There's an app for that: content analysis of paid health and fitness apps

A human centered approach to design a diet app for patients with metabolic syndrome

BACKGROUND

The objective of this study was to utilize a human-centered approach in designing a diet app that would assist in management of patients with metabolic syndrome.

METHODS

A convenience sample of 10 dietetic interns (DIs) who were attending their informatics rotation at the City University of New York School of Public Health and Health Policy (CUNY GSPHHP) were recruited during October 2017. The study was conducted in two phases. In phase 1, the DIs received a tutorial on the use of human-centered approach in designing mobile health applications. In phase 2, the DIs were provided a case study for which they designed an app for patients to manage metabolic syndrome using a human centered approach. The goal of phase 2 was to identify the features that were believed to be most important when designing this metabolic syndrome app. An initial questionnaire was administered to the DIs to gather information on their socio-demographics, prior training in nutrition, smart phone usage, perceptions about food logs, and calorie intake calculations. Subsequent questionnaires gathered information from the DIs on their preferred diet app components, app features, rankings of the features, and mock representations of the diet app with the selected features.

RESULTS

The DIs were enrolled in the supervised practice component of their training to be Registered Dietitian Nutritionists (RDNs). Fifty percent of them had previously worked in a nutrition-related field. One-third of them were currently using a nutrition app. The top five features of the proposed diet app which the DIs identified as very important included (I) personalization of the app based on user preferences (80%, n=8); (II) disease specific education tips (90%, n=9); (III) ability to track progress (80%; n=8); (IV) reminders (70%, n=7) and (V) reinforcement based on user feedback (50%, n=5). In translating the identified features into functional requirements, majority of the DIs felt that the five key features identified should incorporate the following components: (I) personalization of the app should comprise information on medical factors, personal information, personal preferences, and recording weights; (II) disease specific educational tips should comprise information on food selections, low sodium options, and recipes for diabetes; (III) tracking progress should comprise features for storing audio files, viewing previous logs and uploading photos into a library; (IV) reminders should comprise daily messages to the users from the app; and (V) reinforcement should comprise provisions to enter motivational messages.

CONCLUSIONS

Our study lends support to the need for utilizing human-centered design (HCD) approaches in developing e-health dietary apps as well other non-diet related apps. App developers are encouraged to incorporate user characteristics, needs and preferences using a HCD framework that will allow for reproducibility, tailoring, user satisfaction, and effectiveness assessments.

Apps for Hearing Healthcare

This chapter provides a picture of the evolution of mobile applications (apps) for hearing health care (HHC) in terms of availability, variety, penetration, offered services, and target users. Special emphasis is given to newly developed methods that might assist audiologists and hearing professionals to get meaningful information and guidance for informed adoption of apps for themselves as well as for patients and their families. The chapter also shows how these novel methods can be used to characterize and compare a variety of apps across a wide range of services and target user groups. A representative sample of apps, assessed by using such a standardized framework, is analyzed to derive a multifaceted picture of apps for HHC. The chapter outlines and discusses emerging trends and needs in the area and highlights the open challenges as well as potential opportunities for professionals, researchers, developers, and stakeholders at large.

App-Based Intervention Combining Evidence-Based Behavior Change Techniques With a Model-Based Reasoning System to Promote Physical Activity Among Young Adults (Active2Gether): Descriptive Study of the Development and Content

BACKGROUND

The Active2Gether intervention is an app-based intervention designed to help and encourage young adults to become and remain physically active by means of personalized, real-time activity tracking and context-specific feedback.

OBJECTIVE

The objective of our study was to describe the development and content of the Active2Gether intervention for physical activity promotion.

METHODS

A systematic and stepwise approach was used to develop the Active2Gether intervention. This included formulating objectives and a theoretical framework, selecting behavior change techniques, specifying the tailoring, pilot testing, and describing an evaluation protocol.

RESULTS

The development of the Active2Gether intervention comprised seven steps: analyzing the (health) problem, developing a program framework, writing (tailored) messages, developing tailoring assessments, developing the Active2Gether intervention, pilot testing, and testing and evaluating the intervention. The primary objective of the intervention was to increase the total time spent in moderate-vigorous physical activity for those who do not meet the Dutch guideline, maintain physical activity levels of those who meet the guideline, or further increase physical activity levels if they so indicated. The theoretical framework is informed by the social cognitive theory, and insights from other theories and evidence were added for specific topics. Development of the intervention content and communication channel resulted in the development of an app that provides highly tailored coaching messages that are framed in an autonomy-supportive style. These coaching messages include behavior change techniques aiming to address relevant behavioral determinants (eg, self-efficacy and outcome expectations) and are partly context specific. A model-based reasoning engine has been developed to tailor the intervention with respect to the type of support provided by the app, send relevant and context-specific messages to the user, and tailor the graphs displayed in the app. For the input of the tailoring, different instruments and sensors are used, such as an activity monitor (Fitbit One), Web-based and mobile questionnaires, and the location services on the user's mobile phone.

CONCLUSIONS

The systematic and stepwise approach resulted in an intervention that is based on theory and input from end users. The use of a model-based reasoning system to provide context-specific coaching messages goes beyond many existing eHealth and mHealth interventions.

Identifying Evidence-Informed Physical Activity Apps: Content Analysis

Background

Regular moderate to vigorous physical activity is essential for maintaining health and preventing the onset of chronic diseases. Both global rates of smartphone ownership and the market for physical activity and fitness apps have grown rapidly in recent years. The use of physical activity and fitness apps may assist the general population in reaching evidence-based physical activity recommendations. However, it remains unclear whether there are evidence-informed physical activity apps and whether behavior change techniques (BCTs) previously identified as effective for physical activity promotion are used in these apps.

Objective

This study aimed to identify English and German evidence-informed physical activity apps and BCT employment in those apps.

Methods

We identified apps in a systematic search using 25 predefined search terms in the Google Play Store. Two reviewers independently screened the descriptions of apps and screenshots applying predefined inclusion and exclusion criteria. Apps were included if (1) their description contained information about physical activity promotion; (2) they were in English or German; (3) physical activity recommendations of the World Health Organization or the American College of Sports Medicine were mentioned; and (4) any kind of objective physical activity measurement was included. Two researchers downloaded and tested apps matching the inclusion criteria for 2 weeks and coded their content using the Behavioral Change Technique Taxonomy v1 (BCTTv1).

Results

The initial screening in the Google Play Store yielded 6018 apps, 4108 of which were not focused on physical activity and were not in German or English. The descriptions of 1216 apps were further screened for eligibility. Duplicate apps and light versions (n=694) and those with no objective measurement of physical activity, requiring additional equipment, or not outlining any physical activity guideline in their description (n=1184) were excluded. Of the remaining 32 apps, 4 were no longer available at the time of the download. Hence, 28 apps were downloaded and tested; of these apps, 14 did not contain any physical activity guideline as an app feature, despite mentioning it in the description, 5 had technical problems, and 3 did not provide objective physical activity measurement. Thus, 6 were included in the final analyses. Of 93 individual BCTs of the BCTTv1, on average, 9 (SD 5) were identified in these apps. Of 16 hierarchical clusters, on average, 5 (SD 3) were addressed. Only BCTs of the 2 hierarchical clusters “goals and planning” and “feedback and monitoring” were identified in all apps.

Conclusions

Despite the availability of several thousand physical activity and fitness apps for Android platforms, very few addressed evidence-based physical activity guidelines and provided objective physical activity measurement. Furthermore, available descriptions did not accurately reflect the app content and only a few evidence-informed physical activity apps incorporated several BCTs. Future apps should address evidence-based physical activity guidelines and a greater scope of BCTs to further increase their potential impact for physical activity promotion.

A randomized controlled trial of three smartphone apps for enhancing public mental health

Many smartphone applications (apps) for mental health (MHapps) are available to the public. However, few have been the subject of a randomized controlled trial (RCT), and the change processes that are hypothesized to mediate claimed effects have not been previously studied. This RCT compared the efficacy of three publicly available MHapps to a waitlist control condition in a community sample, in which no MHapp was provided. The three MHapps included cognitive behavioural therapy (CBT) toolkit app MoodKit, mood tracking app MoodPrism, and CBT strategy app MoodMission. Participants were randomly allocated to each condition, completed a baseline assessment, downloaded their allocated MHapp, and completed a second assessment 30 days later, with n = 226 included in final analyses (81% female; M age = 34 years). Compared to the control condition, all MHapp groups experienced increases in mental wellbeing, MoodKit and MoodMission groups experienced decreases in depression, and no groups experienced effects on anxiety. Mediated regressions revealed that increasing coping self-efficacy, rather than emotional self-awareness or mental health literacy, was the underlying process contributing to effects on mental health for all three MHapps. MHapps appear to be an effective solution for improving public mental health, notably by improving users' confidence in their ability to cope.

Should We Recommend Renal Diet-Related Apps to Our Patients? An Evaluation of the Quality and Health Literacy Demand of Renal Diet-Related Mobile Applications

OBJECTIVE

Mobile phone applications (apps) are increasingly being used by patients with chronic kidney disease (CKD). We sought to describe the main purpose of commonly available renal diet apps and to quantify the accuracy of information, technical quality, and health literacy demand of renal diet apps.

DESIGN

The design was content analysis. All eligible renal diet apps in the Australian Apple App Store, Google Play, Windows Phone, and Blackberry App World were evaluated.

SUBJECTS

Eligible apps were in English and were related to kidney disease in humans (of any type or stage). Exclusion criteria included apps which were prohibited because of password protection.

MAIN OUTCOME MEASURE

Renal diet information in the apps was compared with evidence-based guidelines for the management of kidney disease to quantify information accuracy. App information was evaluated using the Silberg Scale. Technical quality and health literacy demand were evaluated using the Mobile Application Rating Scale.

RESULTS

A total of 21 apps were eligible for evaluation. The main purpose of these apps was to provide food and nutrition information (57.1%) or for educative purposes for CKD patients (38.1%). Only 47.6% (10/21) of apps contained accurate evidence-based information. Overall, app technical quality was considered acceptable (mean Mobile Application Rating Scale score 3.19 ± 0.35 out of 5), with 80.9% of apps scoring acceptable or greater for app technical quality. Scores for health literacy demand also indicated that most apps (15/21, 71.4%) were acceptable.

CONCLUSIONS

A range of apps currently exist that may provide individuals with CKD with useful food and nutrition information or increase their knowledge of the renal diet. These apps are also mainly of acceptable technical quality and health literacy demand. However, caution is required when using renal diet apps because more than half of the apps evaluated were not accurate and evidence based.

Analysis of the Features Important for the Effectiveness of Physical Activity-Related Apps for Recreational Sports: Expert Panel Approach

Background

A large number of people participate in individual or unorganized sports on a recreational level. Furthermore, many participants drop out because of injury or lowered motivation. Potentially, physical activity–related apps could motivate people during sport participation and help them to follow and maintain a healthy active lifestyle. It remains unclear what the quality of running, cycling, and walking apps is and how it can be assessed. Quality of these apps was defined as having a positive influence on participation in recreational sports. This information will show which features need to be assessed when rating physical activity–related app quality.

Objective

The aim of this study was to identify expert perception on which features are important for the effectiveness of physical activity–related apps for participation in individual, recreational sports.

Methods

Data were gathered via an expert panel approach using the nominal group technique. Two expert panels were organized to identify and rank app features relevant for sport participation. Experts were researchers or professionals in the field of industrial design and information technology (technology expert panel) and in the field of behavior change, health, and human movement sciences who had affinity with physical activity–related apps (health science expert panel). Of the 24 experts who were approached, 11 (46%) agreed to participate. Each panel session consisted of three consultation rounds. The 10 most important features per expert were collected. We calculated the frequency of the top 10 features and the mean importance score per feature (0-100). The sessions were taped and transcribed verbatim; a thematic analysis was conducted on the qualitative data.

Results

In the technology expert panel, applied feedback and feedforward (91.3) and fun (91.3) were found most important (scale 0-100). Together with flexibility and look and feel, these features were mentioned most often (all n=4 [number of experts]; importance scores=41.3 and 43.8, respectively). The experts in the health science expert panels a and b found instructional feedback (95.0), motivating or challenging (95.0), peer rating and use (92.0), motivating feedback (91.3), and monitoring or statistics (91.0) most important. Most often ranked features were monitoring or statistics, motivating feedback, works good technically, tailoring starting point, fun, usability anticipating or context awareness, and privacy (all n=3-4 [number of experts]; importance scores=16.7-95.0). The qualitative analysis resulted in four overarching themes: (1) combination behavior change, technical, and design features needed; (2) extended feedback and tailoring is advised; (3) theoretical or evidence base as standard; and (4) entry requirements related to app use.

Conclusions

The results show that a variety of features, including design, technical, and behavior change, are considered important for the effectiveness of physical activity–related apps by experts from different fields of expertise. These insights may assist in the development of an improved app rating scale.

MyLARC: A Theory-Based Interactive Smartphone App to Support Adolescents' Use of Long-Acting Reversible Contraception

STUDY OBJECTIVE

Develop and test the feasibility of a Health Belief Model theory-based interactive smartphone application (app) aimed at providing information and support to adolescents with long-acting reversible contraception (LARC).

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Using a mixed-method design, we conducted 30 in-person interviews with adolescent LARC users who were enrolled in school-based health centers in New York City. Interviews were conducted in 2 phases: during phase 1, 12 participants viewed a pilot version of the app (MyLARC); during phase 2, 18 additional participants interacted with an expanded version of the app. Phase 2 participants downloaded MyLARC onto their smartphone and app usage was tracked.

MAIN OUTCOME MEASURES

Participants' responses to the in-person interviews and data usage of MyLARC from phase 2 determined the feasibility and acceptability of using MyLARC to support young women's satisfaction and continuation of LARC methods.

RESULTS

Noneducational games were recommended as an approach to provide information to adolescents in an engaging way, as well as educational graphics and visually appealing content. Data tracking of MyLARC usage among phase 2 participants revealed a total of 67 unique logins to the app with 18 average page visits per unique login. The total amount of times MyLARC was opened was 1197. The most frequented features were 'Info about LARC' (95 unique visits) and 'Games' (80 unique plays).

CONCLUSION

A theory-based interactive smartphone app with LARC-specific information and support is an appropriate and appealing medium to provide information and support to adolescents using LARC. Games represented a novel opportunity to engage adolescents with health information.

Prevalence, Demographic Correlates, and Perceived Impacts of Mobile Health App Use Amongst Chinese Adults: Cross-Sectional Survey Study

BACKGROUND

Mobile health apps have changed the way people obtain health information and services and advance their understanding and management of their health. Although many health apps are available, little is known about the prevalence of their use for different purposes, whether such use is associated with demographic characteristics, and the impacts of their use on health knowledge and management.

OBJECTIVE

The main objectives of this study were to examine the prevalence, extent, and demographic correlates of health app use and the perceived impacts of health app use on increased health knowledge and improved health condition management.

METHODS

We conducted a cross-sectional questionnaire survey of 633 Chinese adults randomly drawn from the general population in Hong Kong.

RESULTS

Of the 633 participants, 612 (96.7%) reported using mobile devices. Of them, 235 (38.4%) reported using multiple types of health apps. The most-used type of health app was about healthy living information (197/612, 32.2%), followed by measuring/recording vital signs (80/612, 13.1%), health and medical reminders (64/612, 10.5%), recovery and rehabilitation information (42/612, 6.9%), diagnosis assistance (28/612, 4.6%), emergency services (16/612, 2.6%), telehealth (11/612, 1.8%), and “other” (19/612, 3.1%). Multivariate logistic regression analysis found that health app users were more likely to be women (odds ratio [OR] 1.68, 95% CI 1.14-2.48, P=.01) of a higher self-rated social class (OR 3.66, 95% CI 1.11-12.11, P=.03). Participants who worked in education/culture/academia (OR 2.31, 95% CI 1.16-4.59, P=.02) or disciplinary forces (OR 5.07, 95% CI 1.25-20.62, p=.02) were more likely to believe that using health apps could increase their health knowledge; participants working in education/culture/academia were also more likely to believe that using health apps could improve the effectiveness of health condition management (OR 2.18, 95% CI 1.10-4.34, P=.03).

CONCLUSIONS

Effort should be made to promote health app use, especially to demographic groups that are currently less likely to use health apps (eg, males, individuals from lower social classes). From the public health perspective, guidelines could be developed to help individuals identify quality health apps that meet their needs. Moreover, app developers could improve the usability of health apps to promote health app use.

Quality of Publicly Available Physical Activity Apps: Review and Content Analysis

Background

Within the new digital health landscape, the rise of health apps creates novel prospects for health promotion. The market is saturated with apps that aim to increase physical activity (PA). Despite the wide distribution and popularity of PA apps, there are limited data on their effectiveness, user experience, and safety of personal data.

Objective

The purpose of this review and content analysis was to evaluate the quality of the most popular PA apps on the market using health care quality indicators.

Methods

The top-ranked 400 free and paid apps from iTunes and Google Play stores were screened. Apps were included if the primary behavior targeted was PA, targeted users were adults, and the apps had stand-alone functionality. The apps were downloaded on mobile phones and assessed by 2 reviewers against the following quality assessment criteria: (1) users’ data privacy and security, (2) presence of behavior change techniques (BCTs) and quality of the development and evaluation processes, and (3) user ratings and usability.

Results

Out of 400 apps, 156 met the inclusion criteria, of which 65 apps were randomly selected to be downloaded and assessed. Almost 30% apps (19/65) did not have privacy policy. Every app contained at least one BCT, with an average number of 7 and a maximum of 13 BCTs. All but one app had commercial affiliation, 12 consulted an expert, and none reported involving users in the app development. Only 12 of 65 apps had a peer-reviewed study connected to the app. User ratings were high, with only a quarter of the ratings falling below 4 stars. The median usability score was excellent—86.3 out of 100.

Conclusions

Despite the popularity of PA apps available on the commercial market, there were substantial shortcomings in the areas of data safety and likelihood of effectiveness of the apps assessed. The limited quality of the apps may represent a missed opportunity for PA promotion.

Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach

BACKGROUND

Although mobile technologies such as smartphone apps are promising means for motivating people to adopt a healthier lifestyle (mHealth apps), previous studies have shown low adoption and continued use rates. Developing the means to address this issue requires further understanding of mHealth app nonusers and adoption processes. This study utilized a stage model approach based on the Precaution Adoption Process Model (PAPM), which proposes that people pass through qualitatively different motivational stages when adopting a behavior.

OBJECTIVE

To establish a better understanding of between-stage transitions during app adoption, this study aimed to investigate the adoption process of nutrition and fitness app usage, and the sociodemographic and behavioral characteristics and decision-making style preferences of people at different adoption stages.

METHODS

Participants (N=1236) were recruited onsite within the cohort study Konstanz Life Study. Use of mobile devices and nutrition and fitness apps, 5 behavior adoption stages of using nutrition and fitness apps, preference for intuition and deliberation in eating decision-making (E-PID), healthy eating style, sociodemographic variables, and body mass index (BMI) were assessed.

RESULTS

Analysis of the 5 behavior adoption stages showed that stage 1 ("unengaged") was the most prevalent motivational stage for both nutrition and fitness app use, with half of the participants stating that they had never thought about using a nutrition app (52.41%, 533/1017), whereas less than one-third stated they had never thought about using a fitness app (29.25%, 301/1029). "Unengaged" nonusers (stage 1) showed a higher preference for an intuitive decision-making style when making eating decisions, whereas those who were already "acting" (stage 4) showed a greater preference for a deliberative decision-making style (F4,1012=21.83, P<.001). Furthermore, participants differed widely in their readiness to adopt nutrition and fitness apps, ranging from having "decided to" but not yet begun to act (stage 2; nutrition: 6.88%, 70/1017; fitness: 9.23%, 95/1029) to being "disengaged" following previous adoption (stage 5; nutrition: 13.77%, 140/1017; fitness: 15.06%, 155/1029).

CONCLUSIONS

Using a behavior stage model approach to describe the process of adopting nutrition and fitness apps revealed motivational stage differences between nonusers (being "unengaged," having "decided not to act," having "decided to act," and being "disengaged"), which might contribute to a better understanding of the process of adopting mHealth apps and thus inform the future development of digital interventions. This study highlights that new user groups might be better reached by apps designed to address a more intuitive decision-making style.

Users' intention to continue using social fitness-tracking apps: expectation confirmation theory and social comparison theory perspective

Introduction: The key step in changing health behavior is understanding why users continue to use fitness apps. Therefore, we intend to investigate the users' intention to continue using social fitness-tracking apps. Materials and Methods: We identify two major forces driving continuous behavior. Expectation confirmation is the internal driving force and social comparison is the external driving force. A survey was conducted to test this proposed research model. We obtained 211 valid questionnaires. Results: Our results indicate that activity amount ranking (p < 0.001) and activity frequency ranking (p < 0.001) positively affect confirmation and that confirmation (p < 0.001) also positively affects the continuous intention of individuals using fitness-tracking apps. In addition, the impact of activity amount ranking and activity frequency ranking on continuous intention is moderated by expectation confirmation. Meanwhile, as the upward comparison tendency increases, the positive effect of confirmation on continuous intention decreases (p < 0.001). Conclusions: Social rank expectation and confirmation are the primary driving forces of continuous intention in individuals using fitness-tracking apps. Social rank is a meaningful and straightforward measurement individuals can use to evaluate their activity performance. An upward comparison tendency weakens the effect of confirmation on continuous intention.

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

Background

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.

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

Evaluating the Dietary and Nutritional Apps in the Google Play Store

Objectives

The objective of this study was to evaluate the features of diet and nutrition apps available in the Google Play Store.

Methods

A search was conducted in August 2017 using the Google Play Store database to identify apps related to diet and nutrition. Terms entered into the app search engine included 'diet apps' and 'nutrition apps'. The first 50 apps resulting from each search term was assessed. Duplicates were removed, and a comparative analysis was performed on the remaining diet and nutrition apps.

Results

A total of 86 diet and nutrition apps were identified. One hundred percent (n = 86) of the apps retrieved were freely available. More than half of the apps were applicable to a target user group of all ages (94%, n = 81). Stratified analysis across unique diet and nutrition apps (total, n = 72) showed a higher average rating for the diet apps (4.4) in comparison to that for the nutrition apps (4.3). Diet apps were more likely to be recently updated than the nutrition apps (72% vs. 66%), and diet apps were more likely to feature app purchase than nutrition apps (36% vs. 19%). The average rating was slightly higher for diet apps not featuring in-app purchases, but ratings were similar for the nutrition apps.

Conclusions

A centralized resource is needed that can provide information on health-related apps to allow for systematic evaluation of their effectiveness. Further research needs to examine improved methods of designing app-store platforms and presenting the available apps to properly guide users in app selection.

I'll Be Back: On the Multiple Lives of Users of a Mobile Activity Tracking Application

Mobile health applications that track activities, such as exercise, sleep, and diet, are becoming widely used. While these activity tracking applications have the potential to improve our health, user engagement and retention are critical factors for their success. However, long-term user engagement patterns in real-world activity tracking applications are not yet well understood. Here we study user engagement patterns within a mobile physical activity tracking application consisting of 115 million logged activities taken by over a million users over 31 months. Specifically, we show that over 75% of users return and re-engage with the application after prolonged periods of inactivity, no matter the duration of the inactivity. We find a surprising result that the re-engagement usage patterns resemble those of the start of the initial engagement period, rather than being a simple continuation of the end of the initial engagement period. This evidence points to a conceptual model of multiple lives of user engagement, extending the prevalent single life view of user activity. We demonstrate that these multiple lives occur because the users have a variety of different primary intents or goals for using the app. These primary intents are associated with how long each life lasts and how likely the user is to re-engage for a new life. We find evidence for users being more likely to stop using the app once they achieved their primary intent or goal (e.g., weight loss). However, these users might return once their original intent resurfaces (e.g., wanting to lose newly gained weight). We discuss implications of the multiple life paradigm and propose a novel prediction task of predicting the number of lives of a user. Based on insights developed in this work, including a marker of improved primary intent performance, our prediction models achieve 71% ROC AUC. Overall, our research has implications for modeling user re-engagement in health activity tracking applications and has consequences for how notifications, recommendations as well as gamification can be used to increase engagement.

Women's experiences with using a smartphone app (the Pregnant+ app) to manage gestational diabetes mellitus in a randomised controlled trial

OBJECTIVE

The purpose of this study was to explore the experiences of women with gestational diabetes mellitus (GDM) with controlling their blood glucose values and receiving health and nutrition information using a smartphone app (the Pregnant+ app).

DESIGN AND PARTICIPANTS

The study utilised the interpretative phenomenological analysis method. Semi-structured interviews were conducted with 17 participants among those participating to the randomised controlled trial.

RESULTS

The women experienced sorrow and disappointment when they were diagnosed with GDM, but they all went through a process of learning to self-manage their condition that was strongly motivated by theirdesire to care for their unborn babies. The women found that the app increased their confidence in their self management of GDM and their motivation for behavioural change. For some women, the app contributed to feelings offrustration or obsession. In addition, some technological problems and a lack of support from health-care professionals limited several women from using the app.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTISE

The findings suggest that asmartphone app may have potential for supporting women with GDM, particularly in their blood glucose management. However, it also highlights some of the potential challenges of using mHealth technologies. The findings indicate that a closer collaboration between health-care professionals and patients is of great importance in the implementation of apps for women with GDM.

A biopsy of Breast Cancer mobile applications: state of the practice review

BACKGROUND

Breast cancer is the most common cancer in women. The use of mobile software applications for health and wellbeing promotion has grown exponentially in recent years. We systematically reviewed the breast cancer apps available in today's leading smartphone application stores and characterized them based on their features, evidence base and target audiences.

METHODS

A cross-sectional study was performed to characterize breast cancer apps from the two major smartphone app stores (iOS and Android). Apps that matched the keywords "breast cancer" were identified and data was extracted using a structured form. Reviewers independently evaluated the eligibility and independently classified the apps.

RESULTS

A total of 1473 apps were a match. After removing duplicates and applying the selection criteria only 599 apps remained. Inter-rater reliability was determined using Fleiss-Cohen's Kappa. The majority of apps were free 471 (78.63%). The most common type of application was Disease and Treatment information apps (29.22%), Disease Management (19.03%) and Awareness Raising apps (15.03%). Close to 1 out of 10 apps dealt with alternative or homeopathic medicine. The majority of the apps were intended for patients (75.79%). Only one quarter of all apps (24.54%) had a disclaimer about usage and less than one fifth (19.70%) mentioned references or source material. Gamification specialists determined that 19.36% contained gamification elements.

CONCLUSIONS

This study analyzed a large number of breast cancer-focused apps available to consumers. There has been a steady increase of breast cancer apps over the years. The breast cancer app ecosystem largely consists of start-ups and entrepreneurs. Evidence base seems to be lacking in these apps and it would seem essential that expert medical personnel be involved in the creation of medical apps.

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

OBJECTIVE

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.

DESIGN

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.

SETTING

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.

SUBJECTS

A sample of eleven mobile apps that met predefined inclusion criteria to ensure relevance and good quality.

RESULTS

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.

CONCLUSIONS

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.

Mental and Emotional Self-Help Technology Apps: Cross-Sectional Study of Theory, Technology, and Mental Health Behaviors

BACKGROUND

Mental and emotional self-help apps have emerged as potential mental illness prevention and treatment tools. The health behavior theory mechanisms by which these apps influence mental health-related behavior change have not been thoroughly examined.

OBJECTIVE

The objective of this study was to examine the association between theoretical behavior change mechanisms and use of mental and emotional self-help apps and whether the use of such apps is associated with mental health behaviors.

METHODS

This study utilized a cross-sectional survey of 150 users of mental or emotional health apps in the past 6 months. Survey questions included theory-based items, app engagement and likeability items, and behavior change items. Stata version 14 was used to calculate all statistics. Descriptive statistics were calculated for each of the demographic, theory, engagement, and behavior variables. Multiple regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior after controlling for potentially confounding variables.

RESULTS

Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. Engagement (P<.001) was positively associated with the reported changes in theory items, whereas perceived behavior change was positively associated with theory (P<.001), engagement (P=.004), frequency of use of apps (P=.01), and income (P=.049).

CONCLUSIONS

Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. This increase in perceptions, beliefs, and attitudes surrounding their mental and emotional health was considerably associated with perceived change in behavior. There was a positive association between the level of engagement with the app and the impact on theory items. Future efforts should consider the value of impacting key theoretical constructs when designing mental and emotional health apps. As apps are evaluated and additional theory-based apps are created, cost-effective self-help apps may become common preventative and treatment tools in the mental health field.

Do Arabic weight-loss apps adhere to evidence-informed practices?

Mobile technology has been used successfully for promoting health and weight loss and for treating obesity. There is a high prevalence of smartphone and tablet users among the Saudi population. This study aimed to identify whether current Arabic weight-loss apps had features that adhered to evidence-informed practices. The six most relevant app stores were systematically searched using the Arabic words for weight and diet (n = 298). All apps that met the inclusion criteria (n = 65) were downloaded and examined for adherence to 13 evidence-informed practices. Latent class analysis identified two subgroups of apps: self-monitoring (15 % of apps) and advice-giving apps (85 %). The median number of evidence-informed practices was 1 (1, 2), with no apps having more than six and only nine apps including four to six. Meal planning was the most common feature (38 % of apps). These findings identify serious weaknesses in the currently available Arabic weight-loss apps. Thus, existing and future apps should include more features based on the best available evidence in the context of Arab culture.

Cross-national comparisons of college students' attitudes toward diet/fitness apps on smartphones

OBJECTIVE

Based on the technology acceptance model (TAM), we explored the nationally-bounded roles of four predictors (subjective norms, entertainment, recordability, and networkability) in determining the TAM variables of perceived usefulness (PU), perceived ease of use (PEOU), and behavioral intention (BI) to use diet/fitness apps on smartphones.

PARTICIPANTS/METHODS

College students in the US and South Korea were invited to participate in a survey. We obtained 508 questionnaires (304 from the US and 204 from Korea). Data were analyzed mainly through path analysis.

RESULTS

The four factors positively predicted the PU and PEOU of diet/fitness apps. While the effects of the predictors on the three TAM components were generally stronger among the US students than Korean students, the effect of subjective norms on the BI of diet/fitness apps was weaker among Korean students.

CONCLUSION

Findings from the cross-national comparisons were helpful for thoroughly understanding the contextualized mechanisms involved in the adoption of diet/fitness apps.

Systematic Review and Meta-Analysis Examining the Effectiveness of Mobile Health Technologies in Using Self-Monitoring for Pediatric Weight Management

BACKGROUND

Pediatric obesity is a public health concern related to multiple negative physical and psychosocial problems. While behavioral weight control (BWC) interventions are generally effective in decreasing pediatric weight status, these interventions are not able to reach the third of U.S. children currently classified as overweight or obese.

METHOD

This review and meta-analysis examined the overall effectiveness of mobile health (mHealth) technologies employing self-monitoring, a central component of change within BWC, to decrease pediatric weight status.

RESULTS

Overall, a small, but significant overall effect size (d = 0.42) was found with the inclusion of nine eligible studies examining the effect on weight status. However, the quality of studies included within this weight status meta-analysis was weak, therefore limiting the interpretability of results. Analyses were also conducted examining the effect of mHealth technologies employing self-monitoring on secondary behavioral outcomes of physical activity and diet. Results indicated a small to medium, but nonsignificant effect (d = 0.41; four samples) on physical activity and a small, but significant effect on diet (d = 0.10; eight samples).

CONCLUSIONS

Overall, the articles included in behavioral outcomes were of generally moderate quality. More work is needed to better identify the utility of mHealth and specific treatment components (such as self-monitoring), for pediatric weight management.

The role of smartphones in encouraging physical activity in adults

Lack of physical activity is a global public health issue. Behavioral change interventions utilizing smartphone applications (apps) are considered a potential solution. The purpose of this literature review was to: 1) determine whether smartphone-based interventions encourage the initiation of, and participation in, physical activity; 2) explore the success of interventions in different populations; and 3) examine the key factors of the interventions that successfully encouraged physical activity. Eight databases (Medline, Scopus, EBM Reviews–Cochrane Central Register of Controlled Trials, EBM Reviews–Cochrane Database of Systematic Reviews, PsycInfo, SportDISCUS, CINAHL, and EMBASE) were searched and studies reporting physical activity outcomes following interventions using smartphone apps in adults were included in the narrative review. Results were mixed with eight studies reporting increased physical activity and ten reporting no change. Interventions did not appear to be successful in specific populations defined by age, sex, country, or clinical diagnosis. There was no conclusive evidence that a specific behavioral theory or behavioral change technique was superior in eliciting behavioral change. The literature remains limited primarily to short-term studies, many of which are underpowered feasibility or pilot studies; therefore, many knowledge gaps regarding the effectiveness of smartphone apps in encouraging physical activity remain. Robust studies that can accommodate the fast pace of the technology industry are needed to examine outcomes in large populations.

Development and Evaluation of an iPad Application to Promote Knowledge of Tobacco Use and Cessation by Pregnant Women

We describe the development and evaluation of an iPad application to promote knowledge of tobacco risk and cessation resources for pregnant women. Pregnant women completed a survey on tobacco use in pregnancy, and clinicians reviewed their tobacco cessation practices and resources. The women reported that content was easy to understand (98%) and helped them understand tobacco risks (94%). Tobacco users reported that the information helped them want to quit smoking (75%) and provided ideas on how to quit (58%). Clinicians reported themes that reflected ease of use, support of pregnant women, and use of electronic resources. We conclude that iPad applications and other electronic health education delivery methods are useful tools that can augment coordinated and consistent tobacco cessation efforts in clinical settings.

How Do Apps Work? An Analysis of Physical Activity App Users' Perceptions of Behavior Change Mechanisms

Background

Physical activity apps are commonly used to increase levels of activity and health status. To date, the focus of research has been to determine the potential of apps to influence behavior, to ascertain the efficacy of a limited number of apps to change behavior, and to identify the characteristics of apps that users prefer.

Objective

The purpose of this study was to identify the mechanisms by which the use of physical activity apps may influence the users’ physical activity behavior.

Methods

This study used a cross-sectional survey of users of health-related physical activity apps during the past 6 months. An electronic survey was created in Qualtrics’ Web-based survey software and deployed on Amazon Mechanical Turk. Individuals who had used at least one physical activity app in the past 6 months were eligible to respond. The final sample comprised 207 adults living in the United States. 86.0% (178/207) of respondents were between the ages of 26 and 54 years, with 51.2% (106/207) of respondents being female. Behavior change theory informed the creation of 20 survey items relating to the mechanisms of behavior change. Respondents also reported about engagement with the apps, app likeability, and physical activity behavior.

Results

Respondents reported that using a physical activity app in the past 6 months resulted in a change in their attitudes, beliefs, perceptions, and motivation. Engagement with the app (P<.001), frequency of app use (P=.03), and app price (P=.01) were related to the reported impact of the behavior change theory or mechanisms of change. The mechanisms of change were associated with self-reported physical activity behaviors (P<.001).

Conclusions

The findings from this study provide an overview of the mechanisms by which apps may impact behavior. App developers may wish to incorporate these mechanisms in an effort to increase impact. Practitioners should consider the extent to which behavior change theory is integrated into a particular app when they consider making recommendations to others wishing to increase levels of physical activity.

Social anxiety apps: a systematic review and assessment of app descriptors across mobile store platforms

QUESTION

The aim of this systematic review is twofold: (1) to characterise the purpose and description of available social anxiety apps and (2) to review the evidence on the effectiveness of social anxiety apps.

STUDY SELECTION AND ANALYSIS

A search was conducted on three major mobile platforms: Apple iTunes, Google Play and Windows Store. Apps were included if they addressed social anxiety and used an English language interface. A systematic review of the literature from MEDLINE, EMBASE, PsycINFO, Cochrane, Scopus and Web of Science to identify evidence-based evaluations of social anxiety apps was also undertaken.

FINDINGS

Of the 1154 apps identified, 38 apps met the inclusion criteria: iTunes (n=18), Google Play (n=16) and Windows Store (n=4). Over 60% of apps were exclusively focused on social anxiety, while the remainder targeted social anxiety and related conditions. Most developers did not provide information on their organisational affiliations or their content source. Most apps used multimedia while 17 apps used text only. Finally, although the systematic review of the literature identified 94 articles, none of which met inclusion criteria.

CONCLUSIONS

Social anxiety apps have the potential to overcome barriers to accessing treatment; however, none of the apps identified have had studies on their effectiveness published. As the evidence base is lacking, it is therefore not currently possible to recommend their use.

Who uses running apps and sports watches? Determinants and consumer profiles of event runners' usage of running-related smartphone applications and sports watches

Individual and unorganized sports with a health-related focus, such as recreational running, have grown extensively in the last decade. Consistent with this development, there has been an exponential increase in the availability and use of electronic monitoring devices such as smartphone applications (apps) and sports watches. These electronic devices could provide support and monitoring for unorganized runners, who have no access to professional trainers and coaches. The purpose of this paper is to gain insight into the characteristics of event runners who use running-related apps and sports watches. This knowledge is useful from research, design, and marketing perspectives to adequately address unorganized runners' needs, and to support them in healthy and sustainable running through personalized technology. Data used in this study are drawn from the standardized online Eindhoven Running Survey 2014 (ERS14). In total, 2,172 participants in the Half Marathon Eindhoven 2014 completed the questionnaire (a response rate of 40.0%). Binary logistic regressions were used to analyze the impact of socio-demographic variables, running-related variables, and psychographic characteristics on the use of running-related apps and sports watches. Next, consumer profiles were identified. The results indicate that the use of monitoring devices is affected by socio-demographics as well as sports-related and psychographic variables, and this relationship depends on the type of monitoring device. Therefore, distinctive consumer profiles have been developed to provide a tool for designers and manufacturers of electronic running-related devices to better target (unorganized) runners' needs through personalized and differentiated approaches. Apps are more likely to be used by younger, less experienced and involved runners. Hence, apps have the potential to target this group of novice, less trained, and unorganized runners. In contrast, sports watches are more likely to be used by a different group of runners, older and more experienced runners with higher involvement. Although apps and sports watches may potentially promote and stimulate sports participation, these electronic devices do require a more differentiated approach to target specific needs of runners. Considerable efforts in terms of personalization and tailoring have to be made to develop the full potential of these electronic devices as drivers for healthy and sustainable sports participation.

Controlling Your "App"etite: How Diet and Nutrition-Related Mobile Apps Lead to Behavior Change

BACKGROUND

In recent years, obesity has become a serious public health crisis in the United States. Although the problem of obesity is being addressed through a variety of strategies, the use of mobile apps is a relatively new development that could prove useful in helping people to develop healthy dietary habits. Though such apps might lead to health behavior change, especially when relevant behavior change theory constructs are integrated into them, the mechanisms by which these apps facilitate behavior change are largely unknown.

OBJECTIVE

The purpose of this study was to identify which behavior change mechanisms are associated with the use of diet- and nutrition-related health apps and whether the use of diet- and nutrition-related apps is associated with health behavior change.

METHODS

A cross-sectional survey was administered to a total of 217 participants. Participants responded to questions on demographics, use of diet and nutrition apps in the past 6 months, engagement and likability of apps, and changes in the participant's dietary behaviors. Regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior, after controlling for potential confounding variables.

RESULTS

The majority of study participants agreed or strongly agreed with statements regarding app use increasing their motivation to eat a healthy diet, improving their self-efficacy, and increasing their desire to set and achieve health diet goals. Additionally, majority of participants strongly agreed that using diet/nutrition apps led to changes in their behavior, namely increases in actual goal setting to eat a healthy diet (58.5%, 127/217), increases in their frequency of eating healthy foods (57.6%, 125/217), and increases in their consistency of eating healthy foods (54.4%, 118/217). Participants also responded favorably to questions related to engagement and likability of diet/nutrition apps. A number of predictors were also positively associated with diet-related behavior change. Theory (P<.001), app engagement (P<.001), app use (P<.003), and education (P<.010) were all positively associated with behavior change.

CONCLUSIONS

Study findings indicate that the use of diet/nutrition apps is associated with diet-related behavior change. Hence, diet- and nutrition-related apps that focus on improving motivation, desire, self-efficacy, attitudes, knowledge, and goal setting may be particularly useful. As the number of diet- and nutrition-related apps continues to grow, developers should consider integrating appropriate theoretical constructs for health behavior change into the newly developed mobile apps.

Design Features in Games for Health: Disciplinary and Interdisciplinary Expert Perspectives

Games for health (G4H) aim to improve health outcomes and encourage behavior change. While existing theoretical frameworks describe features of both games and health interventions, there has been limited systematic investigation into how disciplinary and interdisciplinary stakeholders understand design features in G4H. We recruited 18 experts from the fields of game design, behavioral health, and games for health, and prompted them with 16 sample games. Applying methods including open card sorting and triading, we elicited themes and features (e.g., real-world interaction, game mechanics) around G4H. We found evidence of conceptual differences suggesting that a G4H perspective is not simply the sum of game and health perspectives. At the same time, we found evidence of convergence in stakeholder views, including areas where game experts provided insights about health and vice versa. We discuss how this work can be applied to provide conceptual tools, improve the G4H design process, and guide approaches to encoding G4H-related data for large-scale empirical analysis.

Towards Usable E-Health. A Systematic Review of Usability Questionnaires

BACKGROUND

The use of e-health can lead to several positive outcomes. However, the potential for e-health to improve healthcare is partially dependent on its ease of use. In order to determine the usability for any technology, rigorously developed and appropriate measures must be chosen.

OBJECTIVES

To identify psychometrically tested questionnaires that measure usability of e-health tools, and to appraise their generalizability, attributes coverage, and quality.

METHODS

We conducted a systematic review of studies that measured usability of e-health tools using four databases (Scopus, PubMed, CINAHL, and HAPI). Non-primary research, studies that did not report measures, studies with children or people with cognitive limitations, and studies about assistive devices or medical equipment were systematically excluded. Two authors independently extracted information including: questionnaire name, number of questions, scoring method, item generation, and psychometrics using a data extraction tool with pre-established categories and a quality appraisal scoring table.

RESULTS

Using a broad search strategy, 5,558 potentially relevant papers were identified. After removing duplicates and applying exclusion criteria, 35 articles remained that used 15 unique questionnaires. From the 15 questionnaires, only 5 were general enough to be used across studies. Usability attributes covered by the questionnaires were: learnability (15), efficiency (12), and satisfaction (11). Memorability (1) was the least covered attribute. Quality appraisal showed that face/content (14) and construct (7) validity were the most frequent types of validity assessed. All questionnaires reported reliability measurement. Some questionnaires scored low in the quality appraisal for the following reasons: limited validity testing (7), small sample size (3), no reporting of user centeredness (9) or feasibility estimates of time, effort, and expense (7).

CONCLUSIONS

Existing questionnaires provide a foundation for research on e-health usability. However, future research is needed to broaden the coverage of the usability attributes and psychometric properties of the available questionnaires.

Use of Fitness and Nutrition Apps: Associations With Body Mass Index, Snacking, and Drinking Habits in Adolescents

Background

Efforts to improve snacking and drinking habits are needed to promote a healthy body mass index (BMI) in adolescents. Although commercial fitness and nutrition mobile phone apps are widely used, little is known regarding their potential to improve health behaviors, especially in adolescents. In addition, evidence on the mechanisms through which such fitness and nutrition apps influence behavior is lacking.

Objectives

This study assessed whether the use of commercial fitness or nutrition apps was associated with a lower BMI and healthier snacking and drinking habits in adolescents. Additionally, it explored if perceived behavioral control to eat healthy; attitudes to eat healthy for the good taste of healthy foods, for overall health or for appearance; social norm on healthy eating and social support to eat healthy mediated the associations between the frequency of use of fitness or nutrition apps and BMI, the healthy snack, and beverage ratio.

Methods

Cross-sectional self-reported data on snack and beverage consumption, healthy eating determinants, and fitness and nutrition app use of adolescents (N=889; mean age 14.7 years, SD 0.8; 54.8% [481/878] boys; 18.1% [145/803] overweight) were collected in a representative sample of 20 schools in Flanders, Belgium. Height and weight were measured by the researchers. The healthy snack ratio and the healthy beverage ratio were calculated as follows: gram healthy snacks or beverages/(gram healthy snacks or beverages+gram unhealthy snacks or beverages)×100. Multilevel regression and structural equation modeling were used to analyze the proposed associations and to explore multiple mediation.

Results

A total of 27.6% (245/889) of the adolescents used fitness, nutrition apps or both. Frequency of using nutrition apps was positively associated with a higher healthy beverage ratio (b=2.96 [1.11], P=.008) and a higher body mass index z-scores (zBMI; b=0.13 [0.05], P=.008. A significant interaction was found between the frequency of using nutrition and for the zBMI (b=−0.03 [0.02], P=.04) and the healthy snack ratio (b=−0.84 [0.37], P=.03). Attitude to eat healthy for appearance mediated both the fitness app use frequency-zBMI (a × b=0.02 [0.01], P=.02) and the nutrition app use frequency-zBMI (a × b=0.04 [0.01], P=.001) associations. No mediation was observed for the associations between the frequency of use of fitness or nutrition apps and the healthy snack or beverage ratio.

Conclusions

Commercial fitness and nutrition apps show some association with healthier eating behaviors and BMI in adolescents. However, effective behavior change techniques should be included to affect key determinants of healthy eating.

Improving Exercise Performance with an Accelerometer-Based Smartphone App: A Randomized Controlled Trial

OBJECTIVE

Proper exercise form is critical for the safety and efficacy of therapeutic exercise. This research examines if a novel smartphone application, designed to monitor and provide real-time corrections during resistance training, can reduce performance errors and elicit a motor learning response.

DESIGN

Forty-two participants aged 18 to 65 years were randomly assigned to treatment and control groups. Both groups were tested for the number of movement errors made during a 10-repetition set completed at baseline, immediately after, and 1 to 2 weeks after a single training session of knee extensions. The treatment group trained with real-time, smartphone-generated feedback, whereas the control subjects did not. Group performance (number of errors) was compared across test sets using a 2-factor mixed-model analysis of variance.

RESULTS

No differences were observed between groups for age, sex, or resistance training experience. There was a significant interaction between test set and group. The treatment group demonstrated fewer errors on posttests 1 and 2 compared with pretest (P < 0.05). There was no reduction in the number of errors on any posttest for control subjects.

CONCLUSION

Smartphone apps, such as the one used in this study, may enhance patient supervision, safety, and exercise efficacy across rehabilitation settings. A single training session with the app promoted motor learning and improved exercise performance.

Using Persuasive Technology to Increase Physical Activity in People With Chronic Obstructive Pulmonary Disease by Encouraging Regular Walking: A Mixed-Methods Study Exploring Opinions and Preferences

Background

People with chronic obstructive pulmonary disease (PwCOPD) often experience breathlessness and fatigue, making physical activity challenging. Although many persuasive technologies (such as mobile phone apps) have been designed to support physical activity among members of the general population, current technologies aimed at PwCOPD are underdeveloped and only use a limited range of persuasive technology design principles.

Objective

The aim of this study was to explore how acceptable different persuasive technology design principles were considered to be in supporting and encouraging physical activity among PwCOPD.

Methods

Three prototypes for mobile apps using different persuasive technology design principles as defined by the persuasive systems design (PSD) model—namely, dialogue support, primary task support, and social support—were developed. Opinions of these prototypes were explored through 28 interviews with PwCOPD, carers, and the health care professionals (HCPs) involved in their care and questionnaires completed by 87 PwCOPD. Participants also ranked how likely individual techniques (eg, competition) would be to convince them to use a technology designed to support physical activity. Data were analyzed using framework analysis, Friedman tests, and Wilcoxon signed rank tests and a convergent mixed methods design was used to integrate findings.

Results

The prototypes for mobile apps were received positively by participants. The prototype that used a dialogue support approach was identified as the most likely to be used or recommended by those interviewed, and was perceived as more persuasive than both of the other prototypes (Z=−3.06, P=.002; Z=−5.50, P<.001) by those who completed the questionnaire. PwCOPD identified dialogue support and primary task support techniques as more likely to convince them to use a technology than social support techniques (Z=−5.00, P<.001; Z=−4.92, P<.001, respectively). Opinions of social support techniques such as competition and collaboration were divided.

Conclusions

Dialogue support and primary task support approaches are considered to be both acceptable and likely to be persuasive by PwCOPD, carers, and HCPs. In the future, these approaches should be considered when designing apps to encourage physical activity by PwCOPD.

Designing Health Apps to Support Dietetic Professional Practice and Their Patients: Qualitative Results From an International Survey

Background

Dietitians are engaging with mobile health (mHealth) technologies, particularly with diet and nutrition apps in their patient care. Despite the plethora of apps available, the majority are not designed with a dietitian’s input.

Objective

The aim of this study was to identify the user preferences of dietitians in relation to tools, resources, and design features for smartphone health apps that would support their dietetic professional practice and their patients.

Methods

As part of a larger international Web-based survey of health-app use among dietitians, three open-ended responses were included for specific exploration of app design features and additional resources or tools that could guide the development of apps for use in dietetic practice and patient care. Inductive thematic analysis of responses was conducted using the qualitative data analysis program, NVivo version 11 (QSR International Pty Ltd), to understand the design preferences and features valued by dietitians.

Results

The responses from 381 dietitian respondents were analyzed. Five key themes were identified. Dietitians wanted access to credible apps, suggesting that dietetic associations should have greater involvement in reviewing and endorsing evidence-based apps for use in dietary counseling. Improvements to the usability of apps, relating to their ease of use and design, were also raised, as self-monitoring of dietary behaviors using existing nutrition apps was deemed to be burdensome. Furthermore, apps providing dietitian-oriented support were favored, for example, those with the ability to streamline the dietary assessment process, so that dietitians could spend more time on dietary counseling and negotiating patient goals for dietary and lifestyle behavior change. Provision of patient-oriented support, such as functionality to tailor apps to patient-specific needs, was also considered important. Finally, respondents valued apps that could integrate into their work systems to enhance the quality of the dietitian-patient relationship.

Conclusions

App developers should draw upon the features and characteristics valued by dietitians to guide their development of apps that support dietetic practice and enhance patient care. Moreover, to achieve better dietitian and patient-centered app design, it is imperative that app developers take a collaborative approach with dietitians, their professional associations, and their patients.

Characteristics of Smartphone Applications for Nutrition Improvement in Community Settings: A Scoping Review

Smartphone applications are increasingly being used to support nutrition improvement in community settings. However, there is a scarcity of practical literature to support researchers and practitioners in choosing or developing health applications. This work maps the features, key content, theoretical approaches, and methods of consumer testing of applications intended for nutrition improvement in community settings. A systematic, scoping review methodology was used to map published, peer-reviewed literature reporting on applications with a specific nutrition-improvement focus intended for use in the community setting. After screening, articles were grouped into 4 categories: dietary self-monitoring trials, nutrition improvement trials, application description articles, and qualitative application development studies. For mapping, studies were also grouped into categories based on the target population and aim of the application or program. Of the 4818 titles identified from the database search, 64 articles were included. The broad categories of features found to be included in applications generally corresponded to different behavior change support strategies common to many classic behavioral change models. Key content of applications generally focused on food composition, with tailored feedback most commonly used to deliver educational content. Consumer testing before application deployment was reported in just over half of the studies. Collaboration between practitioners and application developers promotes an appropriate balance of evidence-based content and functionality. This work provides a unique resource for program development teams and practitioners seeking to use an application for nutrition improvement in community settings.

Girl Talk: A Smartphone Application to Teach Sexual Health Education to Adolescent Girls

STUDY OBJECTIVE

Produce Girl Talk, a free smartphone application containing comprehensive sexual health information, and determine the application's desirability and appeal among teenage girls.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Thirty-nine girls ages 12 to 17 years from Rhode Island participated in a 2-phase prospective study. In phase I, 22 girls assessed a sexual health questionnaire in focus groups. In phase II, 17 girls with iPhones used Girl Talk for 2 weeks and answered the revised sexual health questionnaire and interview questions before and after use.

MAIN OUTCOME MEASURES

Participants' responses to the sexual health questionnaire, interviews, and time viewing the application were used to determine feasibility and desirability of Girl Talk.

RESULTS

Girl Talk was used on average for 48 minutes during participants' free time on weekends for 10- to 15-minute intervals. Reported usefulness of Girl Talk as a sexual health application from baseline (6 participants) to follow-up (16 participants) increased significantly (35.3% vs 94.1%; P < .001). Knowledge improved most in topics related to anatomy and physiology (70.5% to 74.7% out of 7 questions), sexuality and relationships (76.5% to 80.0% out of 10 questions), and STI prevention (75.6% to 79.0% out of 7 questions). Most phase II participants (13 out of 17, or 76.5%) were exposed to sexual health education before using Girl Talk, but 16 out of 17 participants (94.1%) stated that the application provided new and/or more detailed information than health classes.

CONCLUSION

Girl Talk can potentially connect teenage girls to more information about sexual health vs traditional methods, and participants recommended the application as a valuable resource to learn about comprehensive sexual health.

The fitness of apps: a theory-based examination of mobile fitness app usage over 5 months

BACKGROUND

There are thousands of fitness-related smartphone applications ("apps") available for free and purchase, but there is uncertainty if these apps help individuals achieve and maintain personal fitness. Technology usage attrition is also a concern among research studies on health technologies.

METHODS

Usage of three fitness apps was examined over 5 months to assess adherence and effectiveness. Initially, 64 participants downloaded three free apps available on Android and iOS and 47 remained in the study until posttest. With a one group pre-posttest design and checkpoints at months 1, 3, and 5, exercise and exercise with fitness apps were examined in the framework of the Theory of Planned Behavior (TPB) using a validated survey. Apps were selected based on their function from the Functional Triad. Perceived fitness was also measured. T-tests, sign tests, Fisher's exact tests, and linear and logistic regression were used to compare pre to posttests and users to non-users of the apps.

RESULTS

Forty-seven participants completed both pre and posttests. Individual item scores indicated no significant change pre to posttest except for decreases observed in usefulness of using apps for exercise (attitude) (-0.78, P<0.01), peer influence on exercise (subjective norm) (-0.51, P<0.05), peer influence on exercise with apps (subjective norm) (-1.02, P<0.01), perceived difficulties in exercising with apps (perceived behavioral control) (-1.29, P<0.001), and the expected frequency of exercise with apps over the next 2 weeks (behavioral intention) (P<0.0001 in a sign test). Subscale total scores indicated significant decreases in subjective norm regarding exercise (-0.72, P<0.05), subjective norm regarding exercise with apps (-1.72, P<0.01), and perceived behavioral control over exercising with apps (-2.56, P<0.01) between pre and posttest. When comparing app users (n=32) to non-users (n=15), there was only a significant difference in subscale total scores at posttest for attitude toward exercising using apps, which was significantly more favorable among users than non-users (32.3 vs. 27.6, P<0.05). Fitness perception did not change over 5 months regarding cardiovascular fitness, strength, endurance, flexibility, or body composition. Technology usage attrition was desirable at 31.9%.

CONCLUSIONS

App usage and effectiveness appears to have a connection to usefulness (attitude) and to perceived difficulties of exercising using apps (perceived behavioral control). Exercise and exercise using apps are not influenced by peer influence (subjective norm). Intention to exercise using these particular apps decreased (behavioral intention). Those who utilized the apps were more likely to have a positive attitude about the apps. Usefulness and perceived difficulties in particular should be considered with future app development. App usefulness and ease of use may be facilitated by using health behavior theories to guide development.

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

OBJECTIVE

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.

METHODS

Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price.

DATA SOURCES

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.

RESULTS

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; r_s=0.23) or price (p=0.45; r_s=0.10).

CONCLUSIONS

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.

TRIAL REGISTRATION NUMBER

CRD42015029841.