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Mobile-izing Savings with Automatic Contributions: Experimental Evidence on Dynamic Inconsistency and the Default Effect in Afghanistan

J Blumenstock, M Callen, T Ghani

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Through a field experiment in Afghanistan, we show that default enrollment in payroll deductions increases rates of savings by 40 percentage points, and that this increase is driven by present-biased preferences. Working with Afghanistan’s primary mobile phone operator, we designed and deployed a new mobile phone-based automatic payroll deduction system. Each of 967 employees at the country’s largest firm was randomly assigned a default contribution rate (either 0% or 5%) as well as a matching incentive rate (0%, 25%, or 50%). We find that employees initially assigned a default contribution rate of 5% are 40 percentage points more likely to contribute to the account 6months later than individuals assigned to a default contribution rate of zero; to achieve this effect through financial incentives alone would require a 50% match from the employer. We also find evidence of habit formation: default enrollment increases the likelihood that employees continue to save after the trial ended, and increases employees’ self-reported interest in saving and sense of financial security. To understand why default enrollment increases participation, we conducted several interventions designed to induce employees to make a non-default election, and separately measured employee time preferences. Ruling out several competing explanations, we find evidence that the default effect is driven largely by present-biased preferences that cause the employee to procrastinate in making a non-default election.

 



Member Centered Credit Union Banking: How behavioral insights can help credit unions better serve members

ideas42

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A loan application should collect necessary information while providing a painless, easy, and engaging experience for members and potential new members. Our recommendations for improving the loan application process were driven by three behavioral principles essential to the design of any human process: (1) reducing perceived hassles and uncer-tainty wherever possible; (2) avoiding jargon; and (3) designing with potential user error in mind. Our recommen-dations for Alliant included a new process timeline to more accurately set applicant expectations and reflected progress through the application; reframing key decision points to ensure users do not accidentally cancel their applications; and revising language that may be unfamiliar to some applicants, such as “collateral,” “debt-to-income,” and “co-borrower.” These principles and recommendations may seem simple, but through our work we have seen how even small changes can have big impacts on client behaviors. Moreover, as service designers, intimately aware of the loan process, it can be difficult for financial experts to design financial products and services that feel intuitive and easy to understand to new users. Alliant has incorporated the majority of our design recommendations into the new loan application process.

 



Using computer, mobile and wearable technology enhanced interventions to reduce sedentary behaviour: a systematic review and meta-analysis.

Aoife Stephenson, Suzanne McDonough, Marie Murphy, Chris Nugent, Jacqueline Mair

The international journal of behavioral nutrition and physical activity [14:105] (2017)

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High levels of sedentary behaviour (SB) are associated with negative health consequences. Technology enhanced solutions such as mobile applications, activity monitors, prompting software, texts, emails and websites are being harnessed to reduce SB. The aim of this paper is to evaluate the effectiveness of such technology enhanced interventions aimed at reducing SB in healthy adults and to examine the behaviour change techniques (BCTs) used. Five electronic databases were searched to identify randomised-controlled trials (RCTs), published up to June 2016. Interventions using computer, mobile or wearable technologies to facilitate a reduction in SB, using a measure of sedentary time as an outcome, were eligible for inclusion. Risk of bias was assessed using the Cochrane Collaboration's tool and interventions were coded using the BCT Taxonomy (v1). Meta-analysis of 15/17 RCTs suggested that computer, mobile and wearable technology tools resulted in a mean reduction of -41.28 min per day (min/day) of sitting time (95% CI -60.99, -21.58, I2 = 77%, n = 1402), in favour of the intervention group at end point follow-up. The pooled effects showed mean reductions at short (≤ 3 months), medium (>3 to 6 months), and long-term follow-up (>6 months) of -42.42 min/day, -37.23 min/day and -1.65 min/day, respectively. Overall, 16/17 studies were deemed as having a high or unclear risk of bias, and 1/17 was judged to be at a low risk of bias. A total of 46 BCTs (14 unique) were coded for the computer, mobile and wearable components of the interventions. The most frequently coded were "prompts and cues", "self-monitoring of behaviour", "social support (unspecified)" and "goal setting (behaviour)". Interventions using computer, mobile and wearable technologies can be effective in reducing SB. Effectiveness appeared most prominent in the short-term and lessened over time. A range of BCTs have been implemented in these interventions. Future studies need to improve reporting of BCTs within interventions and address the methodological flaws identified within the review through the use of more rigorously controlled study designs with longer-term follow-ups, objective measures of SB and the incorporation of strategies to reduce attrition. The review protocol was registered with PROSPERO: CRD42016038187.

 


Remotely Delivered Exercise-Based Cardiac Rehabilitation: Design and Content Development of a Novel mHealth Platform.

Jonathan Rawstorn, Nicholas Gant, Andrew Meads, Ian Warren, Ralph Maddison

JMIR mHealth and uHealth [4:e57] (2016)

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Participation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on. We aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location. An iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support. The REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients' exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription. The REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.

 


An mHealth Intervention Using a Smartphone App to Increase Walking Behavior in Young Adults: A Pilot Study.

Jane Walsh, Teresa Corbett, Michael Hogan, Jim Duggan, Abra McNamara

JMIR mHealth and uHealth [4:e109] (2016)

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Physical inactivity is a growing concern for society and is a risk factor for cardiovascular disease, obesity, and other chronic diseases. This study aimed to determine the efficacy of the Accupedo-Pro Pedometer mobile phone app intervention, with the goal of increasing daily step counts in young adults. Mobile phone users (n=58) between 17-26 years of age were randomized to one of two conditions (experimental and control). Both groups downloaded an app that recorded their daily step counts. Baseline data were recorded and followed-up at 5 weeks. Both groups were given a daily walking goal of 30 minutes, but the experimental group participants were told the equivalent goal in steps taken, via feedback from the app. The primary outcome was daily step count between baseline and follow-up. A significant time x group interaction effect was observed for daily step counts (P=.04). Both the experimental (P<.001) and control group (P=.03) demonstrated a significant increase in daily step counts, with the experimental group walking an additional 2000 steps per day. The results of this study demonstrate that a mobile phone app can significantly increase physical activity in a young adult sample by setting specific goals, using self-monitoring, and feedback.

 


mHealth Technologies to Influence Physical Activity and Sedentary Behaviors: Behavior Change Techniques, Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Artur Direito, Eliana Carraça, Jonathan Rawstorn, Robyn Whittaker, Ralph Maddison

Annals of behavioral medicine : a publication of the Society of Behavioral Medicine (2016)

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mHealth programs offer potential for practical and cost-effective delivery of interventions capable of reaching many individuals. To (1) compare the effectiveness of mHealth interventions to promote physical activity (PA) and reduce sedentary behavior (SB) in free-living young people and adults with a comparator exposed to usual care/minimal intervention; (2) determine whether, and to what extent, such interventions affect PA and SB levels and (3) use the taxonomy of behavior change techniques (BCTs) to describe intervention characteristics. A systematic review and meta-analysis following PRISMA guidelines was undertaken to identify randomized controlled trials (RCTs) comparing mHealth interventions with usual or minimal care among individuals free from conditions that could limit PA. Total PA, moderate-to-vigorous intensity physical activity (MVPA), walking and SB outcomes were extracted. Intervention content was independently coded following the 93-item taxonomy of BCTs. Twenty-one RCTs (1701 participants-700 with objectively measured PA) met eligibility criteria. SB decreased more following mHealth interventions than after usual care (standardised mean difference (SMD) -0.26, 95 % confidence interval (CI) -0.53 to -0.00). Summary effects across studies were small to moderate and non-significant for total PA (SMD 0.14, 95 % CI -0.12 to 0.41); MVPA (SMD 0.37, 95 % CI -0.03 to 0.77); and walking (SMD 0.14, 95 % CI -0.01 to 0.29). BCTs were employed more frequently in intervention (mean = 6.9, range 2 to 12) than in comparator conditions (mean = 3.1, range 0 to 10). Of all BCTs, only 31 were employed in intervention conditions. Current mHealth interventions have small effects on PA/SB. Technological advancements will enable more comprehensive, interactive and responsive intervention delivery. Future mHealth PA studies should ensure that all the active ingredients of the intervention are reported in sufficient detail.

 


A user-centred approach to developing bWell, a mobile app for arm and shoulder exercises after breast cancer treatment.

Helena Harder, Patrick Holroyd, Lynn Burkinshaw, Phil Watten, Charles Zammit, Peter Harris, Anna Good, Val Jenkins

Journal of cancer survivorship : research and practice (2017)

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The study aim was to develop a mobile application (app) supported by user preferences to optimise self-management of arm and shoulder exercises for upper-limb dysfunction (ULD) after breast cancer treatment. Focus groups with breast cancer patients were held to identify user needs and requirements. Behaviour change techniques were explored by researchers and discussed during the focus groups. Concepts for content were identified by thematic analysis. A rapid review was conducted to inform the exercise programme. Preliminary testing was carried out to obtain user feedback from breast cancer patients who used the app for 8 weeks post surgery. Breast cancer patients' experiences with ULD and exercise advice and routines varied widely. They identified and prioritised several app features: tailored information, video demonstrations of the exercises, push notifications, and tracking and progress features. An evidence-based programme was developed with a physiotherapist with progressive exercises for passive and active mobilisation, stretching and strengthening. The exercise demonstration videos were filmed with a breast cancer patient. Early user testing demonstrated ease of use, and clear and motivating app content. bWell, a novel app for arm and shoulder exercises, was developed by breast cancer patients, health care professionals and academics. Further research is warranted to confirm its clinical effectiveness. Mobile health has great potential to provide patients with information specific to their needs. bWell is a promising way to support breast cancer patients with exercise routines after treatment and may improve future self-management of clinical care.

 


Can existing mobile apps support healthier food purchasing behaviour? Content analysis of nutrition content, behaviour change theory and user quality integration.

Sarah-Jane Flaherty, Mary McCarthy, Alan Collins, Fionnuala McAuliffe

Public health nutrition [21:288-298] (2018)

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To assess the quality of nutrition content and the integration of user quality components and behaviour change theory relevant to food purchasing behaviour in a sample of existing mobile apps. Descriptive comparative analysis of eleven mobile apps comprising an assessment of their alignment with existing evidence on nutrition, behaviour change and user quality, and their potential ability to support healthier food purchasing behaviour. Mobile apps freely available for public use in GoogePlay were assessed and scored according to agreed criteria to assess nutrition content quality and integration of behaviour change theory and user quality components. A sample of eleven mobile apps that met predefined inclusion criteria to ensure relevance and good quality. The quality of the nutrition content varied. Improvements to the accuracy and appropriateness of nutrition content are needed to ensure mobile apps support a healthy behaviour change process and are accessible to a wider population. There appears to be a narrow focus towards behaviour change with an overemphasis on behavioural outcomes and a small number of behaviour change techniques, which may limit effectiveness. A significant effort from the user was required to use the mobile apps appropriately which may negatively influence user acceptability and subsequent utilisation. Existing mobile apps may offer a potentially effective approach to supporting healthier food purchasing behaviour but improvements in mobile app design are required to maximise their potential effectiveness. Engagement of mobile app users and nutrition professionals is recommended to support effective design.

 


Design of a Mobile App for Nutrition Education (TreC-LifeStyle) and Formative Evaluation With Families of Overweight Children.

Silvia Gabrielli, Marco Dianti, Rosa Maimone, Marta Betta, Lorena Filippi, Monica Ghezzi, Stefano Forti

JMIR mHealth and uHealth [5:e48] (2017)

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Nutrition and diet apps represent today a popular area of mobile health (mHealth), offering the possibility of delivering behavior change (BC) interventions for healthy eating and weight management in a scalable and cost-effective way. However, if commercial apps for pediatric weight management fail to retain users because of a lack of theoretical background and evidence-based content, mHealth apps that are more evidence-based are found less engaging and popular among consumers. Approaching the apps development process from a multidisciplinary and user-centered design (UCD) perspective is likely to help overcome these limitations, raising the chances for an easier adoption and integration of nutrition education apps within primary care interventions. The aim of this study was to describe the design and development of the TreC-LifeStyle nutrition education app and the results of a formative evaluation with families. The design of the nutrition education intervention was based on a multidisciplinary UCD approach, involving a team of BC experts, working with 2 nutritionists and 3 pediatricians from a primary care center. The app content was derived from evidence-based knowledge founded on the Food Pyramid and Mediterranean Diet guidelines used by pediatricians in primary care. A formative evaluation of the TreC-LifeStyle app involved 6 families of overweight children (aged 7-12 years) self-reporting daily food intake of children for 6 weeks and providing feedback on the user experience with the mHealth intervention. Analysis of the app's usage patterns during the intervention and of participants' feedback informed the refinement of the app design and a tuning of the nutrition education strategies to improve user engagement and compliance with the intervention. Design sessions with the contribution of pediatricians and nutritionists helped define the nutrition education app and intervention, providing an effective human and virtual coaching approach to raise parents' awareness about children's eating behavior and lifestyle. The 6 families participating in the pilot study found the app usable and showed high compliance with the intervention over the 6 weeks, but analysis of their interaction and feedback showed the need for improving some of the app features related to the BC techniques "monitoring of the behavior" and "information provision." The UCD and formative evaluation of TreC-LifeStyle show that nutrition education apps are feasible and acceptable solutions to support health promotion interventions in primary care.

 


Iterative development of Vegethon: a theory-based mobile app intervention to increase vegetable consumption.

Sarah Mummah, Abby King, Christopher Gardner, Stephen Sutton

The international journal of behavioral nutrition and physical activity [13:90] (2016)

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Mobile technology may serve as a cost-effective and scalable tool for delivering behavioral nutrition interventions. This research sought to iteratively develop a theory-driven mobile app, Vegethon, to increase vegetable consumption. Development of Vegethon followed phases outlined by the IDEAS framework: 1) empathize with users (qualitative interviews, n = 18); 2) specify target behavior; 3) ground in behavioral theory; 4) ideate implementation strategies; 5) prototype potential products; 6) gather user feedback (qualitative interviews, n = 14; questionnaire, n = 41); 7) build minimum viable product; and 8) pilot potential efficacy and usability (pilot RCT, n = 17). Findings from each phase informed subsequent phases. The target population that informed intervention development was 18-50 years of age, had BMIs of 28-40 kg/m(2), and lived in the geographical area surrounding Stanford University. A full description of the final version of Vegethon is included in the paper. Qualitative findings that shaped initial intervention conception were: participants' interests in accountability without judgment; their desire for simple and efficient dietary self-monitoring; and the importance of planning meals in advance. Qualitative findings identified during intervention refinement were the need for a focus on vegetable self-monitoring; inclusion of vegetable challenges; simplification of features; advice and inspiration for eating vegetables; reminder notifications; and peer comparison. Pilot RCT findings suggested the initial efficacy, acceptance, and feasibility of the intervention. The final version of Vegethon enabled easy self-monitoring of vegetable consumption and included a range of features designed to engage the user (e.g., surprise challenges; leaderboard; weekly reports). Vegethon was coded for its inclusion of 18 behavior change techniques (BCTs) (e.g., goal setting; feedback; social comparison; prompts/cues; framing/reframing; identity). Vegethon is a theory-based, user-informed mobile intervention that was systematically developed using the IDEAS framework. Vegethon targets increased vegetable consumption among overweight adults and is currently being evaluated in a randomized controlled efficacy trial. Clinical Trials.gov: NCT01826591.

 


Implementation of behavior change techniques in mobile applications for physical activity.

Chih-Hsiang Yang, Jaclyn Maher, David Conroy

American journal of preventive medicine [48:452-5] (2015)

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Mobile applications (apps) for physical activity are popular and hold promise for promoting behavior change and reducing non-communicable disease risk. App marketing materials describe a limited number of behavior change techniques (BCTs), but apps may include unmarketed BCTs, which are important as well. To characterize the extent to which BCTs have been implemented in apps from a systematic user inspection of apps. Top-ranked physical activity apps (N=100) were identified in November 2013 and analyzed in 2014. BCTs were coded using a contemporary taxonomy following a user inspection of apps. Users identified an average of 6.6 BCTs per app and most BCTs in the taxonomy were not represented in any apps. The most common BCTs involved providing social support, information about others' approval, instructions on how to perform a behavior, demonstrations of the behavior, and feedback on the behavior. A latent class analysis of BCT configurations revealed that apps focused on providing support and feedback as well as support and education. Contemporary physical activity apps have implemented a limited number of BCTs and have favored BCTs with a modest evidence base over others with more established evidence of efficacy (e.g., social media integration for providing social support versus active self-monitoring by users). Social support is a ubiquitous feature of contemporary physical activity apps and differences between apps lie primarily in whether the limited BCTs provide education or feedback about physical activity.

 


Dutch Young Adults Ratings of Behavior Change Techniques Applied in Mobile Phone Apps to Promote Physical Activity: A Cross-Sectional Survey.

Laura Belmon, Anouk Middelweerd, Saskia J Te Velde, Johannes Brug

JMIR mHealth and uHealth [3:e103] (2015)

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Interventions delivered through new device technology, including mobile phone apps, appear to be an effective method to reach young adults. Previous research indicates that self-efficacy and social support for physical activity and self-regulation behavior change techniques (BCT), such as goal setting, feedback, and self-monitoring, are important for promoting physical activity; however, little is known about evaluations by the target population of BCTs applied to physical activity apps and whether these preferences are associated with individual personality characteristics. This study aimed to explore young adults' opinions regarding BCTs (including self-regulation techniques) applied in mobile phone physical activity apps, and to examine associations between personality characteristics and ratings of BCTs applied in physical activity apps. We conducted a cross-sectional online survey among healthy 18 to 30-year-old adults (N=179). Data on participants' gender, age, height, weight, current education level, living situation, mobile phone use, personality traits, exercise self-efficacy, exercise self-identity, total physical activity level, and whether participants met Dutch physical activity guidelines were collected. Items for rating BCTs applied in physical activity apps were selected from a hierarchical taxonomy for BCTs, and were clustered into three BCT categories according to factor analysis: "goal setting and goal reviewing," "feedback and self-monitoring," and "social support and social comparison." Most participants were female (n=146), highly educated (n=169), physically active, and had high levels of self-efficacy. In general, we observed high ratings of BCTs aimed to increase "goal setting and goal reviewing" and "feedback and self-monitoring," but not for BCTs addressing "social support and social comparison." Only 3 (out of 16 tested) significant associations between personality characteristics and BCTs were observed: "agreeableness" was related to more positive ratings of BCTs addressing "goal setting and goal reviewing" (OR 1.61, 95% CI 1.06-2.41), "neuroticism" was related to BCTs addressing "feedback and self-monitoring" (OR 0.76, 95% CI 0.58-1.00), and "exercise self-efficacy" was related to a high rating of BCTs addressing "feedback and self-monitoring" (OR 1.06, 95% CI 1.02-1.11). No associations were observed between personality characteristics (ie, personality, exercise self-efficacy, exercise self-identity) and participants' ratings of BCTs addressing "social support and social comparison." Young Dutch physically active adults rate self-regulation techniques as most positive and techniques addressing social support as less positive among mobile phone apps that aim to promote physical activity. Such ratings of BCTs differ according to personality traits and exercise self-efficacy. Future research should focus on which behavior change techniques in app-based interventions are most effective to increase physical activity.

 


Development of a web-based and mobile app to support physical activity in individuals with rheumatoid arthritis: results from the second step of a co-design process.

Åsa Revenäs, Christina Opava, Cathrin Martin, Ingrid Demmelmaier, Christina Keller, Pernilla Åsenlöf

JMIR research protocols [4:e22] (2015)

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Long-term adherence to physical activity recommendations remains challenging for most individuals with rheumatoid arthritis (RA) despite evidence for its health benefits. The aim of this study was to provide basic data on system requirement specifications for a Web-based and mobile app to self-manage physical activity. More specifically, we explored the target user group, features of the future app, and correlations between the system requirements and the established behavior change techniques (BCTs). We used a participatory action research design. Qualitative data were collected using multiple methods in four workshops. Participants were 5 individuals with RA, a clinical physiotherapist, an officer from the Swedish Rheumatism Association, a Web designer, and 2 physiotherapy researchers. A taxonomy was used to determine the degree of correlation between the system requirements and established BCTs. Participants agreed that the future Web-based and mobile app should be based on two major components important for maintaining physical activity: (1) a calendar feature for goal setting, planning, and recording of physical activity performance and progress, and (2) a small community feature for positive feedback and support from peers. All system requirements correlated with established BCTs, which were coded as 24 different BCTs. To our knowledge, this study is the first to involve individuals with RA as co-designers, in collaboration with clinicians, researchers, and Web designers, to produce basic data to generate system requirement specifications for an eHealth service. The system requirements correlated to the BCTs, making specifications of content and future evaluation of effectiveness possible.

 


Testing the effects of narrative and play on physical activity among breast cancer survivors using mobile apps: study protocol for a randomized controlled trial.

Elizabeth Lyons, Tom Baranowski, Karen Basen-Engquist, Zakkoyya Lewis, Maria Swartz, Kristofer Jennings, Elena Volpi

BMC cancer [16:202] (2016)

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Physical activity reduces risk for numerous negative health outcomes, but postmenopausal breast cancer survivors do not reach recommended levels. Many interventions encourage self-monitoring of steps, which can increase physical activity in the short term. However, these interventions appear insufficient to increase motivation for sustained change. There is a need for innovative strategies to increase physical activity motivation in this population. Narratives are uniquely persuasive, and video games show promise for increasing motivation. This study will determine the effectiveness of an intervention that combines narrative and gaming to encourage sustained physical activity. SMARTGOAL (Self-Monitoring Activity: a Randomized Trial of Game-Oriented AppLications) is a randomized controlled intervention trial. The intervention period is six months, followed by a six month maintenance period. Participants (overweight, sedentary postmenopausal breast cancer survivors aged 45-75) will be randomized to a self-monitoring group or an enhanced narrative game group. The self-monitoring group will be encouraged to use a mobile application for self-monitoring and feedback and will receive 15 counseling phone calls emphasizing self-regulation. The narrative game group will be encouraged to use a mobile application that includes self-monitoring and feedback as well as a narrative-based active video game. The 15 calls for this group will emphasize concepts related to the game storyline. Counseling calls in both groups will occur weekly in months 1 - 3 and monthly in months 4 - 6. No counseling calls will occur after month 6, but both groups will be encouraged to continue using their apps. The primary outcome of the study is minutes of moderate to vigorous physical activity at six months. Other objectively measured outcomes include fitness and physical function. Self-reported outcomes include quality of life, depression, and motivation. This protocol will result in implementation and evaluation of two technology-based physical activity interventions among breast cancer survivors. Both interventions hold promise for broad dissemination. Understanding the potential benefit of adding narrative and game elements to interventions will provide critical information to interventionists, researchers, clinicians, and policymakers. This study is uniquely suited to investigate not just whether but how and why game elements may improve breast cancer survivors' health. clinicaltrials.gov NCT02341235 (January 9, 2015).

 


Mobile Technology Interventions for Asthma Self-Management: Systematic Review and Meta-Analysis.

Lisa Miller, Benjamin Schüz, Julia Walters, E Haydn Walters

JMIR mHealth and uHealth [5:e57] (2017)

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Mobile technology interventions (MTI) are becoming increasingly popular in the management of chronic health behaviors. Most MTI allow individuals to monitor medication use, record symptoms, or store and activate disease-management action plans. Therefore, MTI may have the potential to improve low adherence to medication and action plans for individuals with asthma, which is associated with poor clinical outcomes. A systematic review and meta-analysis were conducted to evaluate the efficacy of MTI on clinical outcomes as well as adherence in individuals with asthma. As the use of evidence-based behavior change techniques (BCT) has been shown to improve intervention effects, we also conducted exploratory analyses to determine the role of BCT and engagement with MTI as moderators of MTI efficacy. We searched electronic databases for randomized controlled trials up until June 2016. Random effect models were used to assess the effect of MTI on clinical outcomes as well as adherence to preventer medication or symptom monitoring. Mixed effects models assessed whether the features of the MTI (ie, use of BCT) and how often a person engaged with MTI moderated the effects of MTI. The literature search located 11 studies meeting the inclusion criteria, with 9 providing satisfactory data for meta-analysis. Compared with standard treatment, MTI had moderate to large effect sizes (Hedges g) on medication adherence and clinical outcomes. MTI had no additional effects on adherence or clinical outcomes when compared with paper-based monitoring. No moderator effects were found, and the number of studies was small. A narrative review of the two studies, which are not included in the meta-analysis, found similar results. This review indicated the efficacy of MTI for self-management in individuals with asthma and also indicated that MTI appears to be as efficacious as paper-based monitoring. This review also suggested a need for robust studies to examine the effects of BCT use and engagement on MTI efficacy to inform the evidence base for MTI in individuals with asthma.

 


Using a mobile health application to reduce alcohol consumption: a mixed-methods evaluation of the drinkaware track & calculate units application.

Sophie Attwood, Hannah Parke, John Larsen, Katie Morton

BMC public health [17:394] (2017)

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Smartphone applications ("apps") offer promise as tools to help people monitor and reduce their alcohol consumption. To date, few evaluations of alcohol reduction apps exist, with even fewer considering apps already available to the public. The aim of this study was to evaluate an existing publically available app, designed by Drinkaware, a UK-based alcohol awareness charity. We adopted a mixed-methods design, analysing routinely collected app usage data to explore user characteristics and patterns of usage. Following this, in-depth interviews were conducted with a sub-sample of app users to examine perceptions of acceptability, usability and perceived effectiveness, as well as to provide recommendations on how to improve the app. One hundred nineteen thousand seven hundred thirteen people downloaded and entered data into the app over a 13-month period. High attrition was observed after 1 week. Users who engaged with the app tended to be "high risk" drinkers and to report being motivated "to reduce drinking" at the point of first download. In those who consistently engaged with the app over time, self-reported alcohol consumption levels reduced, with most change occurring in the first week of usage. Our qualitative findings indicate satisfaction with the usability of the app, but mixed feedback was given regarding individual features. Users expressed conflicting views concerning the type of feedback and notifications that the app currently provides. A common preference was expressed for more personalised content. The Drinkaware app is a useful tool to support behaviour change in individuals who are already motivated and committed to reducing their alcohol consumption. The Drinkaware app would benefit from greater personalisation and tailoring to promote longer term use. This evaluation provides insight into the usability and acceptability of various app features and contains a number of recommendations for improving user satisfaction and the potential effectiveness of apps designed to encourage reductions in alcohol consumption.

 


A systematic review of randomised control trials of sexual health interventions delivered by mobile technologies.

Kara Burns, Patrick Keating, Caroline Free

BMC public health [16:778] (2016)

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Sexually transmitted infections (STIs) pose a serious public health problem globally. The rapid spread of mobile technology creates an opportunity to use innovative methods to reduce the burden of STIs. This systematic review identified recent randomised controlled trials that employed mobile technology to improve sexual health outcomes. The following databases were searched for randomised controlled trials of mobile technology based sexual health interventions with any outcome measures and all patient populations: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, NHS Health Technology Assessment Database, and Web of Science (science and social science citation index) (Jan 1999-July 2014). Interventions designed to increase adherence to HIV medication were not included. Two authors independently extracted data on the following elements: interventions, allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. Trials were assessed for methodological quality using the Cochrane risk of bias tool. We calculated effect estimates using intention to treat analysis. A total of ten randomised trials were identified with nine separate study groups. No trials had a low risk of bias. The trials targeted: 1) promotion of uptake of sexual health services, 2) reduction of risky sexual behaviours and 3) reduction of recall bias in reporting sexual activity. Interventions employed up to five behaviour change techniques. Meta-analysis was not possible due to heterogeneity in trial assessment and reporting. Two trials reported statistically significant improvements in the uptake of sexual health services using SMS reminders compared to controls. One trial increased knowledge. One trial reported promising results in increasing condom use but no trial reported statistically significant increases in condom use. Finally, one trial showed that collection of sexual health information using mobile technology was acceptable. The findings suggest interventions delivered by SMS interventions can increase uptake of sexual health services and STI testing. High quality trials of interventions using standardised objective measures and employing a wider range of behavioural change techniques are needed to assess if interventions delivered by mobile phone can alter safer sex behaviours carried out between couples and reduce STIs.

 


The use of a mobile app to motivate evidence-based oral hygiene behaviour.

Underwood, Birdsall B, Kay J

British dental journal [219:166-7] (2015)

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Mobile apps are software programmes that run on smartphones and other mobile devices. Mobile health apps can help people manage their own health and wellness, promote healthy living and gain access to useful information when and where they need it. The Brush DJ oral health app was developed to use the opportunity mobile apps offer to motivate an evidence-based oral hygiene routine. A literature review has found no research investigating the use of a mobile app to motivate evidence-based oral hygiene behaviour. The objective of this preliminary investigation was to assess user perception of an oral health app to give a basis for future research and development of app technology in relation to oral health. A cross-sectional qualitative user perception questionnaire. One hundred and eighty-nine people responded to the questionnaire. Seventy percent (n = 113) of respondents reported that their teeth felt cleaner since using the app. Eighty-eight percent (n = 133) reported the app motivated them to brush their teeth for longer and 92.3% (n = 144) would recommend the app to their friends and family. Four broad themes relating to how the app helped toothbrushing were reported. These themes were motivation, education, compliance and perceived benefits. A mobile app is a promising tool to motivate an evidence-based oral hygiene routine.

 


Pregnancy, exercise and nutrition research study with smart phone app support (Pears): Study protocol of a randomized controlled trial.

Maria Kennelly, Kate Ainscough, Karen Lindsay, Eileen Gibney, Mary McCarthy, Fionnuala McAuliffe

Contemporary clinical trials [46:92-9] (2016)

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Maternal adiposity confers an increased risk of GDM in pregnancy. A low glycemic index (GI) dietary intervention has been found to improve glucose homeostasis and reduce gestational weight gain. Mobile Health (mHealth) Technology-assisted interventions are becoming commonplace as an aid to treating many chronic diseases. The aim of this study is to assess the impact of a 'healthy lifestyle package' with mHealth smart phone technology as support compared with usual care on the incidence of GDM in an overweight and obese pregnant population. We propose a randomized controlled trial of an mHealth assisted healthy lifestyle intervention package versus standard obstetric care in pregnant women with a BMI ≥25kg/m(2)-39.9kg/m(2). Patients are randomized to control or intervention group in a 1:1 ratio. The intervention arm healthy lifestyle package includes a motivational counseling session to encourage behavior change, involving targeted, low GI nutritional advice and daily physical activity prescription delivered before 18weeks gestation, as well as a smart phone app to provide ongoing healthy lifestyle advice and support throughout pregnancy. The primary outcome is the incidence of GDM at 29weeks' gestation and power analysis indicates that 253 women are required in each group to detect a difference. This will be the first clinical trial to evaluate the effectiveness of a smart phone technology-assisted targeted healthy lifestyle intervention, which is grounded in behavior change theories and techniques, to support antenatal management of an overweight and obese pregnant population in preventing GDM.

 


Self-Monitoring Utilization Patterns Among Individuals in an Incentivized Program for Healthy Behaviors.

Ju Young Kim, Nathan Wineinger, Michael Taitel, Jennifer Radin, Osayi Akinbosoye, Jenny Jiang, Nima Nikzad, Gregory Orr, Eric Topol, Steve Steinhubl

Journal of medical Internet research [18:e292] (2016)

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The advent of digital technology has enabled individuals to track meaningful biometric data about themselves. This novel capability has spurred nontraditional health care organizations to develop systems that aid users in managing their health. One of the most prolific systems is Walgreens Balance Rewards for healthy choices (BRhc) program, an incentivized, Web-based self-monitoring program. This study was performed to evaluate health data self-tracking characteristics of individuals enrolled in the Walgreens' BRhc program, including the impact of manual versus automatic data entries through a supported device or apps. We obtained activity tracking data from a total of 455,341 BRhc users during 2014. Upon identifying users with sufficient follow-up data, we explored temporal trends in user participation. Thirty-four percent of users quit participating after a single entry of an activity. Among users who tracked at least two activities on different dates, the median length of participating was 8 weeks, with an average of 5.8 activities entered per week. Furthermore, users who participated for at least twenty weeks (28.3% of users; 33,078/116,621) consistently entered 8 to 9 activities per week. The majority of users (77%; 243,774/315,744) recorded activities through manual data entry alone. However, individuals who entered activities automatically through supported devices or apps participated roughly four times longer than their manual activity-entering counterparts (average 20 and 5 weeks, respectively; P<.001). This study provides insights into the utilization patterns of individuals participating in an incentivized, Web-based self-monitoring program. Our results suggest automated health tracking could significantly improve long-term health engagement.

 



Kick.it: The development of an evidence-based smoking cessation smartphone app.

JEM van Agteren, S Lawn, Billie Bonevski, BJ Smith

Translational behavioral medicine [8:243-267] (2018)

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Currently, the evidence for mobile health (mHealth) smoking cessation interventions is limited and heterogeneous, warranting the need for innovative rigorously developed solutions. The aim of this study was to describe the development of a smoking cessation smartphone application (app) developed using evidence-based principles. The app (Kick.it) was designed using the Intervention Mapping framework, incorporating an extensive literature review and qualitative study, in combination with the Behavioural Change Taxonomy v1, the Theoretical Domains Framework, and the Persuasive System Design framework. Kick.it provides quit smoking education, skills training, motivational content and self-regulation functionality for smokers, as well as their social support network. By logging cravings and cigarettes smoked, users will create their own smoking profile, which will be used to provide tailored interventions. It hosts a social network to allow 24/7 social support and provides in-app tools to help with urges to smoke. The app aims to motivate smokers to retry if they slip-up or relapse, allowing them to learn from previous smoking cessation attempts. Rather than basing the app on a singular behavioral change approach, Kick.it will use elements stemming from a variety of behavioral approaches by combining methods of multiple psychological theories. The use of best-practice intervention development frameworks in conjunction with evidence-based behavioral change techniques is expected to result in a smartphone app that has an optimal chance of helping people to quit smoking.

 


Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps.

E Edwards, J Lumsden, C Rivas, L Steed, L Edwards, A Thiyagarajan, R Sohanpal, H Caton, C Griffiths, M Munafò, S Taylor, R Walton

BMJ open [6:e012447] (2016)

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Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques. Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price. We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using 'gamification' (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals. 64 of 1680 (4%) health apps included gamification and met inclusion criteria; only 3 of these were in the NHS Library. Behaviour change categories used were: feedback and monitoring (n=60, 94% of apps), reward and threat (n=52, 81%), and goals and planning (n=52, 81%). Individual techniques were: self-monitoring of behaviour (n=55, 86%), non-specific reward (n=49, 82%), social support unspecified (n=48, 75%), non-specific incentive (n=49, 82%) and focus on past success (n=47, 73%). Median number of techniques per app was 14 (range: 5-22). Common combinations were: goal setting, self-monitoring, non-specific reward and non-specific incentive (n=35, 55%); goal setting, self-monitoring and focus on past success (n=33, 52%). There was no correlation between number of techniques and user ratings (p=0.07; rs=0.23) or price (p=0.45; rs=0.10). Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes. CRD42015029841.

 


A Smartphone App to Promote an Active Lifestyle in Lower-Educated Working Young Adults: Development, Usability, Acceptability, and Feasibility Study.

Dorien Simons, Ilse De Bourdeaudhuij, Peter Clarys, Katrien De Cocker, Corneel Vandelanotte, Benedicte Deforche

JMIR mHealth and uHealth [6:e44] (2018)

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Physical activity (PA) levels are problematic in lower-educated working young adults (18-26 years). To promote PA, smartphone apps have great potential, but there is no evidence for their effectiveness in this population. To increase the likelihood that a newly developed app will be effective, formative research and user testing are required. The aim of this study was to describe the development, usability, acceptability, and feasibility of a new theory- and evidence-based smartphone app to promote an active lifestyle in lower-educated working young adults. The new app was developed by applying 4 steps. First, determinants important to promote an active lifestyle in this population were selected. Second, evidence-based behavior change techniques were selected to convert the determinants into practical applications. Third, a new smartphone app was developed. Fourth, volunteers (n=11, both lower and higher educated) tested the app on usability, and lower-educated working young adults (n=16) tested its acceptability and feasibility via (think aloud) interviews, a questionnaire, and Google Analytics. The app was accordingly adapted for the final version. A new Android app, Active Coach, was developed that focused on knowledge, attitude, social support, and self-efficacy (based on outcomes from step 1), and that applied self-regulation techniques (based on outcomes from step 2). The app consists of a 9-week program with personal goals, practical tips, and scientific facts to encourage an active lifestyle. To ensure all-day and automatic self-monitoring of the activity behavior, the Active Coach app works in combination with a wearable activity tracker, the Fitbit Charge. Issues detected by the usability test (eg, text errors, wrong messages) were all fixed. The acceptability and feasibility test showed that participants found the app clear, understandable, and motivating, although some aspects needed to be more personal. By applying a stepwise, user-centered approach that regularly consulted the target group, the new app is adapted to their specific needs and preferences. The Active Coach app was overall positively evaluated by the lower-educated working young adults at the end of the development process.