APLICATIVOS MÓVEIS DESENVOLVIDOS PARA A ÁREA DA SAÚDE NO BRASIL : REVISÃO INTEGRATIVA DA LITERATURA MOBILE APPLICATIONS DEVELOPED FOR THE HEALTH SECTOR IN BRAZIL : AN INTEGRATIVE LITERATURE

The popularization of smartphones has been considered by many the technological revolution of greatest impact in recent years. Considered a pocket computer with access to millions of applications, its main feature is the breaking of the limitations of mobility, following its user 24 hours a day, anywhere. This quality is essential to assisting in healthcare activities, since these professionals constantly move around within the institutions in which they work. This study aimed to identify prior research developed in Brazil which involved mobile technology applied to healthcare. The methodology used in this study was an integrative literature review. The final sample included 27 articles. Analysis of results showed that the most commonly addressed theme in the production of mobile applications for the healthcare field was support for healthcare professionals. Analyzing the focus of mobile applications, it could be found that the category of interdisciplinarity was the most benefited by research in mobile technology. The review concluded that it is of great importance to develop mobile applications linked to scientific research on healthcare, since their content will be analyzed and tested by professionals who know the final users’ real needs.


INTRODUCTION
The popularization of smartphones has been considered by many the technological revolution with the greatest impact in recent years, surpassed only by the revolution sparked by the Internet and social networks. 1rowth in the mobile devices market has generated both commercial and social opportunities in a wide range of areas.These devices are considered pocket computers with access to millions of applications.In 2012 alone, more than 40 billion applications were downloaded on smartphones, and the forecast is that this number will reach 300 billion in 2016. 2 This is mainly due to the facility with which these applications can be accessed in their respective online stores.In this manner, the development of computer solutions in mobile application formats represents an efficient means through which to make a tool available and reach the desired target public.
The main feature of these mobile applications is the breaking of the limitations of mobility, since smartphones are simply pocket computers and can follow their user 24 hours a day, anywhere.Another important aspect is the personalization that the equipment brings to its users, considering that professionals can use their own devices, which they use regularly on a daily basis. 3he use of computer tools in healthcare is growing, as this type of support can allow the professional to achieve greater precision and agility in their work.As regards nursing care in Brazil, the adoption of technological resources is a fact that has been growing since the 60's, with the scientific foundation of the registered nurse as a profession. 4obile technology can be applied in many spheres of healthcare.Among these applications, what stand out are remote monitoring, diagnostic support, and assistance in decision-making. 5,6his literature review is part of a larger project aimed at the development of mobile technology for the fields of healthcare and nursing.In addition, this review is also essential to identifying the gaps to be filled by future research on the theme.
In this light, the present study aimed to identify the current state of the art and research tendencies throughout Brazil that use mobile technology in the health sector.

MATERIALS AND METHOD
This study was an integrative literature review aimed at learning about what exists in the Brazilian scientific journals on the theme of technology and mobile applications in the health sector from January 2006 to July 2013.
This method allows one to gather prior research and draw conclusions on this specific technological theme. 7As this study is an integrative literature review, it was not necessary to obtain approval from a Research Ethics Committee, as set forth in Resolution 466/12 by the Brazilian Health Ministry. 8To per-form this review, the study followed that proposed by Ganong 9 , which involves the following steps: l selection of the questions for review; l defining of the study inclusion criteria and the search for literature; l presentation of the characteristics of the reviewed studies; l analysis of the studies using a specific instrument; l interpretation of the results; l presentation of the results and a synthesis of the knowledge.
To guide the integrative review, the following question was posed: "what has been developed in Brazil as regards scientific research in the health sector concerning mobile applications?" The following databases were used to select the articles: the virtual libraries of SCIELO, LILACS, and Google Scholar.The Google Scholar library was consulted in an attempt to expand the scope of this study, encompassing, in addition to indexed articles, theses, dissertations, and final papers of courses not found in the indexed libraries, which minimized the possible routes in this step of the process geared toward the gathering of studies to be reviewed.Any studies found in more than one database were considered only once.
The study inclusion criteria were the following: publications available online, in Portuguese, developed by Brazilian researchers, and published in the period between 2006 and 2013.The exclusion criteria included: articles in which it was not possible to identify any relation to the theme by reading the title or the abstract, research that was not developed by Brazilian researchers, and review articles.The key words used were: application and health and smartphone.The article selection process is presented in Figure 1.

RESULTS
Through the searches performed in the chosen databases, 319 studies were found.All of the titles and abstracts were read, respecting the inclusion and exclusion criteria, and 27 studies were selected for more detailed analysis.To better identify each selected study, the articles were organized in an alphanumeric sequence, from A1 to A27 (Table 1) The selected articles were summarized and classified according to the following criteria: Year of publication, type of publication, thematic approach, and the application's focus on a specific profession.According to the year of publication, the following distribution was employed: 2013 (1), 2012 (10) A specially designed instrument was used to extract and analyze the data from the selected studies.In this instrument, it is necessary to identify the study, its home institution, the type of journal in which the work was published, the methodological characteristics of the study, and the assessment of the methodological accuracy. 10o classify the evidence level of the works, the categorization established by the Agency for Healthcare Research and Quality (AHRQ) was used. 11The quality of the evidence is classified in six levels, as follows:

Year 2012
Continues… practices of a wide range of healthcare professionals.The great majority of studies developed technologies that used the vital signs of the patients as the core idea, aimed at viewing these data and healthcare professionals' constant follow-up of patients, without the need to remain at the patient's bedside, in turn facilitating access to information in any environment. 12,14,18,24,25,27,30,33 Ang these, one study reported on a differential mechanism used to view a patient's vital signs by using a photoplethysmography 14 , while the others used data transmission through a mobile device connection with technological devices attached to the patient.All of the studies showed the importance of facilitating the professionals' access to the patients optimizing their activities, in turn aiding in the communication among the professionals when the patient was in an unstable condition.One of the studies proposed the use of mobile technology to help follow the medical protocols for attending to ST-segment elevation acute myocardial infarctions (STSAMI) 15 ; another developed a computer display system to remotely monitor the respiratory parameters of the patients with amyotrophic lateral sclerosis (ALS) in a hospital environment 35 ; another study analyzed the use of mobile technologies with a didactic proposal within a healthcare context 31 ; while other authors researched and proposed a ubiquitous healthcare environment through the use of mobile technology. 36

Studies that focus on nurses
In the category "Studies that focus on nurses", three studies were selected that contemplated the use of mobile devices geared toward nursing practices.
As regards the type of publication, no theses were found; the other types of publications were summarized as: article (13), dissertation (7), and final paper for a course (7).All of the identified studies were classified with an evidence level of 4, based in the AHRQ categorization, 11 as it contained a non-experimental framework with a descriptive, applied, or correlational type of research.
To analyze and discuss the mobile application developed for the health sector, the studies were organized in categories by adding the theme to the target public of each study, as follows: "Studies that focus on interdisciplinarity"; "Studies that focus on nurses"; "Studies that focus on doctors"; "Studies that focus on dentists"; "Studies that focus on patients" (Table 2).

Studies that focus on interdisciplinarity
As regards the category of "Studies that focus on interdisciplinarity", 12 publications were selected that dealt with the theme of mobile technology geared toward assistance in the
Studies that focus on dentists A21, A26.
plications were developed with the purpose of being used directly with the patient, thus representing remote medical support.

DISCUSSION
The analyzed data demonstrated that the publications in the line of research regarding mobile technology applied to healthcare is a new field and is growing.The publications found between 2006 and 2013 had their largest concentration in 2012, with 10 published articles.An increase in publications on the theme could be observed over the years, and it is believed that this number will be even higher in 2013 due mainly to the popularization of smartphones and tablets.One indication that this is a new field of research is the fact that no "thesis" could be found on the theme, which may well be due to the sheer amount of time needed to conclude work in this category.
The analysis of articles showed that the professional category that was most benefitted by the development of mobile applications in the health sector was that of interdisciplinarity, with 12 studies (interdisciplinarity is understood as works that involve two or more distinct professional categories in the health sector).The professional categories that were analyzed exclusively included doctors, nurses, and dentists, with seven, three, and two studies, respectively.
Among the works analyzed in this study, it was possible to identify three applications that are geared toward the patient as the end user.The development of applications to provide medical support to the patient stands out as a gap that warrants further examination.This is because the use of mobile devices is becoming more and more common, since these devices are available to the user 24 hours a day and, as a pocket computer, can be taken to any environment.This role played by mobile devices may well represent an important aid in the adherence to behavioral and/or medicinal treatments.
Work developed at the University of Columbia 39 identified a total of 83 mobile applications documented in international literature.Of these, 57 were geared toward healthcare professionals, with the most common focus being on assisting in doctor's diagnoses.Another 11 applications were found to be geared toward medical and nursing students and 15 toward patients.Such data are similar to findings from the present integrative review, given that the population that was most benefitted by the mobile applications was that of healthcare professionals, with a special emphasis placed on applications developed to assist doctors.
No integrative review on a similar theme could be found in Brazil.Despite the low number of studies applied and/or developed by healthcare professionals selected in this review, it is still important to highlight the importance of investments in this field of research.Healthcare professionals are in constant One mobile application was developed about vaccinations in Brazil, stemming from current data from the Brazilian Health Ministry's National Immunization Program. 29Another mobile application classified patients and evaluated the work load of nurses who work in intensive care units, the Nursing Activities Score (NAS). 19,23Both applications are in their final development stages and posterior evaluation of the software in clinical practices, aimed at updating the nurses' professional knowledge as well as at a greater insertion of mobile technology in their work environments.

Studies that focus on doctors
Eight "Studies that focus on doctors" were selected.This category was the second most commonly found theme, surpassed only by the "Studies that focus on interdisciplinarity." Among the selected applications were two initiatives that aid doctors in making decision about diagnoses. 20,21Both studies, in addition to assisting the doctor in the diagnostic process, also use imagery processing technology in this process of identifying and classifying diseases.A third initiative, in addition to aiding in the diagnostic process, also transmits exam data from remote locations. 26he patient data transmission technology was developed and used in another four works focused on medical professionals. 13,16,22,34These applications, with data transmission functions, in addition to helping doctors follow their patients remotely, also encourage evidence-based practices, providing medical consultations of specialized knowledge based on data retrieved through the application.

Studies that focus on dentists
In the category of "Studies that focus on dentists", only two studies were selected.Both works presented the development and use of applications as support offered to dentists working in the Brazilian government's Family Health Strategy (FHS) program.These systems are designed to store information about the oral health of patients who receive home care. 32,37Both studies reported that the systems were proposed as a means through which to ensure efficiency in home care and in the organization of collected data.

Studies that focus on patients
Finally, three studies were selected according to their main focus on the category of "Studies that focus on the patient".In this category, two applications were developed to aid patients in adhering to both pharmacological and behavioral treatments. 17,28he third application of this category sought to aid in the mobility of the visually impaired in urban environments. 38All of the ap-movement throughout the different sectors of the health institutions in which they work, and mobile technology contains the exact main feature that serves to break this limitation of mobility and can thus offer remote support to these professionals.In addition, the use of mobile devices promotes better communication through their multimedia functions and further boosts scientific research in this field of work, thus giving incentive to evidence-based practices. 39t is important to note that the devices and information technology analyzed in this study can only be found in their prototype form and are not yet available for use in daily medical practices.In a recently published study, 40 the authors assessed and described mobile applications for healthcare uses that are available for download and for use by the end user.However, upon evaluating these applications, what stands out is that the majority of these have no ties to research projects, but rather to private developers.In this light, it can be concluded that, despite the importance and popularization of mobile applications in the healthcare field, research in this field is still in its beginning stages.

FINAL CONSIDER ATIONS
This study presented mobile applications for the health sector that could be identified in prior Brazilian scientific literature.The majority of the selected studies had the objective of being used by three or more healthcare professionals concomitantly, which highlights the importance of tools that encourage interdisciplinary integration.
Despite the reduced number articles developed in Brazil on this theme, a constant growth can be seen over the years analyzed in this study.It is understood that the development of mobile applications for scientific purposes is important, since the content tends to be analyzed and tested by professionals who understand the true needs of end users.Recognizing the needs of these users is essential to planning and implementing new technologies in a coherent and appropriate manner, according to specific demands that have been tested in research and implemented in healthcare practices.
In addition to research on applications that provide support to healthcare professionals, future studies should also develop applications geared toward providing support to patients.In this manner, patients can become more involved in aspects related to their own health, have access to information, and, when necessary, receive remote support for self-care and treatments.
Figure 1 -Synthesis of the article selection process for the integrative literature review.

Table 1 -
analysis of the controlled studies; study with no experimental framework, such as correlational and qualitative descriptive studies or case studies; Works selected for analysis l level 4 -Title Nursing Activities Score System: Stages of development of a mobile system for nursing Authors Silveira DT, et al.Continues… REME • Rev Min Enferm.2014 abr/jun; 18(2): 479-486 DOI: 10.5935/1415-2762.20140035

Table 1 -
Works selected for analysis TitleVirtual Caregiver: a system for supporting collaboration in elderly monitoring Authors Ugulino U, Ferreira M, Velloso E, Fuks H.

Table 1 -
Works selected for analysis

Table 2 -
Classification of the studies in thematic categories