Behavior Change Apps Research Articles

Nudge goes to Silicon Valley: designing for the disengaged and the irrational

ABSTRACT An array of software apps, from fitness to finance, enrolls behavioral economics, and economists, in their product designs, value propositions, or else sales pitches, to make products more engaging and to afford users new capabilities in their daily lives. Drawing on 30 interviews with product strategists, designers, and user researchers who work on these self-styled ‘behavior change apps,’ this paper empirically studies the behavioral economic proposition and its operationalization in routine practices of software development and design. Setting aside the behavioral addiction and manipulation frame that critical work on app design typically summons, I approach behavioral economics applications as market work and tease out the different, co-existing logics of attachment between products and their users, that emerge from how market actors decide what product to build, which features to have and how to design the user experience. In doing so, I show that strictly focusing on the frequency of repeated interaction is also empirically inadequate. The product is rather strategized, developed, and designed to become something that the user ‘cannot do without,’ not because it is addictive, but because it is made indispensable to the distributed action universe of the behavioral problem that it addresses.

Development of a ParticipACTION App–Based Intervention for Improving Postsecondary Students’ 24-Hour Movement Guideline Behaviors: Protocol for the Application of Intervention Mapping

The Canadian 24-Hour Movement Guidelines for adults provide specific recommendations for levels of physical activity, sedentary behavior, and sleep (ie, the movement behaviors) required for optimal health. Performance of the movement behaviors is associated with improved mental well-being. However, most postsecondary students do not meet the movement behavior recommendations within the Canadian 24-Hour Movement Guidelines and experience increased stress and declining well-being, suggesting the need for an intervention targeting students' movement behaviors. We aimed to develop and implement a theory-informed intervention intended to improve the movement behaviors and mental well-being of first-year postsecondary students. The Intervention Mapping protocol was applied in the development and implementation of the intervention. Intervention Mapping entailed performing a needs assessment, determining the intervention outcomes, selecting theory- and evidence-based change methods and applications, preparing and producing intervention plans and materials, developing the implementation plan, and finally developing an evaluation plan. The Theoretical Domains Framework and the Behavior Change Wheel were also used in conjunction with the Intervention Mapping protocol to ensure a solid theoretical basis for the intervention. This protocol led to the development and implementation of a 6-week, theory-informed ParticipACTION app-based intervention aimed at helping first-year postsecondary students improve their movement behaviors and mental well-being. The developed app content provided students with information on each of the movement behaviors and behavioral strategies (ie, goal setting, action planning, monitoring, and coping planning). The use of Intervention Mapping allowed for the continuous involvement of various multidisciplinary partners and end users, ensuring that the intervention design and implementation was appropriate for the target audience. The feasibility, acceptability, and potential impact of the intervention will be examined in a subsequent proof-of-concept study at 2 Canadian university campuses. Participant recruitment occurred during September 2021, and the intervention was conducted from October to December 2021. The deadline for completion of the postintervention questionnaire by participants was mid-December 2021. The analysis of data examining the feasibility, acceptability, and potential impact of the intervention began in January 2022, with the publication of the proof-of-concept evaluation expected in 2023. Intervention Mapping with the Theoretical Domains Framework and Behavior Change Wheel was a useful approach to combine evidence and theoretical concepts to guide the design and implementation of a ParticipACTION app-based intervention targeting postsecondary students' movement behaviors and mental well-being. This process may serve as an example for other researchers developing multiple behavior change app-based interventions. Should the forthcoming evaluation demonstrate the intervention's acceptability, feasibility, and potential impact, the intervention may provide a scalable method of improving postsecondary students' movement behaviors and mental well-being. RR1-10.2196/39977.

Looking beyond the hype: Conditions affecting the promise of behaviour change apps as social innovations for low-carbon transitions

Digital tools, specifically smartphone apps, have emerged as enablers of social innovation for low-carbon transitions by using novel feedback to creatively engage people to act more sustainably, and thus capture the power of collective individual action. Such apps have increasingly been implemented in real-world experiments with positive results in the short-term. However critical reflection is required to look beyond this hype to understand the conditions for longer term impact, thus reaching a transformative social innovation potential. In this paper, we take two exemplary behaviour change apps and perform a cost-benefit analysis to assess the break-even point in number of users to achieve net-positive impact and discuss relevant technical, organisational, political and financial conditions that enable or impede this impact. We find that the required scale-up in users seems challenging, yet feasible. However, guaranteeing that the supportive conditions are available is necessary to warrant the focus on behaviour change apps by research and policy.

Behavior Change App for Self-management of Gestational Diabetes: Design and Evaluation of Desirable Features.

BackgroundGestational diabetes (GDM) has considerable and increasing health effects as it raises both the mother’s and the offspring’s risk for short- and long-term health problems. GDM can usually be treated with a healthier lifestyle, such as appropriate dietary modifications and sufficient physical activity. Although telemedicine interventions providing weekly or more frequent feedback from health care professionals have shown the potential to improve glycemic control among women with GDM, apps without extensive input from health care professionals are limited and have not been shown to be effective. Different features in personalization and support have been proposed to increase the efficacy of GDM apps, but the knowledge of how these features should be designed is lacking.ObjectiveThe aim of this study is to investigate how GDM apps should be designed, considering the desirable features based on the previous literature.MethodsWe designed an interactive GDM prototype app that provided example implementations of desirable features, such as providing automatic and personalized suggestions and social support through the app. Women with GDM explored the prototype and provided feedback in semistructured interviews.ResultsWe identified that (1) self-tracking data in GDM apps should be extended with written feedback, (2) habits and goals should be highly customizable to be useful, (3) the app should have different functions to provide social support, and (4) health care professionals should be notified through the app if something unusual occurs. In addition, we found 2 additional themes. First, basic functionalities that are fast to learn by women with GDM who have recently received the diagnosis should be provided, but there should also be deeper features to maintain interest for women with GDM at a later stage of pregnancy. Second, as women with GDM may have feelings of guilt, the app should have a tolerance for and a supporting approach to unfavorable behavior.ConclusionsThe feedback on the GDM prototype app supported the need for desirable features and provided new insights into how these features should be incorporated into GDM apps. We expect that following the proposed designs and feedback will increase the efficacy of GDM self-management apps.Trial RegistrationClinicalTrials.gov NCT03941652; https://clinicaltrials.gov/ct2/show/NCT03941652

Novel Implementation Strategy to Electronically Screen and Signpost Patients to Health Behavior Apps: Mixed Methods Implementation Study (OptiMine Study).

BackgroundBehavior change apps have the potential to provide individual support on a population scale at low cost, but they face numerous barriers to implementation. Electronic health records (EHRs) in acute care hospitals provide a valuable resource for identifying patients at risk, who may benefit from behavior change apps. A novel, emerging implementation strategy is to use digital technologies not only for providing support to help-seeking individuals but also for signposting patients at risk to support services (also called proactive referral in the United States).ObjectiveThe OptiMine study aimed to increase the reach of behavior change apps by implementing electronic signposting for smoking cessation and alcohol reduction in a large, at-risk population that was identified through an acute care hospital EHR.MethodsThis 3-phase, mixed methods implementation study assessed the acceptability, feasibility, and reach of electronic signposting to behavior change apps by using a hospital’s EHR system to identify patients who are at risk. Phase 1 explored the acceptability of the implementation strategy among the patients and staff through focus groups. Phase 2 investigated the feasibility of using the hospital EHR to identify patients with target risk behaviors and contact them via SMS text message, email, or patient portal. Phase 3 assessed the impact of SMS text messages sent to patients who were identified as smokers or risky drinkers, which signposted them to behavior change apps. The primary outcome was the proportion of participants who clicked on the embedded link in the SMS text message to access information about the apps. The acceptability of the SMS text messages among the patients who had received them was also explored in a web-based survey.ResultsOur electronic signposting strategy—using SMS text messages to promote health behavior change apps to patients at risk—was found to be acceptable and feasible and had good reach. The hospital sent 1526 SMS text messages, signposting patients to either the National Health Service Smokefree or Drink Free Days apps. A total of 13.56% (207/1526) of the patients clicked on the embedded link to the apps, which exceeded our 5% a priori success criterion. Patients and staff contributed to the SMS text message content and delivery approach, which were perceived as acceptable before and after the delivery of the SMS text messages. The feasibility of the SMS text message format was determined and the target population was identified by mining the EHR.ConclusionsThe OptiMine study demonstrated the proof of concept for this novel implementation strategy, which used SMS text messages to signpost at-risk individuals to behavior change apps at scale. The level of reach exceeded our a priori success criterion in a non–help-seeking population of patients receiving unsolicited SMS text messages, disconnected from hospital visits.International Registered Report Identifier (IRRID)RR2-10.2196/23669

Behavior Change Apps for Gestational Diabetes Management: Exploring Desirable Features

ABSTRACT Gestational diabetes mellitus (GDM) has considerable and increasing health effects as it raises both the mother’s and offspring’s risk for short- and long-term health problems. GDM can usually be treated with a healthier lifestyle, such as appropriate dietary modifications and engaging insufficient physical activity. While telemedicine interventions requiring weekly or more frequent feedback from health care professionals have shown the potential to improve glycemic control amongst women with GDM, apps without extensive input from health care professionals are limited and have not shown to be effective. We aimed to improve the efficacy of GDM self-management apps by exploring desirable features in a review. We derived six desirable features from the multidisciplinary literature and we evaluated the state of implementation of these features in existing GDM apps. The results showed that features for increasing competence to manage GDM and for providing social support were largely lacking.

Supporting Mental Health During the COVID-19 Pandemic Using a Digital Behavior Change Intervention: An Open-Label, Single-Arm, Pre-Post Intervention Study.

BackgroundThe COVID-19 pandemic is taking a toll on people’s mental health, particularly as people are advised to adhere to social distancing, self-isolation measures, and government-imposed national lockdowns. Digital health technologies have an important role to play in keeping people connected and in supporting their mental health and well-being. Even before the COVID-19 pandemic, mental health and social services were already strained.ObjectiveOur objective was to evaluate the 12-week outcomes of the digitally delivered Gro Health intervention, a holistic digital behavior change app designed for self-management of mental well-being, sleep, activity, and nutrition.MethodsThe study used a quasi-experimental research design consisting of an open-label, single-arm, pre-post intervention engagement using a convenience sample. Adults who had joined the Gro Health app (intervention) and had a complete baseline dataset (ie, 7-item Generalized Anxiety Disorder scale, Perceived Stress Scale, and 9-item Patient Health Questionnaire) were followed up at 12 weeks (n=273), including 33 (12.1%) app users who reported a positive COVID-19 diagnosis during the study period. User engagement with the Gro Health platform was tracked by measuring total minutes of app engagement. Paired t tests were used to compare pre-post intervention scores. Linear regression analysis was performed to assess the relationship between minutes of active engagement with the Gro Health app and changes in scores across the different mental health measures.ResultsOf the 347 study participants, 273 (78.67%) completed both the baseline and follow-up surveys. Changes in scores for anxiety, perceived stress, and depression were predicted by app engagement, with the strongest effect observed for changes in perceived stress score (F1,271=251.397; R2=0.479; P<.001).ConclusionsA digital behavior change platform that provides remote mental well-being support can be effective in managing depression, anxiety, and perceived stress during times of crisis such as the current COVID-19 pandemic. The outcomes of this study may also support the implementation of remote digital health apps supporting behavior change and providing support for low levels of mental health within the community.

Personalization Paradox in Behavior Change Apps

Social comparison-based features are widely used in social computing apps. However, most existing apps are not grounded in social comparison theories and do not consider individual differences in social comparison preferences and reactions. This paper is among the first to automatically personalize social comparison targets. In the context of an m-health app for physical activity, we use artificial intelligence (AI) techniques of multi-armed bandits. Results from our user study (n=53) indicate that there is some evidence that motivation can be increased using the AI-based personalization of social comparison. The detected effects achieved small-to-moderate effect sizes, illustrating the real-world implications of the intervention for enhancing motivation and physical activity. In addition to design implications for social comparison features in social apps, this paper identified the personalization paradox, the conflict between user modeling and adaptation, as a key design challenge of personalized applications for behavior change. Additionally, we propose research directions to mitigate this Personalization Paradox.

Systematic review of cost-effectiveness analysis of behavior change communication apps: Assessment of key methods.

ObjectiveEvidence backing the effectiveness of mobile health technology is growing, and behavior change communication applications (apps) are fast becoming a useful platform for behavioral health programs. However, data to support the cost-effectiveness of these interventions are limited. Suggestions for overcoming the low output of economic data include addressing the methodological challenges for conducting cost-effectiveness analysis of behavior change app programs. This study is a systematic review of cost-effectiveness analyses of behavior change communication apps and a documentation of the reported challenges for investigating their cost-effectiveness.Materials and methodsFour academic databases: Medline (Ovid), CINAHL, EMBASE and Google Scholar, were searched. Eligibility criteria included original articles that use a cost-effectiveness evaluation method, published between 2008 and 2018, and in the English language.ResultsOut of the 60 potentially eligible studies, 6 used cost-effectiveness analysis method and met the inclusion criteria.ConclusionThe evidence to support the cost-effectiveness of behavior change communication apps is insufficient, with all studies reporting significant study challenges for estimating program costs and outcomes. The main challenges included limited or lack of cost data, inappropriate cost measures, difficulty with identifying and quantifying app effectiveness, representing app effects as Quality-adjusted Life Years, and aggregating cost and effects into a single quantitative measure like Incremental Cost Effectiveness Ratio. These challenges highlight the need for comprehensive economic evaluation methods that balance app data quality issues with practical concerns. This would likely improve the usefulness of cost-effectiveness data for decisions on adoption, implementation, scalability, sustainability, and the benefits of broader healthcare investments.

Engagement With a Behavior Change App for Alcohol Reduction: Data Visualization for Longitudinal Observational Study.

BackgroundBehavior change apps can develop iteratively, where the app evolves into a complex, dynamic, or personalized intervention through cycles of research, development, and implementation. Understanding how existing users engage with an app (eg, frequency, amount, depth, and duration of use) can help guide further incremental improvements. We aim to explore how simple visualizations can provide a good understanding of temporal patterns of engagement, as usage data are often longitudinal and rich.ObjectiveThis study aims to visualize behavioral engagement with Drink Less, a behavior change app to help reduce hazardous and harmful alcohol consumption in the general adult population of the United Kingdom.MethodsWe explored behavioral engagement among 19,233 existing users of Drink Less. Users were included in the sample if they were from the United Kingdom; were 18 years or older; were interested in reducing their alcohol consumption; had a baseline Alcohol Use Disorders Identification Test score of 8 or above, indicative of excessive drinking; and had downloaded the app between May 17, 2017, and January 22, 2019 (615 days). Measures of when sessions begin, length of sessions, time to disengagement, and patterns of use were visualized with heat maps, timeline plots, k-modes clustering analyses, and Kaplan-Meier plots.ResultsThe daily 11 AM notification is strongly associated with a change in engagement in the following hour; reduction in behavioral engagement over time, with 50.00% (9617/19,233) of users disengaging (defined as no use for 7 or more consecutive days) 22 days after download; identification of 3 distinct trajectories of use, namely engagers (4651/19,233, 24.18% of users), slow disengagers (3679/19,233, 19.13% of users), and fast disengagers (10,903/19,233, 56.68% of users); and limited depth of engagement with 85.076% (7,095,348/8,340,005) of screen views occurring within the Self-monitoring and Feedback module. In addition, a peak of both frequency and amount of time spent per session was observed in the evenings.ConclusionsVisualizations play an important role in understanding engagement with behavior change apps. Here, we discuss how simple visualizations helped identify important patterns of engagement with Drink Less. Our visualizations of behavioral engagement suggest that the daily notification substantially impacts engagement. Furthermore, the visualizations suggest that a fixed notification policy can be effective for maintaining engagement for some users but ineffective for others. We conclude that optimizing the notification policy to target both effectiveness and engagement is a worthwhile investment. Our future goal is to both understand the causal effect of the notification on engagement and further optimize the notification policy within Drink Less by tailoring to contextual circumstances of individuals over time. Such tailoring will be informed from the findings of our micro-randomized trial (MRT), and these visualizations were useful in both gaining a better understanding of engagement and designing the MRT.

Usability inquiry of a gamified behavior change app for increasing physical activity and reducing sedentary behavior in adults with and without autism spectrum disorder.

The purpose of this study was to conduct the first usability inquiry of a gamified, behavior change theory-guided mobile app PuzzleWalk for increasing physical activity and reducing sedentary behavior in adults with and without autism spectrum disorder (ASD). Eighteen adults with and without ASD participated in a mixed-methods study that consisted of cognitive walkthrough, system usability assessment, and qualitative interviews. The results of the system usability testing indicated satisfactory quality of the PuzzleWalk system that can be readily applicable to both adults with and without ASD. Several notable issues were identified from the qualitative interviews that address critical insights into unique health and social needs in adults with ASD. Future work is warranted to examine the long-term effects of the PuzzleWalk system on increasing physical activity and reducing sedentary behavior in adults with and without ASD in real-world settings.

Notifications to Improve Engagement With an Alcohol Reduction App: Protocol for a Micro-Randomized Trial.

BackgroundDrink Less is a behavior change app that aims to help users in the general adult population reduce hazardous and harmful alcohol consumption. The app includes a daily push notification, delivered at 11 am, asking users to “Please complete your mood and drinking diaries.” Previous analysis of Drink Less engagement data suggests the current notification strongly influences how users engage with the app in the subsequent hour. To exploit a potential increase of vulnerability of excess drinking and opportunity to engage with the app in the evenings, we changed the delivery time from 11 am to 8 pm. We now aim to further optimise the content and sequence of notifications, testing 30 new evidence-informed notifications targeting the user’s perceived usefulness of the app.ObjectiveThe primary objective is to assess whether sending a notification at 8 pm increases behavioral engagement (opening the app) in the subsequent hour. Secondary objectives include comparing the effect of the new bank of messages with the standard message and effect moderation over time. We also aim to more generally understand the role notifications have on the overall duration, depth, and frequency of engagement with Drink Less over the first 30 days after download.MethodsThis is a protocol for a micro-randomized trial with two additional parallel arms. Inclusion criteria are Drink Less users who (1) consent to participate in the trial; (2) self-report a baseline Alcohol Use Disorders Identification Test score of 8 or above; (3) reside in the United Kingdom; (4) age ≥18 years and; (5) report interest in drinking less alcohol. In the micro-randomized trial, participants will be randomized daily at 8 pm to receive no notification, a notification with text from the new message bank, or the standard message. The primary outcome is the time-varying, binary outcome of “Did the user open the app in the hour from 8 pm to 9 pm?”. The primary analysis will estimate the marginal relative risk for the notifications using an estimator developed for micro-randomized trials with binary outcomes. Participants randomized to the parallel arms will receive no notifications (Secondary Arm A), or the standard notification delivered daily at 11 am (Secondary Arm B) over 30 days, allowing the comparison of overall engagement between different notification delivery strategies.ResultsApproval was granted by the University College of London’s Departmental Research Ethics Committee (CEHP/2016/556) on October 11, 2019, and The London School of Hygiene and Tropical Medicine Interventions Research Ethics Committee (17929) on November 27, 2019. Recruitment began on January 2, 2020, and is ongoing.ConclusionsUnderstanding how push notifications may impact engagement with a behavior change app can lead to further improvements in engagement, and ultimately help users reduce their alcohol consumption. This understanding may also be generalizable to other apps that target a variety of behavior changes.International Registered Report Identifier (IRRID)DERR1-10.2196/18690

Co-creating app-based policy measures for mobility behavior change: A trigger for novel governance practices at the urban level

In the framework of “smart city” strategies, cities worldwide are exploiting information and communication technologies to support their efforts in reducing car use. Recent understandings of smart cities suggest to put people at the core, by actively engaging citizens in co-creating innovative urban services. However, notwithstanding the benefits of participatory processes in urban governance are well-known, low receptiveness towards them is still widespread, which can largely hinder the effectiveness of smart city interventions.In this paper we present the experience of a Swiss city, where, against a past background of resistance to participatory processes, a “living” lab experiment was set for the co-creation of a behavior change app targeting a reduction in car-based traffic. Motivated by the opportunity to overcome limitations of such apps, the lab turned out to deliver wider benefits than initially expected. In fact, the concrete experience of new mobility behaviors stimulated by the app activated a collective learning process among lab participants. Discussions in the lab thus spontaneously scaled-up to far-reaching and potentially conflicting topics about future mobility scenarios. Furthermore, the protected space of the lab favored strengthening of reciprocal trust between citizens and policy-makers, opening-up possibilities for adoption of participatory practices also in future decision-making.

End User-Informed Mobile Health Intervention Development for Adolescent Cannabis Use Disorder: Qualitative Study.

BackgroundThe rates of cannabis use continue to increase among adolescents and the current interventions have modest effects and high rates of relapse following treatment. There is increasing evidence for the efficacy of mobile technology–based interventions for adults with substance use disorders, but there is limited study of this technology in adolescents who use cannabis.ObjectiveThe goal of our study was to elucidate elements of an app-based adjunctive intervention for cannabis cessation that resonate with adolescents who use cannabis.MethodsAdolescents, aged between 14 and 17 years, who used cannabis were recruited from San Diego County high schools. Semistructured focus groups (6 total; N=37) were conducted to examine the ways in which participants used smartphones, including the use of any health behavior change apps, as well as to elicit opinions about elements that would promote engagement with an app-based intervention for adolescent cannabis cessation. An iterative coding structure was used with first cycle structural coding, followed by pattern coding.ResultsThemes that emerged from the analysis included (1) youth valued rewards to incentivize the progressive reduction of cannabis use, which included both nontangible rewards that mimic those obtained on social media platforms and prosocial activity-related rewards, (2) having the ability to self-monitor progression, (3) peer social support, (4) privacy and confidentiality discrete logo and name and usernames within the app, and (5) individualizing frequency and content of notifications and reminders.ConclusionsIntegrating content, language, interfaces, delivery systems, and rewards with which adolescents who use cannabis are familiar, engage with on a day-to-day basis, and identify as relevant, may increase treatment engagement and retention for adolescents in substance use treatment. We may increase treatment effectiveness by adapting and individualizing current evidence-based interventions, so that they target the needs of adolescents and are more easily incorporated into their everyday routines.

Design and Development of Smoking Cessation Apps Based on Smokers' and Providers' Perspectives in China: Survey Study.

BackgroundAlthough there are more than 60 smartphone apps for smoking cessation in China, many of them do not include the content and features that health care professionals and smokers prefer—which may make them impractical, unengaging, and ineffective. Therefore, we investigated both health care providers’ and smokers’ preferences for features of future smoking cessation apps.ObjectiveThis study aimed to investigate Chinese health care providers’ and smokers’ desired features of a smoking cessation app, with the goal of providing design recommendations for app designers and researchers.MethodsBoth Chinese smokers who own smartphones (n=357) and Chinese health care providers (n=224) responded to a survey collecting data on their sociodemographic characteristics and opinions on the importance of 20 smoking cessation app design features studied in previous US research.ResultsChinese health care providers expressed strong support of smoking cessation apps on a number of attitude indicators (range 153/224, 68.3% to 204/224, 91.1%). They rated nearly all (18/20) features as very or extremely important (range 52.2%-83.4%) and rated nearly all features (17/20) as more important than the smokers did. More than 60% of smokers rated the following 4 features as very or extremely important: allow sharing the process of smoking cessation with family members and friends (216/319, 67.7%), helping smokers track their progress (such as the amount of smoking per day; 213/319, 66.8%), helping with the side effects of medications and nicotine withdrawal symptoms (201/319, 63.0%), and adapting to ongoing needs and interests of smokers (194/319, 60.8%). Contrary to a similar study of US smokers and health care providers, Chinese smokers and providers rated reputation and ability to communicate with family members and friends as important features, whereas Chinese smokers rated privacy and security as less important.ConclusionsThe design of future smoking cessation and health behavior change apps should consider perspectives of both providers and smokers as well as the role of culture.

Using Health and Well-Being Apps for Behavior Change: A Systematic Search and Rating of Apps.

BackgroundSmartphones have allowed for the development and use of apps. There is now a proliferation of mobile health interventions for physical activity, healthy eating, smoking and alcohol cessation or reduction, and improved mental well-being. However, the strength or potential of these apps to lead to behavior change remains uncertain.ObjectiveThe aim of this study was to review a large sample of healthy lifestyle apps at a single point in time (June to July 2018) to determine their potential for promoting health-related behavior change with a view to sharing this information with the public. In addition, the study sought to test a wide range of apps using a new scale, the App Behavior Change Scale (ABACUS).MethodsApps focusing on 5 major modifiable lifestyle behaviors were identified using a priori key search terms across the Australian Apple iTunes and Google Play stores. Lifestyle behavior categories were selected for their impact on health and included smoking, alcohol use, physical activity, nutrition, and mental well-being. Apps were included if they had an average user rating between 3 and 5, if they were updated in the last 18 months, if the description of the app included 2 of 4 behavior change features, and if they were in English. The selected behavior change apps were rated in 2 ways using previously developed rating scales: the Mobile App Rating Scale (MARS) for functionality and the ABACUS for potential to encourage behavior change.ResultsThe initial search identified 212,352 apps. After applying the filtering criteria, 5018 apps remained. Of these, 344 were classified as behavior change apps and were reviewed and rated. Apps were given an average MARS score of 2.93 out of 5 (SD 0.58, range 1.42-4.16), indicating low-to-moderate functionality. Scores for the ABACUS ranged from 1 to 17, out of 21, with an average score of 7.8 (SD 2.8), indicating a low-to-moderate number of behavior change techniques included in apps. The ability of an app to encourage practice or rehearsal, in addition to daily activities, was the most commonly identified feature across all apps (310/344, 90.1%), whereas the second most common feature was the ability of the user to easily self-monitor behavior (289/344, 84.0%).ConclusionsThe wide variety of apps included in this 2018 study and the limited number of behavior change techniques found in many apps suggest an opportunity for improvement in app design that will promote sustained and significant lifestyle behavior change and, therefore, better health. The use of the 2 scales for the review and rating of the apps was successful and provided a method that could be replicated and tested in other behavior change areas.

Beyond Limitations of Current Behaviour Change Apps for Sustainable Mobility: Insights from a User-Centered Design and Evaluation Process

How can we encourage people to make sustainable mobility choices, reducing car dependency and the related CO 2 emissions and energy consumption? Taking advantage of the wide availability of smartphone devices, we designed GoEco!, an application (app) exploiting automatic mobility tracking, eco-feedback, social comparison and gamification elements to persuade individuals to change their mode of transport. The app features and contents are grounded in the transtheoretical model for behaviour change and were designed to avoid over-reliance on “one-size-fits-all”, simplistic point-based systems. The GoEco! app was designed in a user centred approach and was field-tested in Switzerland in a three-month experiment involving around 150 voluntary users. In this paper, we present the app’s features and comment on their evaluation from the perspective of the field-testers. The insights we collected through an online questionnaire and individual interviews allowed us to develop recommendations for similar persuasive apps and to identify open challenges for the future. In particular, we recommend to endow such apps with multi-modal travel planning components and features evoking the feeling of belonging to a community, that provide support and helping relationships.

Adolescent feedback on predisposing, reinforcing and enabling features in asthma self-management apps

Objective:Mobile health apps hold potential to support and reinforce positive health behaviours, especially among young people with chronic diseases like asthma that require continual self-management. We aimed to gain feedback from adolescents with asthma on two existing asthma self-management apps to guide the development of an evidence- and theory-based asthma app that meets their asthma management needs.Design:A qualitative interview study was conducted with adolescents with persistent asthma ( n = 20), aged 12–16.Setting:Interviews took place after the individual’s clinic appointment and during telephone interviews one week later.Methods:Participants provided feedback on two asthma self-management apps during two semi-structured interviews. Interviews were audio-recorded, transcribed verbatim and analysed thematically using MAXQDA 11. The Precede–Proceed Model (PPM) was used as a framework to evaluate perceptions of app features, including utility. Suggestions for improvements, including addition of predisposing, reinforcing and enabling PPM features, were identified.Results:The majority of app features functioned as enabling (e.g. inputting triggers, recording doctor’s appointments and tracking peak flow). However, participants recommended addition of predisposing and reinforcing features, including knowledge on dealing with asthma triggers (predisposing) and a reward system for daily peak flow entry (reinforcing), to support their asthma management.Conclusion:Findings suggest that including predisposing, reinforcing and enabling features in asthma apps could facilitate asthma self-management. Public health professionals should partner with app developers in the development of asthma self-management apps that include predisposing, reinforcing and enabling features to meet user needs and ensure they are effective and accepted behaviour change apps.

ROUTINE: The Development of a Physical Activity Promoting Journey Planner Web App

Behavior change apps are widespread, but the scientific base of the app-concept is rarely disclosed. The aim of this article is to present the methodological approach used for the development of a so-called “fitness feedback demonstrator” within an already existing journey planner web app to motivate people to increase their physical activity behavior while using public transport. Firstly, we introduce the behavior change theories applied for the design of the feedback, followed by the analysis of focus-group discussions about the desired content of the fitness feedback. Secondly, we describe how we conducted a field test to measure the number of steps taken when using public transport. Finally, we used the feedback from potential users in terms of design/attractiveness and comprehensibility of the added fitness information. The “fitness feedback demonstrator” is a good practical example of how to make use of the different research expertise to develop a theory-based tool to encourage persons to integrate physical activity into their daily routines.

Making it work for me: beliefs about making a personal health record relevant and useable

BackgroundA Personal Health Record (PHR) is an electronic record that individuals use to manage and share their health information, e.g. data from their medical records and data collected by apps. However, engagement with their record can be low if people do not find it beneficial to their health, wellbeing or interactions with health and other services. We have explored the beliefs potential users have about a PHR, how it could be made personally relevant, and barriers to its use.MethodsA qualitative design comprising eight focus groups, each with 6–8 participants. Groups included adults with long-term health conditions, young people, physically active adults, data experts, and members of the voluntary sector. Each group lasted 60–90 min, was audio recorded and transcribed verbatim. We analysed the data using thematic analysis to address the question “What are people’s beliefs about making a Personal Health Record have relevance and impact?”ResultsWe found four themes. Making it work for me is about how to encourage individuals to actively engage with their PHR. I control my information is about individuals deciding what to share and who to share it with. My concerns is about individuals’ concerns about information security and if and how their information will be acted upon. Potential impact shows the potential benefits of a PHR such as increasing self-efficacy, uptake of health-protective behaviours, and professionals taking a more holistic approach to providing care and facilitating behaviour change.ConclusionsOur research shows the functionality that a PHR requires in order for people to engage with it. Interactive functions and integration with lifestyle and health apps are particularly important. A PHR could increase the effectiveness of behaviour change apps by specifying evidence-based behaviour change techniques that apps should incorporate. A PHR has the potential to increase health-protective behaviours and facilitate a more person-driven health and social care system. It could support patients to take responsibility for self-managing their health and treatment regimens, as well as helping patients to play a more active role when care transfers across boundaries of responsibility.