculty of Medicine, Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia

2 Faculty of Medicine, Department of Cardiology and Vascular Medicine; Department of Physiology; Doctoral Study Program, Hasanuddin University, Makassar, Indonesia

\*Address all correspondence to: idar.unhas@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Shrestha BM. Telemedicine and virtual health care during coronavirus disease pandemic. Journal of Nepal Medical Association. 2020;**58**:547-556

[2] World Health Organization. A health telematics policy - in support of WHO's health-for-all strategy for global health development

[3] World Health Organization. Implementing Telemedicine Services During COVID-19: Guiding Principles and Considerations for a Stepwise Approach. 2020. pp. 1-25. Available from: http://iris.wpro.who.int/ handle/10665.1/14651

[4] Hsiao CH, Shiau CY, Liu YM, Chao MM, Lien CY, Chen CH, et al. Use of a rich internet application solution to present medical images. Journal of Digital Imaging. 2011;**24**:967-978

[5] Klabunde RE. Cardiac electrophysiology: Normal and ischemic ionic currents and the ECG. Advances in Physiology Education. 2017;**41**:29-37

[6] Mappangara I, Qanitha A, Uiterwaal CSPM, Henriques JPS, de Mol BAJM. Tele-ECG consulting and outcomes on primary care patients in a low-to-middle income population: The first experience from Makassar telemedicine program, Indonesia. BMC Family Practice. 2020;**21**:1-11

[7] Mboi N, Murty Surbakti I, Trihandini I, Elyazar I, Houston Smith K, Bahjuri Ali P, et al. On the road to universal health care in Indonesia, 1990-2016: A systematic analysis for the global burden of disease study 2016. The Lancet. 2018;**392**:581-591

[8] Horton R. Offline: Indonesia - Unravelling the mystery of a nation. The Lancet. 2016;**387**:830

[9] Cardiovascular Division & Health Services Research Centre. Reducing the burden of CVD in Indonesia: Evidence review. Newtown: The George Institute for Global Health; 2017

[10] Kementerian Kesehatan Republik Indonesia. Situasi kesehatan jantung. Pusat data dan informasi kementerian kesehatan Republik Indonesia. 2014:3

[11] Ministry of Health Republic of Indonesia. Riset Kesehatan Dasar (Riskesdas) 2013. Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan Republik Indonesia

[12] Binns C, Hokama T, Low WY. Island Health: Hope and challenges for public health. Asia-Pacific Journal of Public Health. 2010;**22**:19-24

[13] Myrick JG, Hendryx M. Health information source use and trust among a vulnerable rural disparities population. Journal of Rural Health. 2021;**37**:537-544

[14] Moore PT, O'Hare N, Walsh KP, Ward N, Conlon N. Objective video quality measure for application to tele-echocardiography. Medical and Biological Engineering and Computing. 2008;**46**:807-813

[15] Weisser G, Engelmann U, Ruggiero S, Runa A, Schröter A, Baur S, et al. Teleradiology applications with DICOM-e-mail. European Radiology. 2007;**17**:1331-1340

[16] Ling-ling W, Ni-ni R, Li-xin P, Gang W. Developing a DICOM middleware to implement ECG

*Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare… DOI: http://dx.doi.org/10.5772/intechopen.108486*

conversion and viewing. Annual International Conference of the IEEE Engineering in Medicine and Biology – Proceedings. Vol. 7. 2005. pp. 6953-6956

[17] Bond RR, Finlay DD, Nugent CD, Moore G. A review of ECG storage formats. International Journal of Medical Informatics. 2011;**80**:681-697

[18] Hsieh JC, Lo HC. The clinical application of a PACS-dependent 12-lead ECG and image information system in E-medicine and telemedicine. Journal of Digital Imaging. 2010;**23**:501-513

#### **Chapter 3**

## Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public Data Networks

*Rene Ivan Gonzalez-Fernandez, Margarita Mulet-Cartaya, Gisela Montes de Oca-Colina, Jorge Aguilera-Perez, Juan Dayron Lopez-Cardona and Jose Luis Hernandez-Caceres*

#### **Abstract**

The main characteristics of three approaches to cardiac care using public data networks are presented. All efforts were addressed to get minimum-cost solutions for low-budget public health systems. The first solution was developed to follow-up arrhythmic patients between medical consultations, setting a more closed patientphysician relationship, and a daily recording of cardiac rhythm changes. It is based on a personal battery-powered device for one-channel ECG recording, minimizing electrode setting and operation complexity. An ECG recording taken daily allows a detailed analysis anytime without the patient's traveling to a health institution. A second solution was aimed at monitoring high-risk cardiac patients. A 24-h portable device capable of monitoring heart rate and sudden falls, typically associated with cardiac syncope, was developed. When any cardiac event or fall is detected, an urgent message is sent to relatives and the medical emergency care system asking for help. The third system implemented is oriented to the study of different cardiac parameters in people who suffer from heart disease or in those who are prone to suffering from it. Twelve-lead ECG is recorded periodically by each patient and trend graphics reflect ECG parameters strongly associated with cardiac disturbances, such as sudden death and ischemia. This approach allows the detection of the first troubling electrocardiographic deviations, making possible early medical intervention.

**Keywords:** telemedicine, cardiac home care, ECG processing, cardiac syncope identification, arrhythmia analysis, cardiac disturbance predictors

#### **1. Introduction**

For decades, heart disease has been the leading cause of death worldwide, according to periodic reports from the World Health Organization (WHO) [1, 2]. The high consumption of so-called junk food, sedentary lifestyle, smoking, and other

conditions have driven humankind to this situation. Some years ago, heart disease as the leading cause of death was strongly associated with high-income countries, but nowadays it has been extended to medium and low-income countries, displacing infectious-contagious diseases. In poor countries, the situation becomes even more critical since their economies do not have sufficient resources to face the cost of therapies, medical devices, and high-qualified physicians to cover the population, so the public health system falls into crisis frequently.

The resting electrocardiogram (ECG) is worldwide the leading test to detect cardiac disorders; more than 100 million of ECGs are indicated in the United States annually [3]. For any surgery procedure, it is mandatory to check the cardiovascular status previously and for the rest ECG is the ideal test, since it is noninvasive, easy to perform, and highly standardized, offering significant information about the cardiovascular system status. Its interpretation is supported by more than 100 years of accumulated knowledge [4].

Devices and methods for automatic ECG acquisition and processing have greatly evolved, making it possible for this technology to be used efficiently after minimal training. In fact, several systems have been developed combining this kind of devices with public data networks, web applications, and the proper procedures allowing the implementation of telecardiology services [5–7]. However, new solutions emerge continuously because each region and country have needed a customizing process according to local requirements.

The authors of this chapter have developed solutions that provide health services aimed at the care of heart diseases, but these approaches could be extended to other chronic diseases. The solutions presented have the following in common:


The authors hope the discussed topics will motivate other specialists to contribute to the continuous improvement of public health services, mainly in low-income countries that suffer from the most critical situations.

#### **2. Follow-up of persons suffering from cardiac arrhythmia**

Cardiac arrhythmia is a chronic disease, so persons suffering must visit their cardiologist periodically to check their condition and the medical treatment effectiveness; this is the traditional approach to follow-up persons suffering from chronic disease. The main disadvantage is that changes and disorders occurring between a visit to the cardiologist and the next one never been recorded or known by the cardiologist. Suddenly, no evidence of why the patient got worse after a visit to the cardiologist and died inexplicably, and this is a non-infrequent situation.

The proposal of the authors solves the described situation. The patients are trained to use a portable medical device and are able to acquire and transmit a one-channel ECG, enough for cardiac rhythm analysis purposes. The digital ECG is uploaded to a

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

website in order to be processed, stored, and reviewed at any time by the cardiologist in charge of the studied person. This specialist indicates the frequency of ECG acquisition, maybe 2 or 3 days, and trend charts are generated with the data extracted from the stored signals. This approach provides an easy way to know what changes in the cardiac rhythm take place day by day, contributing to a very close patient-cardiologist relationship. Dynamically, medical treatment can be changed when an abnormal situation is detected. All the process contributes to minimize patient's discomfort and agglomerations at hospital centers since visits to cardiologist can be reduced.

#### **2.1 The proposed solution**

The proposed system enables ECG recording several times per day, so the patient's condition can be analyzed with a detailing level impossible to get with the traditional approach. Any change can be studied from its first manifestations. Another feature to remark on is the possibility to make changes in the medical treatment dynamically, only with a phone call after analyzing the ECGs stored in the system's database. In addition, by reducing the frequency of visits to the cardiologist, patients improve their comfort and agglomerations in hospitals are reduced.

The development of the proposed system was divided into three parts as follows:


Each part will be explained in detail below. The proposed solution can be viewed as a three-layer system. A first layer for the acquisition of the ECG with the developed portable device, a second layer is based on an Android application to guarantee connectivity with the web, data integrity, and a third layer, the web level, where the transferred ECGs are stored and processed. The web application provides complementary tools to help cardiologists to study the evolution of each patient. A representation of the proposed solution is shown in **Figure 1**.

#### *2.1.1 The ECG recorder*

A battery-powered medical device was developed to digitize a bipolar ECG lead; the authors recommend to attach the electrodes as it was defined for lead II from the standard 12-lead ECG because it is the best approach to study cardiac rhythm disturbances.

The ECG recorder was designed as a low-cost solution, so commercial electronic components were used instead of ASIC, FPGA, and so on. However, surface montage electronic components were combined with a multilayer print circuit design to reduce the device size and improve its reliability. The ECG recorder description can be divided as follows:

**Figure 1.** *The proposed three-layer system.*


ECG samples are acquired automatically when the ECG recorder is turned on; the sampling frequency always is set to 250 Hz. Bluetooth protocol is used to transmit digital samples to a mobile phone. Additional information about pacemaker spikes and electrode contact is transmitted too. A circuit for pacemaker spike identification was included in the ECG amplifiers; spike detection is based on signal slope analysis. Another circuit was designed to detect poor contact between the electrodes and the

#### *Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

patient's skin; this process is very important because only one signal is available and its quality is very important for the intended use (**Figure 2**).

ECG samples, pacemaker information, and electrode status are packed and sent with a sync byte. The receiving, called the Android terminal (an app running on an Android-based mobile telephone) can identify the start of each packet and extract the information bits corresponding to ECG samples, electrode status, and pacemaker spike detection. ECG strip duration is set according to the study to be performed; a typical duration could be 3 min. When ECG transmission is finished, the MSP430F5529 microcontroller goes to "sleep mode" in order to minimize energy consumption. Only hardware interrupts generated by the keypad or the timer are able to wake the microcontroller.

#### *2.1.2 The android terminal*

This android application was programmed in Java language, but several other options are available nowadays; the same happens with the programming framework. The best choice of these items will strongly depend on the programmer's skills and will be determinant to shorten or delay the time to get the final solution.

The main features of this part of the proposed solution are the following:


**Figure 2.** *The ECG recorder prototype.*


#### *2.1.3 The analysis station*

This web application is the main part of the proposed solution because it enables cardiologists to analyze the status of any patient based on the collection of all signals captured by the ECG recorders and powerful graphic tools. Several parameters are computed as a complement of the stored digital ECG. A simple SQL database was implemented to store all general data, ECGs, and parameters. Tables and graphics are available to analyze the evolution of any patient, so cardiologists can evaluate the effectiveness of the drug treatment and make any necessary changes. Cardiologists' comments and treatment changes are stored in the database too. In summary, the analysis station provides the following features:


A simple way to appreciate the advantages of the proposed solution is the following example: A cardiologist instructs a patient to capture three ECGs daily with the ECG recorder (morning, afternoon, and night). After a month, the cardiologist has 90 ECGs of the specific patient and he/she can analyze in detail how it is influencing medical treatment in the disease studied. Following the traditional method of visits to the specialist, so much valuable information would never be accumulated. This is why it is said that the proposed system allows a much closer doctor-patient relationship.

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

Digital ECGs are processed at the analysis station to facilitate future software updating tasks. It is easier to update the web application only than to update each of the ECG recorder devices connected to the system or the Android app linked to each one.

#### *2.1.4 ECG processing*

ECG processing starts with digital filtering to remove or attenuate spurious signals. A FIR (finite impulse response) moving average filter proposed by Ligtenberg and Murat [8] was implemented. It was used by the authors in previous projects with good results; an attractive characteristic is that the filter is based on integer arithmetic only. The mathematical expression of the proposed filter is as follows:

$$\mathcal{Y}(k) = \frac{1}{K^2} \sum\_{m=k-K+1}^{k} \sum\_{n=m-K+1}^{m} \varkappa(n) - \frac{1}{L^2} \sum\_{m=k-L+1}^{k} \sum\_{n=m-L+1}^{m} \varkappa(n) \tag{1}$$

where x(n) is the input signal, y(k) is the output filtered signal, K, L are filter constants strongly associated with cut-off frequencies.

The authors have implemented a QRS complex detection based on an energy collector and two thresholds. The energy function is easy to implement because it is based on integer arithmetic; it is an important feature because the same function can be used for real time and offline applications with similar performances.

The energy function is defined as the sum of the squared differences of the samples corresponding to a preestablished time window previous to the studied sample. The windows width is set to 150 ms taking into count the width of ventricular beats which are prone to durations over 120 ms. Eq. (2) corresponds to the described energy collector.

$$\chi(k) = \frac{1}{N} \sum\_{n=k-N+1}^{k} \left[ \varkappa(n) - \varkappa(n-1) \right]^2 \tag{2}$$

where x(n) is the input signal, y(k) is the energy function.

The energy function is combined with two thresholds. The first one is used to detect high-energy peaks and the second threshold is applied to a rough onset and offset identification for each QRS complex. R waves are identified as the wave including the most positive peaks within each QRS complex, so a peak detection algorithm is applied after the onset and offset events were detected.

RR intervals are computed after the identification of all R wave's peaks as the difference between two consecutive peaks. Each cardiac beat is classified as premature or not premature according to their previous RR interval duration. An ECG strip is classified as "arrhythmic" if more than 10% of QRS detected gets into this classification. This percentage should be defined at the Android terminal setup and cardiologists can be modified according to the patients.

The information associated with each digital ECG is stored in a temporary database and uploaded to a sHTTP server. The temporary mobile telephone database can be very useful when public data network is out of service for a prolonged period due to natural disasters, army conflicts, and similar situations. When public data networks are not available, ECG can be reviewed in a limited framework.

The system operation can be summarized as follows:


#### **2.2 Results and discussion**

Five ECG recorder prototypes have been tested according to the IEC 60601-2-47 standard and all results were successful. The proposed device is not a pure ambulatory medical device, but the IEC 60601-2-47 standard is suitable for its evaluation. Some of the most highlighted results are shown in **Table 1**.

The proposed device is safe for patients, according to the test results, following the IEC 60601-2-47 standard requirements.

The android terminal application was fully tested. The Bluetooth communication was checked with 200 simulated 3 min ECG strips with different heart rates: 60, 80, 120, and 150 beats per minute. These strips were acquired with three ECG recorders wireless connected to a mobile phone running the proposed Android terminal. This


#### **Table 1.**

*Some results from technical tests.*

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

test passed without errors, and the signals received by the Android terminal were identical to the original simulated ECGs. Also, the communication process was never aborted by errors.

The digital filter performance has been published in previous papers, so the authors do not consider necessary new evaluation [9]. A similar situation happens with the QRS detection process based on the previous experiences of the authors [9, 10]. Nevertheless, the authors considered it useful for the readers to show the performance when the algorithm was tested with the MIT-BIH arrhythmia database; results are shown in **Table 2**.

Thus, the performance of the QRS complex detection algorithm is enough for the intended use. The MIT-BIH arrhythmia database is a golden reference to test this kind of algorithm.

All the features of the proposed Android terminal have been tested with a significant amount of ECG strips. The performance of the implemented Bluetooth link has


#### **Table 2.**

*Results with 12 ECG strips from MIT-BIH database.*

been stable; no user-level errors have been detected. QRS complex detection algorithm was tested with MIT-BIH arrhythmia database, an international standard for this purpose, and the sensitivity was high, this result is enough for the intended use.

As has been seen, a full version of the proposed solution has been tested with satisfactory results. The ECG recorder safety meets the requirements set by the IEC 60601-1 standard for this kind of medical technology. The functioning of the system has been tested in stressing conditions without failures, demonstrating the robustness of the proposed solution.

The proposed system looks like a useful tool to study arrhythmic patient progression using existing data networks, mainly mobile telephone networks. Other chronic diseases can be studied following the same philosophy.

#### **3. Cardiac monitoring of high-risk persons**

Those persons who are subjected to high stress as part of their daily activities and do not have healthy lifestyle habits are prone to suffer from serious and sudden cardiovascular disorders, whose main manifestations are high blood pressure, malignant cardiac arrhythmia events, and acute myocardial infarctions. This kind of person needs continuous cardiac monitoring to detect dangerous changes since their beginning. Implanted cardiac loop recorders could be a solution for persons suffering from this situation, but these devices and the associated surgery procedure are expensive [11]. Besides, the risk associated with any surgery is always present.

An alternative without surgical risk and much cheaper would be the development of a device capable of monitoring the heart rhythm and transferring the digital signal to a remote central station when any dangerous change is detected from the analyzed person. For this data transfer, the existing public mobile data network in the country would be useful. The authors of this chapter focused their efforts on this kind of solution and present a proposal.

#### **3.1 Proposal for out-of-hospital cardiac monitoring**

We have developed a cardiac telemonitoring system as part of a larger telecardiology system with other final applications. The proposed system is composed of connected two parts using the mobile data network:


*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

message is activated. A specialist analyzes the information and send the proper response, all the process (arriving time, delay to response, and specialist in charge) is stored in a database because this information is useful to optimize the system's performance. The response central station works together with the available ambulances to assign the closest one to the person who requires it.

The target of the ECG recorder design was to minimize the cost without decreasing its reliability. Besides, the device should be user-friendly, safe, and resistant to mechanical impacts. The device is composed of the following blocks:


**Figure 3.** *Representation of the ECG recorder design.*

The electronic design of the ECG recorder was made on a single printed circuit board; the LCD display and the GSM modem are connected to this board using boardto-board connectors. This design approach is robust against severe mechanical impacts and guarantees continuous functioning.

Two bipolar ECG leads are analyzed in real time to detect dangerous events, such as severe cardiac rhythm disturbances and pronounced ST-segment deviations. Since the cardiac patient's conditions are known a priori, the location of the electrodes can be adjusted to capture the ST-segment deviation in a given plane. It should not be forgotten that the heart is a three-dimensional organ and ST-segment deviations can manifest differently in different planes. However, the heart rhythm is unique and can be observed in the same way in any lead, although lead II is preferred due to its coincidence with the ventricular depolarization main vector. The ECG analysis algorithm can be divided as follows: ECG acquisition, QRS-complex detection, QRScomplex classification, ST-segment deviation measurement, and communication.

ECG samples are acquired from two bipolar channels simultaneously using s sampling rate of 250 Hz, enough according to the sampling theorem [12]. A single channel could seem enough, but a second channel is used as a backup because it is known electrode contact is prone to failures in long-term ambulatory monitoring systems, so a good approach is to acquire two channels and select for cardiac rhythm analysis the one with the best signal-to-noise ratio. Also, the two channels provide a better approach to the ST-segment deviation analysis.

The digital ECG is smoothed using a Hanning filter and the energy function is computed sample-by-sample for each channel according to Eq. (2) previously shown.

The QRS-complex detection process is based on the energy collector function computing and two thresholds. The first one is set as 20% of the maximum value of energy and it is used to identify high-energy signal segments. It is known that QRS complexes are integrated by high-energy components. The second threshold is used to set a rough identification of the onset and offset for each QRS complex; it is set as 5% of the maximum energy value. The position of these events is refined using a

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

derivative function and each QRS complex width is computed; the QRS complex candidates should reach a minimum duration (30 ms). The mean RR interval duration is updated when a new QRS complex is detected because its previous RR interval is calculated. A baseline estimation for each QRS complex is set as the mean value of the samples associated with 20 ms before the complex onset. The average heart rate is updated every 10 s.

The proposed system is focused on long-term real-time ambulatory monitoring, a much more complex scenario than the first explained system. This is the reason for introducing a change in the energy function. Instead of using a simple signal slope calculation, the authors introduce the Teager operator as the basis to obtain the signal energy.

The Teager operator is a nonlinear operator that mainly shows the frequency and instantaneous changes of the signal amplitude and is very sensitive to subtle changes. Although the Teager operator was first proposed for modeling nonlinear speech signals, it was later widely applied in ECG and EEG research [13]. Its expression is as follows:

$$TO(\mathcal{X}[n]) = \mathcal{X}^2[n] - (\mathcal{X}[n-1] \* \mathcal{X}[n+1])\tag{3}$$

where TO is the Teager operator, x[n] is the input signal.

Once the QRS complexes have been detected, they are classified to group them as normal (NB), premature (PB), and unclassified. This process is important for the measurement of ST-segment deviation, it is only measured in normal complexes, and for calculating the premature beats rate, which can alert about serious ventricular disorders. To facilitate the execution of these tasks in real time, the criteria to be used must be simple without losing effectiveness. The defined criteria were the following:


The premature beats rate is updated every 10 s. Unclassified beats are not studied. The ST-segment deviation is defined as the difference in voltage between the sample place 80 ms after the QRS complex onset and the baseline estimation for the studied complex (**Figure 4**).

When the ECG recorder is turned on and configured, a first information block is transmitted to the response central station in order to open a patient profile. This block includes the following information:

*Telehealth and Telemedicine - The Far-Reaching Medicine for Everyone and Everywhere*

**Figure 4.**

*ST-segment deviation.*


The response central station responds with a block known as "echo block." If the ECG recorder requesting to be recognized is correctly identified, an echo block identical to the one sent by the ECG recorder is transmitted. If an error occurs and the ECG recorder is not properly identified, the response central station does not send a response block. The ECG recorder tries the connection three times before reporting the error on its screen so that the specialized personnel can take some action to solve this technical problem.

Since the ECG recorder is turned on; it will analyze the ECG in real time to transmit signal segments to the TCS when any electrocardiographic event reflecting a dangerous condition is detected or when the studied subject decides to send an ECG segment because he is feeling discomfort. Also, ECG segments can be sent periodically if the device is configured for this purpose.

Dangerous events that can be identified by the ECG recorder are marked tachycardia and bradycardia, high premature beats rate, and significant ST-segment deviations. The information is transmitted in blocks composed of a header that identifies the type of block, a body that contains the ECG samples, and a tail containing a checksum code to validate data integrity.

An identification block is sent to start the communication with the TCS. The transmitted ECG strip could be split into several signal blocks and, in the end, a final block is transmitted, including the block quantity transmitted. The ECG recorder will wait for an answer, which will be displayed if patient's cooperation is required.

#### **3.2 Implementation results**

Five ECG recorder prototypes were manufactured and tested.

#### *Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

The developed real time ECG processing method has been tested with 25 min ECGs, including eight ECGs with premature beats, from a Holter system. The signals were analyzed by two highly-qualified cardiologists with more than 20 year of experience in analyzing ECG strips. They were helped by a Windows application, developed by the authors of this document, which allowed them to carry out an exhaustive analysis of the digitized ECGs. These cardiologists were not aware of the method outcomes in order to perform a blind evaluation. The opinions and conclusions of the specialists were the golden rule to test the method. The evaluation results can be summarized in **Table 3**.

As can be seen in **Table 3**, all the QRS complexes present in the analyzed signals were detected. This result is remarkable because it is the basis for reliable ECG analysis.

It should not be forgotten that all processing is done in real time on a batterypowered device, so a vital requirement is low power consumption to ensure the expected runtime. For this reason, a trade-off between the simplicity of the rules for classifying QRS complexes and their effectiveness must also be achieved. Complex calculations imply high energy consumption.

The set rules for the QRS complexes classification are simple, and based on lowcomplexity computational operations. Despite this, they have demonstrated high effectiveness with more than 96% of identified premature complexes. Only a small number of normal QRS complexes were misclassified, but this flaw does not affect the intended use of this solution. The main objective is the early detection of cardiac events associated with ventricular disorders and the results obtained are satisfactory. It should be noted that a premature QRS complex was never considered normal, although some of them were identified as unclassified beats (UB).

The ST-measurement algorithm was not evaluated because it was not implemented for the ECG recorder's first version. However, the algorithm was implemented in order to evaluate the real-time performance of the proposed method.

Communication with the response central station was set under the following conditions: more than two premature beats in 10 s; heart rate value over 100 beat per second (bpm) or heart rate value below 60 bpm.

To test the communication process, 40 ECG strips were transferred and these operations were always successful. The signals received at the response central station were compared, sample by sample, with the originally transmitted signal. A graphic program was used for this test and remarkable differences were not observed. Also, communication never was unexpectedly, and the received signals were not corrupted by noise or distortions. These results confirm that the communication process was effective.

The proposed system seems a useful monitoring tool for patients prone to suffer sudden heart attacks. Also, it could be useful for long-term ECG studies.


#### **Table 3.**

*Global results of the proposed method for real time ECG analysis.*

#### **4. A tool for primary and secondary cardiac disease prevention in the community**

It is internationally recognized that all public health systems should focus their efforts and resources on the prevention of chronic diseases, giving top priority to health services related to this purpose [14]. In the particular case of heart disease, the leading cause of death worldwide, the international scientific community accepts that there are certain electrocardiographic parameters strongly related to the prediction of severe cardiac disorders. Based on this criterion, it is proposed that if these parameters are long-term studied; it is possible to predict cardiovascular system complications and take therapeutic actions before they manifest.

Early detection of heart disease ensures that medical treatment is less aggressive and more effective than if the disease progresses to more advanced stages. This is the reason why several multidisciplinary groups of researchers are working to develop tools and strategies for the primary and secondary prevention of heart disease. Primary prevention means medical attention for people who are prone to develop heart disease because of their lifestyle or genetic facts, even before they get sick. These people must learn to improve their lifestyle (eliminating tobacco, proper nutrition, fitness, etc.), but it is also feasible to study them periodically to identify any change toward morbidity from its first manifestations. When a person has already had a heart attack, the medical procedure is to enter that person into a cardiac rehabilitation program. Secondary prevention focuses on inducing healthy lifestyles and regular screening for any early signs of another attack. The study of the evolution of different electrocardiographic parameters can contribute decisively to avoiding a new heart attack.

Resting ECG is an inexpensive cardiac test that provides valuable information for implementing the approaches described above.

The aim of this section is to present and discuss a system designed for the implementation of primary and secondary prevention of heart disease in the community. The periodic study of a group of electrocardiographic parameters is intended to evaluate their evolution and thus predict the onset of severe cardiac disorders. This study is focused on subjects who have already had a heart attack or who are prone to one.

#### **4.1 How to help prevent cardiac diseases?**

The proposed system is composed of two main elements: a portable device for rest ECG acquisition, henceforth, recorder and Windows-compatible software, called a. The designer team's aim was a low-cost device able to get a high-quality rest ECG and ready to be used anywhere, without special requirements. Besides, the proposed system will be addressed to the community and the neighborhood, so it should be friendly for the users, the family doctors, and nurses or paramedics.

#### **4.2 The recorder**

These recorders are based on an ARM9 microprocessor operating at a frequency of 400 MHz; they have the following features:


*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*


The described hardware is enough for the intended use, but the cost could be reduced using alternatives available in the single-board computer market currently.

The multichannel ECG amplifier is dedicated to acquire and adequate the electrocardiographic signals generated by the patient. These analog signals are converted to digital values at a sampling rate of 500 Hz [12] (**Figure 5**).

The main features of the ECG multichannel amplifier are described below. An analog bandpass filter was implemented to limit the frequency spectrum of the signals between 0.05 and 100 Hz according to the requirements of the IEC 60601-2-25 standard. Each amplifier channel is protected against defibrillator discharge with 10 kΩ resistors. A classic right leg circuit for improved common mode rejection ratio was included as part of the amplifier [3]. Pacemaker spike detection is based on lead II; the signal at the output of the corresponding instrumentation amplifier is used to detect the spikes; and this signal is connected to the input of a filter capable of generating a pulse every time a spike is detected, while the rest of the time it has a zero as output.

**Figure 5.** *View of the ECG recorder.*

Another circuit called "trace recovery" is implemented to minimize the required time to recover the reference level when an electrode contact fails and any amplifier is saturated.

The eight independent leads (I, II, V1, V2, V3, V4, V5, and V6) are simultaneously digitized at a rate of 500 Hz with a 12-bit A/D converter; the LSB value is 3.15 microvolts. Leads III, aVR, aVL, and aVF are not implemented in the ECG amplifier because they can be derived from classical expressions when leads I and II are acquired simultaneously.

When signals from the eight channels have been acquired, two digital filters are applied. A notch filter is used to reject the 60 Hz component and a moving average type FIR filter is used to improve signal quality, minimizing noise and removing baseline wandering.

QRS complexes are detected in real time to calculate the heart rate when the ECG is acquired. A function of spatial velocity (FSV) is the basis for this process. This auxiliary function makes so easy to identify the signal segments associated with the QRS complexes [4].

$$FSV(k) = \sum\_{i=1}^{C} \left[ \mathbf{x}(i, \ k) - \mathbf{x}(i, \ k - \mathbf{1}) \right]^2 \tag{4}$$

where FSV(k) is the Function of spatial velocity, x(i, k) is the ECG sample for lead i, C is the number of simultaneous leads.

As it is classic in the resting ECG devices, the electrocardiographic signals are acquired for 10 s and subsequently processed to extract the value of all the variables studied, more than 220 variables in each signal studied. However, the ECG is acquired without specifying when it will be analyzed; the operator is the one who decides when he wants the last 10 s of the ECG to be analyzed. While this process is going on, before it is analyzed in ECG, the device keeps calculating the heart rate in real time and updating its value on the screen every 10 s.

When the operator presses the proper button to start the ECG analysis, the signal acquisition process stops, and the ECG is analyzed automatically. More than 220 variables are calculated, and the process takes about 3 s. All this information is stored on the device. Computed variables can be grouped as follows:


The recorder works as a data logger. For each ECG acquired, the recorder stores general patient data, the ECG (12 leads for 10 s), and measurements in internal memory where it maintains a database. This information is encrypted to guarantee its confidentiality. Data can be transferred to a computer using a USB connection.

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

Data and signals are displayed on the recorder's screen; it is a liquid crystal display (LCD) with a resolution of 800 600 pixels and colors. This peripheral greatly facilitates the interface with the operator. A flat, soft-key keyboard complements the operator interface while making cleanup easy.

In an emergency, the recorders can be connected to a telecardiology system to request specialized help. The recorder can send a digital ECG and receive guidance on the actions to take on the patient suffering from dangerous disturbances. The integrated modem is used to establish the connection using the traditional telephone network or using a TCP/IP stack.

#### **4.3 The analyzer**

The analyzer is a Windows application running on a personal computer with sufficient resources to store all information associated with each patient enrolled in the proposed system. **Figure 6** shows an ECG from a patient and a list, on the left extreme of the screen, of the acquired ECGs. The system language is configured as Spanish. Other languages may also be incorporated.

The physicians use a graphical interface to evaluate patient ECGs; they can see the ECG one by one or they can study the trend of different parameters and thus detect the first signs of a heart disorder. Also, they can upload complex ECGs to a web application, called "The Expert," looking for a second specialized opinion before taking decisions. The parameters studied are:

• Cornell and Sokolow Indexes: These indices are strongly associated with ventricular hypertrophy. They are computed for each ECG and their trend is represented in a proper chart. The aim of the long-term analysis of these indices is the early detection of a ventricular dilation process because this process appears at the beginning of ventricular hypertrophy. Medical intervention at the beginning of this ventricular disturbance could delay its negative effects or even avoid them.

**Figure 6.**

*ECG from a patient enrolled in the proposed system.*


The proposed system studies the trend of the parameters mentioned above. Isolated values can be affected by different factors, while the tendency of a collection of values will indicate its behavior over time. All data associated with each study is displayed on the same screen to facilitate the analysis without continuous window changing.

#### **4.4 Results and discussion**

Five prototypes have been manufactured and tested; they have successfully passed parametric tests and electrical safety tests established in IEC 60601-2-25 for rest ECG devices with automatic wave measurement capabilities. Some of the main results of these tests, from the hardware point of view, are summarized in **Table 4**; it is impossible to show all of them because of the available space for the present document.

The obtained results meet the IEC 60601-1-25 requirements, so it is possible to affirm that the implemented electronic design solutions used in this device have been effective and according to the state-of-the-art. The software developed for ECG processing has been evaluated with CSE and CTS databases according to the same IEC standard [2]. For all studied variables, the maximum permissible error in measuring an ECG event has not been exceeded. Some of the results are shown in **Table 5**.

The QRS-detection algorithm was full-effective, and all the QRS complexes present in the analyzed ECGs were identified; all these signals are from the CTS and CSE databases, considered as an international standard. This result is very promising,


#### **Table 4.**

*Main results of parametric tests.*

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*


#### **Table 5.**

*Mean differences and standard deviations for global intervals on analytical ECGs.*

although it can change a little under extreme-noisy conditions, so it is strongly recommended to take care to minimize noise presence.

When the accuracy of amplitude measurements within the QRS complex was analyzed, automatic measurements never deviated from the reference more than 25 microvolts for amplitudes lower than 500 microvolts or higher than 5% for amplitudes greater than 500 microvolts. This behavior meets the IEC standard requirements.

The full system has also been preliminarily tested with simulated signals and volunteers. The performance has been stable and there were no recorders out of order, software malfunctions, or unexpected errors. The proposed system has been completed with satisfactory results. All the IEC tests have passed successfully.

The analyzer works properly and is a friendly application. Five experienced cardiologists confirmed this criterion after several work sessions. By combining the available analysis tools and data, cardiologists can get new results unreachable using the traditional approaches. The proposed system seems a useful tool for cardiac disease prevention approach at the community level.

#### **5. Final considerations**

The three solutions described in this chapter are aimed at caring for subjects suffering from or prone to cardiac disorders. Two of these solutions are based on medical devices for personal use and the third is a system for the care of subjects in the community, in the environment in which they carry out their daily activities, based on the standard 12-lead ECG. In all solutions, public data networks are used to exchange information without requiring special services, so the cost is minimized for this concept.

Chronic diseases were associated with countries with high industrial development, while low-income countries were more linked with non-chronic diseases, such as dengue, diarrhea, and others. This situation has changed in recent years because of several factors and chronic diseases have reached an equal impact on all countries, regardless of their economic development. The great difference lies in the economic resources available to implement public health policies, while in developed countries the necessary resources are available, the health systems of underdeveloped countries are unable to serve the entire population due to their economic and financial limitations. The use of telemedicine, based on public data networks, can be a powerful tool to expand health services to everyone.

**Table 6** summarizes some of the characteristics of the proposed solutions, showing the elements they have in common and their differences.

It should be noted that the three solutions have been developed in full adherence to the safety and performance requirements established in the IEC standards


#### **Table 6.**

*Main characteristics of the proposed solutions.*

(International Electrotechnical Commission), accepted as international standards and compatible with other similar institutions, such as FDA (Food and Drug Administration) and Japanese regulatory documents. Another aspect to highlight is the multidisciplinary teamwork for the development of the proposed solutions. The scientific level required for this software, mechanical, and electronic solutions was combined with the theoretical knowledge and practical experience of high-qualified cardiologists with more than 20 years dedicated to clinical services in their specialty, who provided valuable criteria for the implementation of the necessary features and for the evaluation of the proposed systems in real conditions of use.

One-channel and two-channel devices were developed to analyze cardiac rhythm disturbances; one solution focused on following up arrhythmic disease and the other for real time surveillance purposes to detect dangerous events immediately. The third solution was developed to predict arrhythmic and non-arrhythmic disorders, so the standard 12-lead ECG is the basis for this task. Several cardiac disorders involve spatial structures and the 12-lead standard ECG is the best noninvasive approach for their analysis.

The three proposed solutions are viable in low-income countries and therefore can be extended to countries with better economic standards. Electronic designs are based on commercial components that are available in the international electronic market; this facilitates manufacturing and after-sales service, guaranteeing the sustainability of the systems.

The two solutions based on portable devices are easy to use for the subjects that require their use. Today, there is a great disposition of most human beings to use portable technology because of the impact of mobile telephony that is part of our lives. The proposed portable devices were designed to minimize their size in order to avoid discomfort and their operation requires minimal user intervention. The third solution proposes the approach of the standard resting ECG to the community to assess the trend of different parameters strongly associated with dangerous cardiac disorders. In this case, the electrocardiographic test is the traditional 12-lead ECG, so its acceptance by the subjects studied is a fact.

The three proposed solutions offer health services that do not exist or are very difficult to implement traditional methods of care for patients suffering from heart disease. It is typical for a subject suffering from cardiac arrhythmias to visit the cardiologist periodically, for instance, it could be every 3 months, but it is impossible to know what happens between two visits while the solution proposed by the authors allows to evaluate the cardiovascular system changes day by day. The second solution proposes a way to keep people with high cardiac risk due to stress or suffering from some cardiac disorder under cardiovascular surveillance. This is also very difficult to achieve in low-income countries, although in developed countries there are more compact solutions than the one proposed, although they are also more expensive.

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

#### **6. Conclusions**

The solutions described in this chapter are examples of simple systems to provide effective tools for cardiac disease analysis and monitoring. The approaches discussed are feasible for other chronic diseases, such as diabetes, arterial blood pressure disturbances, and respiratory diseases. The common element is the measuring of the main parameter characterizing the analyzed disease with a medical device easy to use at home. This element combined with the use of public data networks is the basis for this kind of solution.

The greatest effort has always been aimed at achieving, at a minimum cost, solutions that meet the highest current safety and quality standards.

The proposed systems have been developed and tested under real conditions without any exceptional resources. A public data network of a poor country was the support for all tests and the results were satisfactory.

#### **Acknowledgements**

The authors would like to acknowledge the collaboration of colleagues from hospitals and technical testing laboratories who supported the development of the proposed systems. Without them, it would have been impossible to get these results. The financial support of the Ministry of Science of the Republic of Cuba for the execution of the projects associated with the presented systems is also appreciated.

#### **Conflict of interest**

The authors guarantee that there is no conflict of interest with the information published in this document.

#### **Author details**

Rene Ivan Gonzalez-Fernandez<sup>1</sup> \*, Margarita Mulet-Cartaya<sup>2</sup> , Gisela Montes de Oca-Colina<sup>2</sup> , Jorge Aguilera-Perez<sup>2</sup> , Juan Dayron Lopez-Cardona<sup>3</sup> and Jose Luis Hernandez-Caceres<sup>1</sup>


© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Low-cost Approaches to Follow-up Cardiac Patients in Low-Income Countries Using Public… DOI: http://dx.doi.org/10.5772/intechopen.108222*

#### **References**

[1] Mendis S, Lindholm LH, Mancia G, et al. World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: Assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. Journal of Hypertension. 2007;**25**:1578-1582

[2] The WHO CVD Risk Chart Working Group. World Health Organization cardiovascular disease risk charts: Revised models to estimate risk in 21 global regions. The Lancet Global Health. 2019;**7**:e1332-e1345. DOI: 10.1016/ S2214-109X (19)30318-3

[3] Tison GH, Zhang J, Delling FN, Deo RC. Automated and interpretable patient ECG profiles for disease detection, tracking, and discovery. Circulation. Cardiovascular Quality and Outcomes. 2019, 2019;**12**:e005289. DOI: 10.1161/CIRCOUTCOMES. 118.005289

[4] Macfarlane PW, Kennedy J. Automated ECG interpretation – A brief history from high expectations to deepest networks. Heart. 2021;**2**: 433-448. DOI: 10.3390/hearts2040034

[5] Moraes E, Barros LP, Rodrigues AE, Pagliara AT, Carvalho AC. Pre hospital electrocardiography: Prevalence of clinically important ECG findings of a public health system in a developing country. In: 2nd International Conference on Global Tele Health. 26–28 November, 2012. Australian Tele Health Society. Sydney; 2012

[6] Abraham WT, Stevenson LW, Bourge RC, Lindenfeld JA, Bauman JG, Adamson PB, et al. Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure

therapy: Complete follow-up results from the CHAMPION randomized trial. Lancet. 2016;**387**(10017):453-461. DOI: 10.1016/S0140-6736(15)00723-0. Epub 2015 Nov 9

[7] Frederix I, Solmi F, Piepoli MF, Dendale P. Cardiac telerehabilitation: A novel cost-efficient care delivery strategy that can induce long-term health benefits. European Journal of Preventive Cardiology. 2017 Nov;**24** (16):1708-1717. DOI: 10.1177/ 2047487317732274. Epub 2017 Sep 19

[8] Ligtenberg A, Kunt M. A robustdigital QRS-detection algorithm for arrhythmia monitoring. Computers and Biomedical Research. 1983;**16**(3): 273-286. ISSN 0010-4809. DOI: 10.1016/ 0010-4809(83)90027-7

[9] Gonzalez-Fernandez R et al. Combining ECG and pulse oximetry for newborn cardiovascular screening. Acta Scientific Medical Sciences. 2020;**4**(6): 49-54

[10] Gonzalez-Fernandez R, Mulet-Cartaya M, Lopez-Cardona JD, Lopez-Rodriguez L. A mobile application for cardiac rhythm study. Computing in Cardiology Conference. 2015;**2015**: 393-396. DOI: 10.1109/CIC.2015.7408669

[11] Kwok CS, Darlington D, Mayer J, Panchal G, Walker V, Zachariah D, et al. A review of the wide range of indications and uses of implantable loop recorders: A review of the literature. Heart. 2022;**3**: 45-53. DOI: 10.3390/hearts3020007

[12] Lai E. Converting analog to digital signals and vice versa. In: Practical Digital Signal Processing. Newnes; 2003. pp. 14-49. ISBN 9780750657983. DOI: 10.1016/B978-075065798-3/ 50002-3

[13] Beyramienanlou H, Lotfivand N. An efficient Teager energy operator-based automated QRS complex detection. Journal of Healthcare Engineering. 2018; **2018**:8360475. DOI: 10.1155/2018/ 8360475

[14] Banerjee A, Shanthi Mendis V. Heart Failure: The Need For Global Health Pe rspective. Current Cardiology Reviews. 2013 May;**9**(2):97-98. Published online 2013 May. DOI: 10.2174/ 1573403X11309020001

[15] Hamm W et al. Risk prediction in post-infarction patients with moderately reduced left ventricular ejection fraction by combined assessment of the sympathetic and vagal cardiac autonomic nervous system. International Journal of Cardiology. 2017;**249**:1-5

[16] Xiaojuan X, Björn W, David GS, Galen SW, Jciech Z, Arthur JM. Jean-Philippe Couderc, Automatic QRS. Selvester scoring system in patients with left bundle branch block. EP Europace. Feb 2016;**18**(2):308-314. DOI: 10.1093/ europace/euv040

## Section 2
