IDEAS (Integrate, Design, Assess, and Share): A Framework and Toolkit of Strategies for the Development of More Effective Digital Interventions to Change Health Behavior

Reinforcement Learning to Send Reminders at Right Moments in Smartphone Exercise Application: A Feasibility Study

Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning (RL) technique has been used in a smartphone exercise application to promote physical activity. This RL model determines the 'right' time to deliver a restricted number of notifications adaptively, with respect to users' temporary context information (i.e., time and calendar). A four-week trial study was conducted to examine the feasibility of our model with real target users. JITAI reminders were sent by the RL model in the fourth week of the intervention, while the participants could only access the app's other functionalities during the first 3 weeks. Eleven target users registered for this study, and the data from 7 participants using the application for 4 weeks and receiving the intervening reminders were analyzed. Not only were the reaction behaviors of users after receiving the reminders analyzed from the application data, but the user experience with the reminders was also explored in a questionnaire and exit interviews. The results show that 83.3% reminders sent at adaptive moments were able to elicit user reaction within 50 min, and 66.7% of physical activities in the intervention week were performed within 5 h of the delivery of a reminder. Our findings indicated the usability of the RL model, while the timing of the moments to deliver reminders can be further improved based on lessons learned.

The Body Confident Mums challenge: a feasibility trial and qualitative evaluation of a body acceptance program delivered to mothers using Facebook

Background

Motherhood is a time of intense physical, psychological, and identity transformation, and body dissatisfaction may emerge through the process of pregnancy, birth, and adaptation to parenting. We present a feasibility trial of the Body Confident Mums Challenge, a program developed by adapting existing, effective interventions that focus on self-compassion and appreciation of body functionality to be specific to mothers.

Methods

The program was delivered using the social learning function in a closed Facebook group. Qualitative evaluation of evidence of change was conducted by gathering individual written reflections posted during the challenge (n = 120). Feasibility and acceptability was determined using a feedback survey (n = 22).

Results

Participant’s reflective posts indicated that they were embracing self-compassion, and de-prioritising body image concerns during the challenge. Feedback indicated that the program was mostly feasible and acceptable for mothers, with recommendations from some participants relating to slowing the pace of content delivery and reducing the time commitment of the Challenge.

Conclusions

The social media environment may therefore be a useful setting in which to implement brief intervention programs to improve body image and wellbeing.

Adequate Management of Phosphorus in Patients Undergoing Hemodialysis Using a Dietary Smartphone App: Prospective Pilot Study

Background

The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information.

Objective

The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy.

Methods

This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials.

Results

Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus.

Conclusions

The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention.

Evaluating human-centred design for public health: a case study on developing a healthcare app with refugee communities

BACKGROUND

Australian women from migrant and refugee communities experience reduced access to sexual and reproductive healthcare. Human-centred design can be a more ethical and effective approach to developing health solutions with underserved populations that are more likely to experience significant disadvantage or social marginalisation. This study aimed to evaluate how well Shifra, a small Australian-based not-for-profit, applied human-centred design when developing a web-based application that delivers local, evidence-based and culturally relevant health information to its non-English speaking users.

METHODS

This study undertook a document review, survey, and semi-structured interviews to evaluate how well Shifra was able to achieve its objectives using a human-centred design approach.

RESULTS

A co-design process successfully led to the development of a web-based health app for refugee and migrant women. This evaluation also yielded several important recommendations for improving Shifra's human-centred design approach moving forward.

CONCLUSIONS

Improving refugees' access to sexual and reproductive health is complex and requires innovative and thoughtful problem solving. This evaluation of Shifra's human-centred design approach provides a helpful and rigorous guide in reporting that may encourage other organisations undertaking human-centred design work to evaluate their own implementation.

A Gamification Framework for Cognitive Assessment and Cognitive Training: Qualitative Study

Background

Cognitive tasks designed to measure or train cognition are often repetitive and presented in a monotonous manner, features that lead to participant boredom and disengagement. In this situation, participants do not put forth their best effort to do these tasks well. As a result, neuropsychologists cannot draw accurate conclusions about the data collected, and intervention effects are reduced. It is assumed that greater engagement and motivation will manifest as improved data quality. Gamification, the use of game elements in nongame settings, has been heralded as a potential mechanism for increasing participant engagement in cognitive tasks. Some studies have reported a positive effect of gamification on participant performance, although most studies have shown mixed results. One reason for these contrasting findings is that most studies have applied poor and heterogeneous design techniques to gamify cognitive tasks. Therefore, an appropriate gamification design framework is needed in these tasks.

Objective

This study aimed to propose a framework to guide the design of gamification in cognitive tasks.

Methods

We employed a design science research (DSR) approach to provide a framework for gamifying cognitive assessments and training by synthesizing current gamification design frameworks and gamification works in cognitive assessment and training, as well as incorporating field experiences. The prototypes of the framework were iteratively evaluated with 17 relevant experts.

Results

We proposed a framework consisting of 7 phases: (1) preparation; (2) knowing users; (3) exploring existing tools for assessing or training a targeted cognitive context and determining the suitability of game-up and mapping techniques; (4) ideation; (5) prototyping using the Objects, Mechanics, Dynamics, Emotions (OMDE) design guideline; (6) development; and (7) disseminating and monitoring.

Conclusions

We found that (1) an intermediate design framework is needed to gamify cognitive tasks, which means that game elements should be selected by considering current cognitive assessment or training context characteristics since game elements may impose an irrelevant cognitive load that, in turn, can jeopardize data quality; (2) in addition to developing a new gamified cognitive task from scratch, 2 gamification techniques are widely used (first, adding game elements to an existing cognitive task and second, mapping an existing game to a cognitive function or impairment to assess or train it); and (3) further research is required to investigate the interplay of cognitive processes and game mechanics.

Co-design and qualitative validation of animated assessment item content for a child-reported digital distress screener

PURPOSE

The Interactive Child Distress Screener (ICDS) is a novel, digital screening tool that is currently under development and aims to broadly assess self-reported emotional and behavioural distress in children aged five to 11 years. This study implemented a generative participatory codesign and iterative refinement process to qualitatively validate the content of 30 animated assessment items developed for the ICDS by assessing their acceptability and accuracy from the child's perspective.

METHODS

The participants (N = 62) were five to 11-year-old children. Individual interviews were conducted with each child to determine acceptability and validity of animated items and facilitate the co-design refinement process of the animated assessment items.

RESULTS

Twenty-two out of 30 (73%) items met ≥80% satisfaction and accuracy consensus in their original format, six items (20%) required one round of refinement before meeting consensus, and two items (7%) required two rounds of refinements. Combined acceptability of animated items was high, ranging from 4.1 to 5 out of 5 across all items.

CONCLUSION

Participants were able to accurately identify and understand socio-emotional and behavioural constructs when depicted as animated items. Acceptability was high, even in first iterations when accuracy of understanding required refinement. This study highlighted the importance and benefits of iterative participatory design methodology in ensuring assessment items developed for children are understood, accepted and likely to be effective in obtaining accurate self-report.

Optimizing Engagement in an Online Dietary Intervention for Depression (My Food & Mood Version 3.0): Cohort Study

BACKGROUND

Online interventions can be a cost-effective and efficient way to deliver programs to large numbers of people regardless of geographic location. However, attrition in web-based interventions is often an issue. Developing ways to keep participants engaged is important for ensuring validity and limiting potential biases. We developed a web-based dietary intervention as part of The My Food & Mood study which aimed to optimize ways to engage participants with low mood or depressive symptoms to promote dietary behavior change. Different versions of the My Food & Mood program were tested during optimization. Iterations were developed based on user feedback and usage analysis.

OBJECTIVE

The purpose of this study was to compare engagement and nonusage attrition across 4 program iterations-which differed by platform format, delivery mode, and activity type-to create an optimized version.

METHODS

Each program version contained modular videos with key activities with respect to implementing behavior change techniques of equivalent levels of required participation and length: version 1.0, desktop program and smartphone app; version 2.1, desktop or smartphone program; version 2.2, desktop program; and version 3.0, smartphone app. Adults with PHQ-8 scores of 5 or greater were recruited online and assigned to 1 of the 4 versions. Participants were asked to use the program for 8 weeks and complete measures at weeks 4 and 8. Engagement data were collected from the web-based platform system logs and customized reports. Cox regression survival analysis examined nonusage attrition and Kruskal-Wallis tests compared engagement across each cohort.

RESULTS

A total of 614 adults participated. Kruskal-Wallis tests showed significant differences across the 4 cohorts in all engagement measures. The smartphone app (version 3.0) had the greatest engagement as measured by weeks engaged, total usage time, total time key activities, number of active sessions, percentage of activities completed against protocol, goals completed, and percentage of videos watched. Cox regression multivariate survival analysis showed referral from a health practitioner (hazard ratio [HR] 0.344, P=.001) and greater proficiency with computers (HR 0.796, P=.049) reduced the risk of nonusage attrition. Computer confidence was associated with an increased risk of nonusage attrition.

CONCLUSIONS

My Food & Mood version 3.0, a dietary intervention delivered via smartphone app with self-monitoring tools for diet quality and mood monitoring, was the version with greatest engagement in a population with low mood or depression. The iterative design techniques employed and analysis of feedback from participants resulted in a program that achieved lower rates of nonusage attrition and higher rates of intensity of use.

Development and Evaluation of a Digital Health Intervention for Substance Use Reduction in Young Refugees With Problematic Use of Alcohol and/or Cannabis-Study Protocol for a Single-Armed Feasibility Trial

Background: Refugee populations are at substantial risk of developing substance use disorder (SUD) and other mental health disorders. At the same time, refugee populations face numerous barriers to accessing mental health services. Digital interventions can address some of these issues, as emerging evidence indicates that digital interventions offer an effective, low-cost alternative with high accessibility and similar efficacy as standard SUD prevention programs. As an add-on to traditional services, they further present a viable approach to the lack of personnel available for foreign language communication in preventive and therapeutic settings. In the present study, we thus aim to develop and evaluate a digital health intervention (DHI) for the reduction of substance use for young refugees with problematic use of alcohol and/or cannabis. The intervention will be implemented in a smartphone app, translated into Arabic, English, Farsi, German, and Pashto, and is to be used stand-alone. It is based on methods from cognitive behavioral therapy, contains culturally adapted elements, provides practical information on how to deal safely with alcohol and cannabis, and motivates behavior change through increased self-reflection and behavioral, cognitive, and emotional skills-training in interactive exercises. Methods: We conduct a single-armed feasibility trial among 150 young refugees with problematic use of alcohol and/or cannabis. Participants will receive a digital screening and digital health intervention (DHI) for the reduction of problematic substance use, carried out over a 4-week time frame. The primary outcomes are the intervention's feasibility and the target population's acceptance of the intervention. The secondary outcome is a change in substance use post-intervention from baseline. Measurements are taken pre-intervention (baseline), post-intervention (after 4 weeks), and at 3- and 6-month follow-ups. We expect the intervention to be feasible and accepted by the target group. Discussion: The present study will establish to what degree the digital intervention (the "BePrepared App") is feasible and accepted by the target group. The evaluation of an easily accessible, feasible, and accepted intervention may impact refugees' mental health and health-related consequences. It aims at overcoming barriers to preventive health care in the substance use field for underserved refugee populations as a tool within a larger set of urgently needed interventions. Trial Registration: DRKS00021095 at the "German Clinical Trials Register" (30.03.2020).

An Ecological Momentary Intervention for people with social anxiety: A descriptive case study

This study describes the development and pilot evaluation of a smartphone- delivered Ecological Momentary Intervention (EMI) for people with social anxiety symptoms. Using a software engineering framework (agile modeling, model-driven development, bottom-up development), mental health experts and software developers collaborated to develop a 4-module EMI app designed to reduce social anxiety in real-time. Fifty-five participants with social anxiety were randomly allocated to the EMI or a wait-list control arm. App downloads, usage and user satisfaction data were collected and mental health outcomes assessed at baseline and post-intervention. Software development practices allowed mental health experts to distil core elements of a psychological intervention into discrete software components but there were challenges in engaging mental health experts in the process. Relative to control there was no significant reduction in social anxiety among the EMI participants in the pilot trial. However, post-test data were available for only 4 intervention and 10 control participants and only 2 (4.0%) of the EMI participants downloaded the app. The two participants who both accessed the app and completed the post-test reported being satisfied with the intervention. Future research should address managing resources and providing additional training to support ongoing engagement with key stakeholders.

Knowledge Gaps in Mobile Health Research for Promoting Physical Activity in Adults With Autism Spectrum Disorder

A growing body of research highlights that adults with autism spectrum disorder (ASD) have poor health outcomes, yet effective health interventions are lacking for this population. While mobile health applications demonstrate potential for promoting physical activity (PA) in adults with ASD, scientific evidence for supporting this tool’s long-term effectiveness on PA behavior change remains inconclusive. This study aimed to provide the latest information on PA research and the prospective role of mobile health applications for promoting PA in adults with ASD. A literature review demonstrated that a few available studies show contradictory results regarding PA levels in adults with ASD, and behavior change techniques and gamification-guided mobile health applications can be promising tactics to leverage autism’s strengths and increase PA in these individuals. Optimizing design decisions based on needs analysis and user feedback is crucial to identifying and developing a sustainable mobile health intervention for PA promotion in adults with ASD.

Α Virtual Reality App for Physical and Cognitive Training of Older People With Mild Cognitive Impairment: Mixed Methods Feasibility Study

Background

Therapeutic virtual reality (VR) has emerged as an effective treatment modality for cognitive and physical training in people with mild cognitive impairment (MCI). However, to replace existing nonpharmaceutical treatment training protocols, VR platforms need significant improvement if they are to appeal to older people with symptoms of cognitive decline and meet their specific needs.

Objective

This study aims to design and test the acceptability, usability, and tolerability of an immersive VR platform that allows older people with MCI symptoms to simultaneously practice physical and cognitive skills on a dual task.

Methods

On the basis of interviews with 20 older people with MCI symptoms (15 females; mean age 76.25, SD 5.03 years) and inputs from their health care providers (formative study VR1), an interdisciplinary group of experts developed a VR system called VRADA (VR Exercise App for Dementia and Alzheimer’s Patients). Using an identical training protocol, the VRADA system was first tested with a group of 30 university students (16 females; mean age 20.86, SD 1.17 years) and then with 27 older people (19 females; mean age 73.22, SD 9.26 years) who had been diagnosed with MCI (feasibility studies VR2a and VR2b). Those in the latter group attended two Hellenic Association Day Care Centers for Alzheimer’s Disease and Related Disorders. Participants in both groups were asked to perform a dual task training protocol that combined physical and cognitive exercises in two different training conditions. In condition A, participants performed a cycling task in a lab environment while being asked by the researcher to perform oral math calculations (single-digit additions and subtractions). In condition B, participants performed a cycling task in the virtual environment while performing calculations that appeared within the VR app. Participants in both groups were assessed in the same way; this included questionnaires and semistructured interviews immediately after the experiment to capture perceptions of acceptability, usability, and tolerability, and to determine which of the two training conditions each participant preferred.

Results

Participants in both groups showed a significant preference for the VR condition (students: mean 0.66, SD 0.41, t₂₉=8.74, P<.001; patients with MCI: mean 0.72, SD 0.51, t₂₆=7.36, P<.001), as well as high acceptance scores for intended future use, attitude toward VR training, and enjoyment. System usability scale scores (82.66 for the students and 77.96 for the older group) were well above the acceptability threshold (75/100). The perceived adverse effects were minimal, indicating a satisfactory tolerability.

Conclusions

The findings suggest that VRADA is an acceptable, usable, and tolerable system for physical and cognitive training of older people with MCI and university students. Randomized controlled trial studies are needed to assess the efficacy of VRADA as a tool to promote physical and cognitive health in patients with MCI.

The Design and Development of a Personalized Leisure Time Physical Activity Application Based on Behavior Change Theories, End-User Perceptions, and Principles From Empirical Data Mining

Introduction: Many adults do not reach the recommended physical activity (PA) guidelines, which can lead to serious health problems. A promising method to increase PA is the use of smartphone PA applications. However, despite the development and evaluation of multiple PA apps, it remains unclear how to develop and design engaging and effective PA apps. Furthermore, little is known on ways to harness the potential of artificial intelligence for developing personalized apps. In this paper, we describe the design and development of the Playful data-driven Active Urban Living (PAUL): a personalized PA application.

Methods: The two-phased development process of the PAUL apps rests on principles from the behavior change model; the Integrate, Design, Assess, and Share (IDEAS) framework; and the behavioral intervention technology (BIT) model. During the first phase, we explored whether location-specific information on performing PA in the built environment is an enhancement to a PA app. During the second phase, the other modules of the app were developed. To this end, we first build the theoretical foundation for the PAUL intervention by performing a literature study. Next, a focus group study was performed to translate the theoretical foundations and the needs and wishes in a set of user requirements. Since the participants indicated the need for reminders at a for-them-relevant moment, we developed a self-learning module for the timing of the reminders. To initialize this module, a data-mining study was performed with historical running data to determine good situations for running.

Results: The results of these studies informed the design of a personalized mobile health (mHealth) application for running, walking, and performing strength exercises. The app is implemented as a set of modules based on the persuasive strategies “monitoring of behavior,” “feedback,” “goal setting,” “reminders,” “rewards,” and “providing instruction.” An architecture was set up consisting of a smartphone app for the user, a back-end server for storage and adaptivity, and a research portal to provide access to the research team.

Conclusions: The interdisciplinary research encompassing psychology, human movement sciences, computer science, and artificial intelligence has led to a theoretically and empirically driven leisure time PA application. In the current phase, the feasibility of the PAUL app is being assessed.

Study protocol for autism specific transition resources (T-Res Study): developing a flexible resource package for dealing with the loosening and/or lifting of COVID-19 related restrictions

Autism specific transition resources (T-Res) aims to develop a flexible resource package to support children and young people with a diagnosis of autism spectrum disorder (ASD), as well as their families and educators, during the loosening and/or lifting of coronavirus disease 2019 (COVID-19) related restrictions on movement. A secondary aim is to determine the current and long-term impacts of the COVID-19 related restrictions on the wellbeing of individuals with autism spectrum disorders and their parents/caregivers. Measuring and addressing the psychosocial impact of the COVID-19 pandemic and related restrictions in movement is of prime importance at this time.  The impacts of this crisis will be far reaching and many may not be realised for many years. The proposed research will focus on children and young people with a diagnosis of ASD, their families and educators.  The ASD population alone is sizable with 14,000 (or 1.55%) of students in schools holding a diagnosis. When parents, teachers, tutors and special needs assistants (SNAs) are also considered this is a considerable group. The proposed research has the potential to have impacts that are social, psychological, educational and economic. This will be achieved through development of an online transition package to guide parents and educators in preparing children and young people for the resumption of regular daily routines following the lifting of COVID-19 restrictions.  This resource will be developed based on the needs of families and young people, as measured through surveys, as well as expert consensus on the targets and means of intervention.  This ambitious project can be commenced quickly and is designed to produce outputs quickly, which will in turn be disseminated to key stakeholders.

Mobile Apps for Dental Caries Prevention: Systematic Search and Quality Evaluation

Background

Dental caries is the most common multifactorial oral disease; it affects 60% to 90% of the global population. Dental caries is highly preventable through prevention behaviors aimed at improving oral hygiene, adequate fluoride usage, and dietary intake. Mobile apps have the potential to support patients with dental caries; however, little is known about the availability, target audience, quality, and features of these apps.

Objective

This review aims to systematically examine dental caries prevention apps; to describe their content, availability, target audience, and features; and to assess their quality.

Methods

We systematically identified and evaluated apps in a process paralleling a systematic review. This included a search strategy using search terms; an eligibility assessment using inclusion and exclusion criteria focused on accessibility and dental caries self-management behaviors, including oral hygiene, dietary intake, and fluoride usage; data extraction on app characteristics, including app store metrics; prevention behavior categorization; feature identification and description; a quality appraisal of all apps using the validated Mobile App Rating Scale (MARS) assessment tool; and data comparison and analysis.

Results

Using our search strategy, we retrieved 562 apps from the Google Play Store and iTunes available in Australia. Of these, 7.1% (40/562) of the apps fit our eligibility criteria, of which 55% (22/40) targeted adults, 93% (37/40) were free to download, and 65% (26/40) were recently updated. Oral hygiene was the most common dental caries prevention behavior domain, addressed in 93% (37/40) of the apps, while dietary intake was addressed in 45% (18/40) of the apps and fluoride usage was addressed in 42% (17/40) of the apps. Overall, 50% (20/40) of the apps addressed only 1 behavior, and 38% (15/40) of the apps addressed all 3 behaviors. The mean MARS score was 2.9 (SD 0.7; range 1.8-4.4), with 45% (18/40) of the apps categorized as high quality, with a rating above 3.0 out of 5.0. We identified 21 distinctive features across all dental caries prevention behaviors; however, the top 5 most common features focused on oral hygiene. The highest-ranking app was the Brush DJ app, with an overall MARS score of 4.4 and with the highest number of features (n=13). We did not find any apps that adequately addressed dental caries prevention behaviors in very young children.

Conclusions

Apps addressing dental caries prevention commonly focus on oral hygiene and target young adults; however, many are not of high quality. These apps use a range of features to support consumer engagement, and some of these features may be helpful for specific patient populations. However, it remains unclear how effective these apps are in improving dental caries outcomes, and further evaluation is required before they are widely recommended.

PEERNaija: A Gamified mHealth Behavioral Intervention to Improve Adherence to Antiretroviral Treatment Among Adolescents and Young Adults in Nigeria

Background: HIV is the leading cause of death for youth in Sub-Saharan Africa (SSA). The rapid proliferation of smart phones in SSA provides an opportunity to leverage novel approaches to promote adherence to life-saving antiretroviral therapy (ART) for adolescents and young adults living with HIV (AYA-HIV) that go beyond simple medication reminders.

Methods: Guided by the Integrate, Design, Assess and Share (IDEAS) framework, our multidisciplinary team developed a peer-based mHealth ART adherence intervention—PEERNaija. Grounded in Social Cognitive Theory, and principles of contingency management and supportive accountability, PEERNaija delivers a multi-faceted behavioral intervention within a smartphone application to address important obstacles to adherence.

Results:PEERNaija was developed as a gamified Android-based mHealth application to support the behavioral change goal of improving ART adherence among AYA-HIV within Nigeria, a low- and middle- income country (LMIC). Identified via foundational interviews with the target population and review of the literature, key individual (forgetfulness and poor executive functioning), environmental (poor social support) and structural (indirect cost of clinic-based interventions) barriers to ART adherence for AYA-HIV informed application features. Further informed by established behavioral theories and principles, the intervention aimed to improve self-efficacy and self-regulation of AYA-HIV, leverage peer relationships among AYA to incentivize medication adherence (via contingency management, social accountability), provide peer social support through an app-based chat group, and allow for outreach of the provider team through the incorporation of a provider application. Gamification mechanics incorporated within PEERNaija include: points, progress bar, leaderboard with levels, achievements, badges, avatars and targeted behavior change messages. PEERNaija was designed as a tethered mobile personal health record application, sharing data to the widely deployed OpenMRS electronic health record application. It also uses the secure opensource Nakama gamification platform, in line with Principles of Digital Development that emphasize use of opensource systems within LMICs.

Conclusions: Theory-based gamified mHealth applications that incorporate social incentives have the potential to improve adherence to AYA-HIV. Ongoing evaluations of PEERNaija will provide important data for the potential role for a gamified, smartphones application to deliver multifaceted adherence interventions for vulnerable AYA-HIV in SSA.

Status and Recommendations of Technological and Data-Driven Innovations in Cancer Care: Focus Group Study

BACKGROUND

The status of the data-driven management of cancer care as well as the challenges, opportunities, and recommendations aimed at accelerating the rate of progress in this field are topics of great interest. Two international workshops, one conducted in June 2019 in Cordoba, Spain, and one in October 2019 in Athens, Greece, were organized by four Horizon 2020 (H2020) European Union (EU)-funded projects: BOUNCE, CATCH ITN, DESIREE, and MyPal. The issues covered included patient engagement, knowledge and data-driven decision support systems, patient journey, rehabilitation, personalized diagnosis, trust, assessment of guidelines, and interoperability of information and communication technology (ICT) platforms. A series of recommendations was provided as the complex landscape of data-driven technical innovation in cancer care was portrayed.

OBJECTIVE

This study aims to provide information on the current state of the art of technology and data-driven innovations for the management of cancer care through the work of four EU H2020-funded projects.

METHODS

Two international workshops on ICT in the management of cancer care were held, and several topics were identified through discussion among the participants. A focus group was formulated after the second workshop, in which the status of technological and data-driven cancer management as well as the challenges, opportunities, and recommendations in this area were collected and analyzed.

RESULTS

Technical and data-driven innovations provide promising tools for the management of cancer care. However, several challenges must be successfully addressed, such as patient engagement, interoperability of ICT-based systems, knowledge management, and trust. This paper analyzes these challenges, which can be opportunities for further research and practical implementation and can provide practical recommendations for future work.

CONCLUSIONS

Technology and data-driven innovations are becoming an integral part of cancer care management. In this process, specific challenges need to be addressed, such as increasing trust and engaging the whole stakeholder ecosystem, to fully benefit from these innovations.

CaRE @ Home: Pilot Study of an Online Multidimensional Cancer Rehabilitation and Exercise Program for Cancer Survivors

BACKGROUND

Although facility-based cancer rehabilitation and exercise programs exist, patients are often unable to attend due to distance, cost, and other competing obligations. There is a need for scalable remote interventions that can reach and serve a larger population.

METHODS

We conducted a mixed methods pilot study to assess the feasibility, acceptability and impact of CaRE@Home: an 8-week online multidimensional cancer rehabilitation and exercise program. Feasibility and acceptability data were captured by attendance and adherence metrics and through qualitative interviews. Preliminary estimates of the effects of CaRE@Home on patient-reported and physically measured outcomes were calculated.

RESULTS

A total of n = 35 participated in the study. Recruitment (64%), retention (83%), and adherence (80%) rates, along with qualitative findings, support the feasibility of the CaRE@Home intervention. Acceptability was also high, and participants provided useful feedback for program improvements. Disability (WHODAS 2.0) scores significantly decreased from baseline (T1) to immediately post-intervention (T2) and three months post-intervention (T3) (p = 0.03 and p = 0.008). Physical activity (GSLTPAQ) levels significantly increased for both Total LSI (p = 0.007 and p = 0.0002) and moderate to strenuous LSI (p = 0.003 and p = 0.002) from baseline to T2 and T3. Work productivity (iPCQ) increased from T1 to T3 (p = 0.026). There was a significant increase in six minute walk distance from baseline to T2 and T3 (p < 0.001 and p = 0.010) and in grip strength from baseline to T2 and T3 (p = 0.003 and p < 0.001).

CONCLUSIONS

Results indicate that the CaRE@Home program is a feasible and acceptable cancer rehabilitation program that may help cancer survivors regain functional ability and decrease disability. In order to confirm these findings, a controlled trial is required.

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

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

PuzzleWalk: A theory-driven iterative design inquiry of a mobile game for promoting physical activity in adults with autism spectrum disorder

Primary symptoms of adults with autism spectrum disorder (ASD), such as pervasive social deficits in social interaction and communication, cause adults with ASD to adopt a sedentary lifestyle. Meanwhile, gamified and behavioral theory-based interventions have been shown to improve physical activity in a fun and unobtrusive way. In this paper, we describe the iterative design inquiry process of PuzzleWalk, a gamified, physical activity-promoting mobile app designed for adults with ASD. We report the design rationales and lessons learned across four user-centered design phases with ASD experts and adults with ASD, including user requirement gathering, iterative participatory design, usability evaluation, and field deployment. The design insights generated from this work could inform future research focusing on designing sociotechnical systems, games, and interventions for people with ASD.

Design and Development of a Digital Weight Management Intervention (ToDAy): Qualitative Study

BACKGROUND

The Tailored Diet and Activity (ToDAy) study aims to build on the campaign by adding a digital intervention with the potential to provide wide-reaching, cost-effective weight management support.

OBJECTIVE

The ToDAy study aims to build a tailored intervention using mobile technology to improve diet and physical activity behaviours in adults with overweight and obesity. The main objectives were to identify behavior change techniques for diet and physical activity (PA) change for weight loss and explore preferences for digital intervention features that would be effective in changing diet and PA behaviors.

METHODS

This qualitative study uses the principles of a person-based approach to intervention development; the behavioral intervention technology framework; and the capability, opportunity, motivation, and behavior (COM-B) framework. Focus groups and telephone interviews were conducted with 56 adults in Western Australia. Open-ended questions and example intervention features were used to explore the usability and acceptability of the self-monitoring tools, knowledge about effective weight-loss strategies, and acceptability of tailored feedback. Findings from the focus groups and interviews were analyzed using thematic analysis.

RESULTS

Qualitative findings revealed an awareness of key public health messages but a lack of confidence in how to perform these behaviors to help manage their weight. A total of 4 major themes were identified and mapped to the domains of the COM-B framework: (1) misinformation, (2) environmental support, (3) social norms, and (4) confidence.

CONCLUSIONS

This study explores users' capability, opportunity, and motivation to perform the target behaviors for weight loss. The findings suggested that a digital weight management intervention using a mobile food record and activity trackers to inform tailored feedback may be acceptable and feasible. Participants expressed a preference for simple expert advice, digital self-monitoring tools, and visual feedback.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/12782.

Designing the Future of Children's Mental Health Services

Advancements in evidence-based psychosocial interventions, digital technologies, and implementation strategies (i.e., health services research products) for youth mental health services have yet to yield significant improvement in public health outcomes. Achieving such impact will require that these research products are easy to use, useful, and contextually appropriate. This paper describes how human-centered design (HCD), an approach that aligns product development with the needs of the people and settings that use those products, can be leveraged to improve youth mental health services. We articulate how HCD can advance accessibility, effectiveness, and equity, with specific consideration of unique aspects of youth mental health services.

Health Design Thinking: An Innovative Approach in Public Health to Defining Problems and Finding Solutions

Current trends in the United States health care landscape call for innovative and adaptive approaches to improve outcomes and reduce inefficiencies. Design Thinking is an innovative approach to problem-solving that leverages insights from the end-users of new products, services, and experiences in order to develop best-fit solutions that are rapidly prototyped and iteratively refined. When compared to traditional problem-solving methods in health care and other public health adjacent fields, Design Thinking leads to more successful and sustainable interventions. Design Thinking has facilitated improvements in patient, provider, and community satisfaction, and in public health, has increased efficiency and collaboration in intervention development. Given the promising nature of Design Thinking as an effective problem-solving method, it follows that Design Thinking training would prove a beneficial addition to public health education. The integration of Design Thinking in public health education may equip public health leaders with essential skills necessary to understand and more effectively approach historically intractable challenges. This article describes the development and evaluation of a hands-on Design Thinking workshop, piloted with Master of Public Health (MPH) students in April, 2019 at Thomas Jefferson University. Preceding and following the workshop, evaluation forms were used to assess participants' knowledge about Design Thinking concepts and attitudes towards the workshop experience. Metrics were aligned with established learning objectives related to process, impact, and outcomes of the workshop. We hypothesized that the workshop intervention would increase participants understanding of Design Thinking concepts and applications in public health. Evaluations demonstrated that after attending the workshop, participants were able to understand and apply Design Thinking concepts in a public health context. Following the evaluation of pilot data, the workshop was refined and embedded in the MPH curriculum at Thomas Jefferson University in Philadelphia, PA.

A Digital Substance-Use Harm Reduction Intervention for Students in Higher Education (MyUSE): Protocol for Project Development

BACKGROUND

Digital interventions have been identified as a possible tool for reducing the harm caused by illicit drug use among students attending higher education (ie, college students). However, the success of interventions in this area has been hampered by a lack of user involvement and behavior change theory in their design. The My Understanding of Substance use Experiences (MyUSE) project combines a rigorous user-centered design (UCD) methodology and a robust behavioral change framework to develop a digitally delivered harm reduction intervention for illicit drug use among students in higher education.

OBJECTIVE

This project aims to design and develop a digital intervention that targets drug use-related harm among students in higher education.

METHODS

The MyUSE project will take place over 3 phases. The first phase was exploratory in nature, involving 3 systematic reviews, a large survey, and student workshops to gather a comprehensive evidence base to guide the project. The second phase is the development stage of the project, involving the use of the Behavior Change Wheel theoretical framework to determine the behavior change techniques of the intervention and the use of the UCD methodology to guide the development of the digital intervention. The third phase is the evaluation stage, whereby the intervention will undergo a 5-stage evaluation process to comprehensively evaluate its impacts.

RESULTS

The exploratory phase 1 of the MyUSE project was completed in December 2018. Phase 2 is currently underway, and phase 3 is due to begin in September 2020.

CONCLUSIONS

Higher education institutions (HEIs) are ideally placed to intervene and support students in the area of illicit drug use but are constrained by limited resources. Current digital interventions in this area are sparse and have several weaknesses. The MyUSE project combines a UCD approach with a robust behavior change framework to develop a digitally delivered intervention that is economically viable, effective in changing behavior, usable and acceptable to students, and able to sustain long-term implementation in HEIs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17829.

A Dietary Mobile App for Patients Undergoing Hemodialysis: Prospective Pilot Study to Improve Dietary Intakes

Background

Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners.

Objective

This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly.

Methods

A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials.

Results

A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2).

Conclusions

This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately.

Drivers of Mobile Health Acceptance and Use From the Patient Perspective: Survey Study and Quantitative Model Development

Background

Mobile health (mHealth) has potential to play a significant role in realizing a reversal of the current paradigm in health care toward a more patient-centric and more collaborative system to improve the outcomes obtained along with the quality and sustainability of health care systems.

Objective

The aim of this study was to explore and understand individual mHealth acceptance drivers between two groups of users: those with chronic health conditions and those without.

Methods

The extended unified theory of acceptance and usage of technology (UTAUT2) was enhanced with a new health-related framework: behavior intention to recommend and new mediation effects. We applied partial least squares (PLS) causal modeling to test the research model.

Results

We obtained 322 valid responses through an online questionnaire. The drivers of behavior intention with statistical significance were performance expectancy (β=.29, P<.001), habit (β=.39, P<.001), and personal empowerment (β=.18, P=.01). The precursors of use behavior were habit (β= .47, P<.001) and personal empowerment (β=.17, P=.01). Behavior intention to recommend was significantly influenced by behavior intention (β=.58, P<.001) and personal empowerment (β=.26, P<.001). The model explained 66% of the total variance in behavior intention, 54% of the variance in use behavior, and 70% of the variance in behavior intention to recommend.

Conclusions

Our study demonstrates a significant role of personal empowerment, as a second-order construct, in the mHealth acceptance context. The presence of a chronic health condition predicates an impact on acceptance of this technology.

Exploratory study of clinician and patient views regarding the use of a preconception care app for women with diabetes

Women with diabetes are at increased risk of adverse maternal and foetal outcomes. Preconception care can minimise risk of complications and improve outcomes, but current provision is inadequate. Electronic health technology, particularly apps, could improve preconception care provision but research is lacking in this area. The aim of this article is to explore the views and experiences of clinicians and women with diabetes regarding the use of a mobile app for preconception care. An exploratory study was conducted. Data were collected using focus group and interviews with 19 participants, comprising 10 clinicians and 9 women with type 1 or 2 diabetes. Data were analysed thematically. Women with diabetes and clinicians highlighted the inadequacy and challenges of current preconception care service provision and expressed a high level of enthusiasm and interest, towards a preconception care app that could support preconception care delivery for women with diabetes and overcome barriers to preconception care service provision and uptake. The acceptability of mobile health technology to both women and clinicians creates an important opportunity to overcome existing barriers to service provision, delivery and uptake, and improve both maternal and foetal outcomes for women with diabetes.

Understanding and Preventing Health Concerns About Emerging Mobile Health Technologies

New technologies and innovations have often improved population well-being and societal function; however, these are also often initially accompanied by worry and fear. In some cases, such worries can impede, or even prevent entirely, the adoption of the technology. Mobile health (mHealth), a discipline broadly focused on employing ambulatory technologies to improve the affordability, reach, and effectiveness of health promotion and clinical intervention approaches, offers new innovations and opportunities. Despite emerging evidence supporting mHealth efficacy (eg, for improving health outcomes), some individuals have concerns about mHealth technology that may impede scalability, efficacy, and, ultimately, the public health benefits of mHealth. We present a review and conceptual framework to examine these issues, focusing on three overarching themes: biophysiological, psychological, and societal concerns. There are features of mHealth that lead to worries about the potential negative effects on an individual’s health (eg, due to exposure to electromagnetic or radio waves), despite evidence supporting the safety of these technologies. When present, such beliefs can lead to worry that gives rise to the experience of unpleasant and concerning physical symptoms—the nocebo effect. This may represent an important implementational barrier because of apprehension toward beneficial mHealth products (or features thereof, such as wireless charging, wearable or implantable sensors, etc) and may also have broader ramifications (eg, leading to economic, governmental, and legislative actions). In addition to reviewing evidence on these points, we provide a broad three-step model of implementation research in mHealth that focuses on understanding and preventing health concerns to facilitate the safe and effective scalability of mHealth (and that may be generalizable and applied to similar technologies): (1) evaluating and better discerning public perceptions and misperceptions (and how these may differ between populations), (2) developing theory-based public health communication strategies regarding the safety of mHealth, and (3) disseminating this messaging using evidence-based methods. Collectively, these steps converge on reviewing evidence regarding the potential role of worry and nocebo in mHealth and providing a model for understanding and changing attitudes and preventing unfounded negative perceptions related to mHealth technology.

Selecting Evidence-Based Content for Inclusion in Self-Management Apps for Pressure Injuries in Individuals With Spinal Cord Injury: Participatory Design Study

BACKGROUND

Technological solutions, particularly mobile health (mHealth), have been shown to be potentially viable approaches for sustaining individuals' self-management of chronic health conditions. Theory-based interventions are more successful, as evidence-based information is an essential prerequisite for appropriate self-management. However, several reviews have shown that many existing mobile apps fail to be either theoretically grounded or based on evidence. Although some authors have attempted to address these two issues by focusing on the design and development processes of apps, concrete efforts to systematically select evidence-based content are scant.

OBJECTIVE

The objective of this study was to present a procedure for the participatory identification of evidence-based content to ground the development of a self-management app.

METHODS

To illustrate the procedure, we focused on the prevention and management of pressure injuries (PIs) in individuals with spinal cord injury (SCI). The procedure involves the following three steps: (1) identification of existing evidence through review and synthesis of existing recommendations on the prevention and self-management of PIs in SCI; (2) a consensus meeting with experts from the field of SCI and individuals with SCI to select the recommendations that are relevant and applicable to community-dwelling individuals in their daily lives; and (3) consolidation of the results of the study.

RESULTS

In this case study, at the end of the three-step procedure, the content for an mHealth intervention was selected in the form of 98 recommendations.

CONCLUSIONS

This study describes a procedure for the participatory identification and selection of disease-specific evidence and professional best practices to inform self-management interventions. This procedure might be especially useful in cases of complex chronic health conditions, as every recommendation in these cases needs to be evaluated and considered in light of all other self-management requirements. Hence, the agreement of experts and affected individuals is essential to ensure the selection of evidence-based content that is considered to be relevant and applicable.

A Sexual Health Promotion App for Transgender Women (Trans Women Connected): Development and Usability Study

BACKGROUND

HIV severely impacts the transgender communities in the United States, and transgender women have the highest HIV incidence rates among any identified risk group. Guided by formative research with transgender women and by an expert advisory panel of transgender women, we designed a prototype mobile app to promote HIV prevention among transgender women.

OBJECTIVE

This study aimed to develop and test the usability and acceptability of the prototype Trans Women Connected mobile app.

METHODS

We engaged in a 3-phase prototype development process. After conducting formative research about the health needs of this population, we outlined a theory-based app framework and developed three prototype activities (ie, a vision board, a pre-exposure prophylaxis [PrEP] education activity, and an interactive map). We then tested the usability and acceptability of the mobile app and activities with 16 transgender women using pre- and posttests, think-aloud protocols, and open-ended questions.

RESULTS

Participants reported high acceptability for the mobile app; the mean rating across all usability and likability questions was 5.9 out of 7. Service utilization intention, goal setting, and social support increased at posttest compared with pretest. Increases in self-efficacy in finding lesbian, gay, bisexual, transgender, and queer-friendly services; intention to seek online social support; and PrEP knowledge were statistically significant. Participants described the app as attractive and useful and perceived all three activities positively.

CONCLUSIONS

This study describes the development and usability and acceptability evaluation of a prototype mobile app designed for and with transgender women for HIV prevention. The usability testing findings provided important insights toward refining and the further development of the Trans Women Connected mobile app. The results suggest that a mobile health intervention can support positive changes. The remaining development and efficacy randomized trial of the Trans Women Connected mobile app is currently underway.

Human-Centered Design Strategies for Device Selection in mHealth Programs: Development of a Novel Framework and Case Study

BACKGROUND

Despite the increasing use of remote measurement technologies (RMT) such as wearables or biosensors in health care programs, challenges associated with selecting and implementing these technologies persist. Many health care programs that use RMT rely on commercially available, "off-the-shelf" devices to collect patient data. However, validation of these devices is sparse, the technology landscape is constantly changing, relative benefits between device options are often unclear, and research on patient and health care provider preferences is often lacking.

OBJECTIVE

To address these common challenges, we propose a novel device selection framework extrapolated from human-centered design principles, which are commonly used in de novo digital health product design. We then present a case study in which we used the framework to identify, test, select, and implement off-the-shelf devices for the Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) consortium, a research program using RMT to study central nervous system disease progression.

METHODS

The RADAR-CNS device selection framework describes a human-centered approach to device selection for mobile health programs. The framework guides study designers through stakeholder engagement, technology landscaping, rapid proof of concept testing, and creative problem solving to develop device selection criteria and a robust implementation strategy. It also describes a method for considering compromises when tensions between stakeholder needs occur.

RESULTS

The framework successfully guided device selection for the RADAR-CNS study on relapse in multiple sclerosis. In the initial stage, we engaged a multidisciplinary team of patients, health care professionals, researchers, and technologists to identify our primary device-related goals. We desired regular home-based measurements of gait, balance, fatigue, heart rate, and sleep over the course of the study. However, devices and measurement methods had to be user friendly, secure, and able to produce high quality data. In the second stage, we iteratively refined our strategy and selected devices based on technological and regulatory constraints, user feedback, and research goals. At several points, we used this method to devise compromises that addressed conflicting stakeholder needs. We then implemented a feedback mechanism into the study to gather lessons about devices to improve future versions of the RADAR-CNS program.

CONCLUSIONS

The RADAR device selection framework provides a structured yet flexible approach to device selection for health care programs and can be used to systematically approach complex decisions that require teams to consider patient experiences alongside scientific priorities and logistical, technical, or regulatory constraints.

The Development of a Mobile Health App for Breast Cancer Self-Management Support in Taiwan: Design Thinking Approach

Background

Evidence has shown that breast cancer self-management support from mobile health (mHealth) apps can improve the quality of life of survivors. Although many breast cancer self-management support apps exist, few papers have documented the procedure for the development of a user-friendly app from the patient’s perspective.

Objective

This study aimed to investigate the information needs of Taiwanese women with breast cancer to inform the development of a self-management support mHealth app.

Methods

A 5-step design thinking approach, comprising empathy, define, ideate, prototype, and test steps, was used in the focus groups and individual interviews conducted to collect information on the requirements and expectations of Taiwanese women with breast cancer with respect to the app. A thematic analysis was used to identify information needs.

Results

A total of 8 major themes including treatment, physical activity, diet, emotional support, health records, social resources, experience sharing, and expert consultation were identified. Minor themes included the desire to use the app under professional supervision and a trustworthy app manager to ensure the credibility of information.

Conclusions

The strengths of the design thinking approach were user-centered design and cultural sensitivity. The results retrieved from each step contributed to the development of the app and reduction of the gap between end users and developers. An mHealth app that addresses these 8 main themes can facilitate disease self-management for Taiwanese women with breast cancer.

A Mobile Phone Intervention to Improve Obesity-Related Health Behaviors of Adolescents Across Europe: Iterative Co-Design and Feasibility Study

Background

Promotion of physical activity, healthy eating, adequate sleep, and reduced sedentary behavior in adolescents is a major priority globally given the current increase in population health challenges of noncommunicable diseases and risk factors such as obesity. Adolescents are highly engaged with mobile technology, but the challenge is to engage them with mobile health (mHealth) technology. Recent innovations in mobile technology provide opportunities to promote a healthy lifestyle in adolescents. An increasingly utilized approach to facilitate increased engagement with mHealth technology is to involve potential users in the creation of the technology.

Objective

This study aimed to describe the process of and findings from co-designing and prototyping components of the PEGASO Fit for Future (F4F) mHealth intervention for adolescents from different cultural backgrounds.

Methods

A total of 74 adolescents aged 13 to 16 years from Spain, Italy, and the United Kingdom participated in the co-design of the PEGASO F4F technology. In 3 iterative cycles over 12 months, participants were involved in the co-design, refinement, and feasibility testing of a system consisting of diverse mobile apps with a variety of functions and facilities to encourage healthy weight–promoting behaviors. In the first iteration, participants attended a single workshop session and were presented with mock-ups or early-version prototypes of different apps for user requirements assessment and review. During the second iteration, prototypes of all apps were tested by participants for 1 week at home or school. In the third iteration, further developed prototypes were tested for 2 weeks. Participants’ user experience feedback and development ideas were collected through focus groups and completion of questionnaires.

Results

For the PEGASO F4F technology to be motivating and engaging, participants suggested that it should (1) allow personalization of the interface, (2) have age-appropriate and easy-to-understand language (of icons, labels, instructions, and notifications), (3) provide easily accessible tutorials on how to use the app or navigate through a game, (4) present a clear purpose and end goal, (5) have an appealing and self-explanatory reward system, (6) offer variation in gamified activities within apps and the serious game, and (7) allow to seek peer support and connect with peers for competitive activities within the technology.

Conclusions

Incorporating adolescents’ preferences, the PEGASO F4F technology combines the functions of a self-monitoring, entertainment, advisory, and social support tool. This was the first study demonstrating that it is possible to develop a complex mobile phone-based technological system applying the principles of co-design to mHealth technology with adolescents across 3 countries. The findings from this study informed the development of an mHealth system for healthy weight promotion to be tested in a controlled multinational pilot trial.

Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions

BACKGROUND

Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD.

METHODS

Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data.

RESULTS

Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD.

CONCLUSION

These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.

Developing Embodied Conversational Agents for Coaching People in a Healthy Lifestyle: Scoping Review

BACKGROUND

Embodied conversational agents (ECAs) are animated computer characters that simulate face-to-face counseling. Owing to their capacity to establish and maintain an empathic relationship, they are deemed to be a promising tool for starting and maintaining a healthy lifestyle.

OBJECTIVE

This review aimed to identify the current practices in designing and evaluating ECAs for coaching people in a healthy lifestyle and provide an overview of their efficacy (on behavioral, knowledge, and motivational parameters) and use (on usability, usage, and user satisfaction parameters).

METHODS

We used the Arksey and O'Malley framework to conduct a scoping review. PsycINFO, Medical Literature Analysis and Retrieval System Online, and Scopus were searched with a combination of terms related to ECA and lifestyle. Initially, 1789 unique studies were identified; 20 studies were included.

RESULTS

Most often, ECAs targeted physical activity (n=16) and had the appearance of a middle-aged African American woman (n=13). Multiple behavior change techniques (median=3) and theories or principles (median=3) were applied, but their interpretation and application were usually not reported. ECAs seemed to be designed for the end user rather than with the end user. Stakeholders were usually not involved. A total of 7 out of 15 studies reported better efficacy outcomes for the intervention group, and 5 out of 8 studies reported better use-related outcomes, as compared with the control group.

CONCLUSIONS

ECAs are a promising tool for persuasive communication in the health domain. This review provided valuable insights into the current developmental processes, and it recommends the use of human-centered, stakeholder-inclusive design approaches, along with reporting on the design activities in a systematic and comprehensive manner. The gaps in knowledge were identified on the working mechanisms of intervention components and the right timing and frequency of coaching.

Trends and Visibility of "Digital Health" as a Keyword in Articles by JMIR Publications in the New Millennium: Bibliographic-Bibliometric Analysis

Background

Digital health has become an advancing phenomenon in the health care systems of modern societies. Over the past two decades, various digital health options, technologies, and innovations have been introduced; many of them are still being investigated and evaluated by researchers all around the globe. However, the actual trends and visibility of peer-reviewed publications using “digital health” as a keyword to reflect the topic, published by major relevant journals, still remain to be quantified.

Objective

This study aimed to conduct a bibliographic-bibliometric analysis on articles published in JMIR Publications journals that used “digital health” as a keyword. We evaluated the trends, topics, and citations of these research publications to identify the important share and contribution of JMIR Publications journals in publishing articles on digital health.

Methods

All JMIR Publications journals were searched to find articles in English, published between January 2000 and August 2019, in which the authors focused on, utilized, or discussed digital health in their study and used “digital health” as a keyword. In addition, a bibliographic-bibliometric analysis was conducted using the freely available Profiles Research Networking Software by the Harvard Clinical and Translational Science Center.

Results

Out of 1797 articles having “digital health” as a keyword, published mostly between 2016 and 2019, 277 articles (32.3%) were published by JMIR Publications journals, mainly in the Journal of Medical Internet Research. The most frequently used keyword for the topic was “mHealth.” The average number of times an article had been cited, including self-citations, was above 2.8.

Conclusions

The reflection of “digital health” as a keyword in JMIR Publications journals has increased noticeably over the past few years. To maintain this momentum, more regular bibliographic and bibliometric analyses will be needed. This would encourage authors to consider publishing their articles in relevant, high-visibility journals and help these journals expand their supportive publication policies and become more inclusive of digital health.

Social Media Intervention to Promote Smoking Treatment Utilization and Cessation Among Alaska Native People Who Smoke: Protocol for the Connecting Alaska Native People to Quit Smoking (CAN Quit) Pilot Study

BACKGROUND

Despite the high prevalence of tobacco use among Alaska Native (AN) people, tobacco cessation interventions developed specifically for this group are lacking. Social media hold promise as a scalable intervention strategy to promote smoking treatment utilization and cessation, given the barriers to treatment delivery (ie, geographic remoteness, limited funding, climate, and travel costs) in the state of Alaska (AK). Building on a longstanding tobacco control research partnership with the AK Tribal Health System, in this study, we are developing and pilot-testing a culturally relevant, Facebook (FB)-delivered intervention that incorporates a digital storytelling approach adapted from the effective Centers for Disease Control Tips from Former Smokers campaign.

OBJECTIVE

This study aims to promote evidence-based smoking treatment (eg, state quitline and Tribal cessation programs) uptake and cessation among AN people.

METHODS

This study fulfills the objectives for stage 1 of the National Institute on Drug Abuse behavioral integrative treatment development program. In stage 1a, we will use a mixed method approach to develop the FB intervention. Cultural variance and surface/deep structure frameworks will address the influence of culture in designing health messages. These developmental activities will include qualitative and quantitative assessments, followed by beta testing of proposed intervention content. In stage 1b, we will conduct a randomized pilot trial enrolling 60 AN adults who smoke. We will evaluate the feasibility, uptake, consumer response, and potential efficacy of the FB intervention compared with a control condition (quitline/treatment referral only). Primary outcome measures include feasibility and biochemically verified smoking abstinence at 1-, 3-, and 6-month follow-ups. Secondary outcomes will include self-reported smoking cessation treatment utilization and abstinence from tobacco/nicotine products. We will also explore interdependence (relationship orientation and collaborative efforts in lifestyle change) as a culturally relevant mediator of intervention efficacy.

RESULTS

The study enrolled 40 participants for phase 1, with data saturation being achieved at 30 AN people who smoke and 10 stakeholders. For phase 2, we enrolled 40 participants. Qualitative assessment of proposed intervention content was completed with 30 AN smokers and 10 stakeholders. We are currently analyzing data from the quantitative assessment with 40 participants in preparation for the beta testing, followed by the randomized pilot trial.

CONCLUSIONS

The project is innovative for its use of social media communication tools that are culturally relevant in a behavioral intervention designed to reach AN people statewide to promote smoking treatment utilization and cessation. The study will further advance tobacco cessation research in an underserved disparity group. If the pilot intervention is successful, we will have a blueprint to conduct a large randomized controlled efficacy trial. Our approach could be considered for other remote AN communities to enhance the reach of evidence-based tobacco cessation treatments.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15155.

A design and evaluation framework for digital health interventions

Digital health interventions (DHIs) have the potential to help the growing number of chronic disease patients better manage their everyday lives. However, guidelines for the systematic development of DHIs are still scarce. The current work has, therefore, the objective to propose a framework for the design and evaluation of DHIs (DEDHI). The DEDHI framework is meant to support both researchers and practitioners alike from early conceptual DHI models to large-scale implementations of DHIs in the healthcare market.

Developing interventions to improve health: a systematic mapping review of international practice between 2015 and 2016

BACKGROUND

Researchers publish the processes they use to develop interventions to improve health. Reflecting on this endeavour may help future developers to improve their practice.

METHODS

Our aim was to collate, describe, and analyse the actions developers take when developing complex interventions to improve health. We carried out a systematic mapping review of empirical research studies that report the development of complex interventions to improve health. A search was undertaken of five databases over 2015-2016 using the term 'intervention dev*'. Eighty-seven journal articles reporting the process of intervention development were identified. A purposive subset of 30 articles, using a range of published approaches to developing interventions, was selected for in-depth analysis using principles of realist synthesis to identify the actions of intervention development and rationales underpinning those actions.

RESULTS

The 87 articles were from the USA (39/87), the UK (32/87), continental Europe (6/87), and the rest of the world (10/87). These mainly took a pragmatic self-selected approach (n = 43); a theory- and evidence-based approach, e.g. Intervention Mapping, Behaviour Change Wheel (n = 22); or a partnership approach, e.g. community-based participatory research, co-design (n = 10). Ten actions of intervention development were identified from the subset of 30 articles, including identifying a need for an intervention, selecting the intervention development approach to follow, considering the needs of the target population, reviewing published evidence, involving stakeholders, drawing or generating theory, and designing and refining the intervention. Rationales for these actions were that they would produce more engaging, acceptable, feasible, and effective interventions.

CONCLUSIONS

Developers take a variety of approaches to the international endeavour of complex intervention development. We have identified and described a set of actions taken within this endeavour regardless of whether developers follow a published approach or not. Future developers can use these actions and the rationales that underpin them to help them make decisions about the process of intervention development.

TRIAL REGISTRATION

PROSPERO, CRD42017080545.

Dietary Application for the Management of Patients with Hemodialysis: A Formative Development Study

Objectives

To describe the step-by-step person-centered, theory-based development of the KELA.AE app for Arabic speaking hemodialysis patients.

Methods

A step-by-step person-driven theory-based approach was conducted to develop a self-monitoring and educational dietary app for hemodialysis patients. The development follows the Integration, Design, Assessment, and Sharing (IDEAS) framework. Qualitative, semi-structured interviews with 6 hemodialysis patients and 6 healthcare practitioners (dietitians and nephrologists) were performed to assess the need for an app, the willingness to use an app, and features desired in an app.

Results

The KELA.AE app, which includes a self-monitoring feature, CKD-friendly recipes, and a theory-based, evidence-based educational feature was developed. Qualitative analysis of interviews revealed two predominant themes from patient interviews ‘Experience with the diet’, ‘App evaluation’, and one theme from interviews with healthcare practitioners ‘App evaluation’. Patients expressed frustration with current accessibility of dietary information along with the need for educational materials in the app. The review of the KELA.AE prototype was positive overall, and patients reported a willingness to use the app. Healthcare practitioners considered the app accurate, simple, and culturally sensitive but expressed concerns about app misuse and the replacement of healthcare practitioners.

Conclusions

The KELA.AE app was found to be satisfactory and supportive of the participants' needs. Changes were made to the app as suggested during the interviews.

Identifying Frameworks for Validation and Monitoring of Consensual Behavioral Intervention Technologies: Narrative Review

BACKGROUND

Changing health behaviors, such as smoking, unhealthy eating, inactivity, and alcohol abuse, may have a greater impact on population health than any curative strategy. One of the suggested strategies is the use of behavioral intervention technologies (BITs). They open up new opportunities in the area of prevention and therapy and have begun to show benefits in the durable change of health behaviors in patients or those at risk. A consensual and international paradigm was adopted by health authorities for drugs 50 years ago. It guides their development from research units to their authorization and surveillance. BITs' generalization brings into question their upstream evaluation before being placed on the market and their downstream monitoring once on the market; this is especially the case in view of the marketing information provided by manufacturers and the scarcity and methodological limits of scientific studies on these tools.

OBJECTIVE

This study aims to identify and categorize the frameworks for the validation and monitoring of BITs proposed in the literature.

METHODS

We conducted a narrative literature review using MEDLINE, PsycINFO, and Web of Science. The review items included the following: name, publication year, name of the creator (ie, first author), country, funding organization, health focus, target group, and design (ie, linear, iterative, evolutive, and/or concurrent). The frameworks were then categorized based on (1) translational research thanks to a continuum of steps and (2) the three paradigms that may have inspired the frameworks: biomedical, engineering, and/or behavioral.

RESULTS

We identified 46 frameworks besides the classic US Food and Drug Administration (FDA) five-phase drug development model. A total of 57% (26/46) of frameworks were created in the 2010s and 61% (28/46) involved the final user in an early and systematic way. A total of 4% (2/46) of frameworks had a linear-only sequence of their phases, 37% (17/46) had a linear and iterative structure, 33% (15/46) added an evolutive structure, and 24% (11/46) were associated with a parallel process. Only 12 out of 46 (26%) frameworks covered the continuum of steps and 12 (26%) relied on the three paradigms.

CONCLUSIONS

To date, 46 frameworks of BIT validation and surveillance coexist, besides the classic FDA five-phase drug development model, without the predominance of one of them or convergence in a consensual model. Their number has increased exponentially in the last three decades. Three dangerous scenarios are possible: (1) anarchic continuous development of BITs that depend on companies amalgamating health benefits and usability (ie, user experience, data security, and ergonomics) and limiting implementation to several countries; (2) the movement toward the type of framework for drug evaluation centered on establishing its effectiveness before marketing authorization to guarantee its safety for users, which is heavy and costly; and (3) the implementation of a framework reliant on big data analysis based on a posteriori research and an autoregulation of a market, but that does not address the safety risk for the health user, as the market will not regulate safety or efficacy issues. This paper recommends convergence toward an international validation and surveillance framework based on the specificities of BITs, not equivalent to medical devices, to guarantee their effectiveness and safety for users.

Attending to design when developing complex health interventions: A qualitative interview study with intervention developers and associated stakeholders

BACKGROUND

Guidance and frameworks exist to assist those developing health interventions but may offer limited discussion of 'design', the part of development concerned with generating ideas for and making decisions about an intervention's content, format and delivery. The aim of this paper is to describe and understand the views and experiences of developers and associated stakeholders in relation to how design occurs in health intervention development.

METHODS

Semi-structured interviews were conducted with 21 people who had developed complex interventions to improve health and/or who were relevant stakeholders (e.g. funders and publishers of intervention development work), regarding their views, experiences and approaches to intervention design. Sampling was purposive in terms of maximising diversity. A thematic inductive analysis was conducted.

RESULTS

Approaches to design varied substantially between intervention developers. This contrasted with consistency in other activities undertaken during development, such as literature review. Design also posed more challenges than other parts of development. We identified six 'modes' of design: informed; negotiated; structured; delegated; 'my baby'; and creative partnership. In understanding the differences between these different modes, and the challenges posed by intervention design, we identified three key themes: enabling creativity during the design process; working with different types of knowledge; and 'stabilising' (developing clear shared understandings of) the intervention development to enable design.

CONCLUSIONS

Design has received less attention than other activities undertaken when developing interventions to improve health. Developers take a variety of approaches to design and often find it challenging. Guidance for intervention development in health has tended to see design as proceeding in a predictable and controlled manner from acquired knowledge. Our study suggests that design rarely reflects this rational ideal. Future guidance on intervention development in healthcare should support developers to work effectively with different types of knowledge, to help design progress more smoothly and to maximise creativity.

An approach to revising mHealth interventions for children and families: A case example in sickle cell disease

Frameworks for developing mHealth interventions that are informed by the end-user and improve accessibility are necessary to ensure interventions meet the needs of the intended population and advance the science of health behavior change. The approach described in this paper addresses a gap in the mHealth development literature by describing a step-by-step method for evaluating and revising the mHealth interventions for health behavior change in child-parent dyads. Furthermore, this approach introduces the Website Analysis and MeasureMent Inventory framework as an initial coding structure for analyzing qualitative data to gauge appeal and enhance engagement of intervention for end-users. This method uses specific considerations for child-parent dyads and details an example in the development and refinement of a mobile application for self-management in children with sickle cell disease. This approach is translatable to populations of children with other chronic conditions and to other health behaviors.

Web-Based Prescription Opioid Abuse Prevention for Adolescents: Program Development and Formative Evaluation

Background

The unprecedented number of youths engaged in nonmedical use of prescription opioids (POs), as well as the myriad negative consequences of such misuse, emphasizes the importance of prevention efforts targeting this public health crisis. Although there are several science-based, interactive drug abuse prevention programs focused on preventing the use of nonprescription drugs in youths, to our knowledge, there are no science-based interactive programs that focus on the prevention of PO abuse among adolescents.

Objective

The aim of this study was to develop and conduct a formative evaluation of a science-based interactive Web-based program focused on the prevention of PO abuse among adolescents aged 12 to 17 years (Pop4Teens). This study was conducted to prepare for a randomized controlled trial designed to evaluate the effectiveness of Pop4Teens compared with an active control website, JustThinkTwice.com (Drug Enforcement Administration), in impacting knowledge and attitudes about POs and perceptions of risk associated with the abuse of POs, as well as intentions to use and actual use of POs.

Methods

We conducted 6 focus groups with 30 youths (a mean of 5 per group: the eligibility being aged 12-19 years) along a continuum of exposure to POs (in treatment for opioid use disorder, in general treatment for other substance use disorder, prescribed an opioid, and opioid-naïve) and writing sessions with 30 youths in treatment for opioid use disorder (12-19 years) to inform the development of the Web-based prevention tool. Feasibility and acceptability of a prototype of the Web-based intervention were then assessed through individual feedback sessions with 57 youths (drawn from the same populations as the focus groups).

Results

We successfully completed the development of a Web-based PO abuse prevention program (Pop4Teens). Analyses of focus group transcripts informed the development of the program (eg, quiz content/format, script writing, and story editing). Selected writing session narratives anchored the planned scientific content by lending credibility and informing the development of compelling storylines intended to motivate the youth to engage with the program. Feedback session data indicated that the Web-based tool could be potentially useful and acceptable. In addition, feedback session participants demonstrated significant increases in their knowledge of key topics related to the prevention of PO abuse after the exposure to sections of the Web-based program.

Conclusions

The opioid crisis is predicted to get worse before it gets better. An effective response will likely require a multipronged strategy inclusive of effective evidence-based prevention programs acceptable to, and accessible by, a majority of youths.

A Two-Way Interactive Text Messaging Application for Low-Income Patients with Chronic Medical Conditions: Design-Thinking Development Approach

Background

Two-way interactive text messaging between patient and community health workers (CHWs) through mobile phone SMS (short message service) text messaging is a form of digital health that can potentially enhance patient engagement in young adults and families that have a child with chronic medical conditions such as diabetes mellitus, sickle cell disease, and asthma. These patients have complex needs, and a user-centered way can be useful for designing a tool to address their needs.

Objective

The aim of this study was to utilize the user-centered approach of design thinking to develop a two-way interactive communication SMS text messaging tool for communication between patients or caregivers and CHWs.

Methods

We applied a design thinking methodology for development of the SMS text messaging tool. We collected qualitative data from 127 patients/caregivers and 13 CHWs, health care professionals, and experts. In total, 4 iterative phases were used to design the final prototype.

Results

The design thinking process led to the final SMS text messaging tool that was transformed from a one-dimensional, template-driven prototype (phases 1 and 2) into a dynamic, interactive, and individually tailored tool (phases 3 and 4). The individualized components consider social factors that influence patients’ ability to engage such as transportation issues and appointment reminders. SMS text messaging components also include operational factors to support staff such as patient contact lists, SMS text messaging templates, and technology chat support.

Conclusions

Design thinking can develop a tool to meet the engagement needs of patients with complex health care needs and be user-friendly for health care staff.

Topical Review: Design Considerations When Creating Pediatric Mobile Health Interventions: Applying the IDEAS Framework

OBJECTIVE

To present a guiding framework from the perspective of psychologists and technologists to develop effective mobile health (mHealth) interventions for pediatric populations.

METHODS

This topical review uses the IDEAS framework as an organizational method to summarize current strategies to conceptualize, design, evaluate, and disseminate mHealth interventions.

RESULTS

Incorporating theories of behavior change and feedback from target populations are essential when developing mHealth interventions. Following user-centered approaches that fully incorporate end users into design and development stages increases the likelihood that the intervention will be acceptable. Iterative design cycles and prototyping are important steps to gather user feedback to optimize an mHealth intervention. Broad sharing of knowledge and products generated during intervention development also is recommended. Assessment of behavioral principles, intervention components, or a full intervention package should be conducted to evaluate usability and efficacy.

CONCLUSIONS

Pediatric health-care researchers and clinicians are increasingly using mHealth technology to target health behaviors and improve related outcomes. Pediatric psychologists should consider applying the design strategies outlined in the IDEAS framework to produce and disseminate mHealth interventions tailored to the specific needs of pediatric populations.

The Development of VegEze: Smartphone App to Increase Vegetable Consumption in Australian Adults

Background

Poor-quality dietary patterns are often characterized by inadequate consumption of fruits and vegetables. Changing dietary behavior is difficult, and although it is often clear what needs to change, how to enact change is more difficult. Smartphones have characteristics that may support the complexity of changing dietary behavior.

Objective

This paper describes the iterative process of developing a theory-based smartphone app called VegEze that aimed to increase vegetable consumption.

Methods

To upscale, reach target users, and create a user-friendly end product, a collaborative research-industry partnership was formed to build the app over a 20-week period. The Integrate, Design, Assess, and Share framework was used as a scientific basis to guide the development. The behavior change wheel was also used as a theoretical grounding in combination with other theory-based strategies, such as self-monitoring, social comparison, and gamification—which have all been shown to be successful in dietary change or digital health interventions. We conducted 1 consumer survey (N=1068), 1 usability testing session (N=11), and a pilot effectiveness and usability trial (N=283) to inform the design of the app.

Results

The target behavior for the app was defined as having 3 different types of vegetables at dinner. The perceived achievability of this target behavior was high; 93% of respondents (993/1068 users) felt they were likely or very likely to be able to regularly achieve the behavior. App features that users wanted included the following: recipes and meal ideas (876/1068, 82% of users), functionality to track their intake (662/1068, 62%), and information on how to prepare vegetables (545/1068, 51%). On the basis of importance of self-monitoring as a behavior change technique (BCT) and its rating by users, the vegetable tracker was a core feature of the app and was designed to be quick and simple to use. Daily feedback messages for logging intake and communicating progress were designed to be engaging and fun, using friendly, positive language and emoji icons. Daily and weekly feedback on vegetable consumption was designed to be simple, informative, and reinforce monitoring. A creative team was engaged to assist in the branding of the app to ensure it had an identity that reflected the fun and simple nature of the underlying behavior. The app included 16 BCTs, most of which were from the goals and planning subsection of the BCT taxonomy.

Conclusions

Combining a theoretical framework with an industry perspective and input resulted in an app that was developed in a timely manner while retaining its evidence-base. VegEze is an iOS app currently available in the App Store, and the overall impact of the VegEze app will be evaluated in an uncontrolled, quantitative study.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000481279; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12618000481279 (Archived by WebCite: at http://www.webcitation.org/769oG9EaA)

Taxonomy of approaches to developing interventions to improve health: a systematic methods overview

Background

Interventions need to be developed prior to the feasibility and piloting phase of a study. There are a variety of published approaches to developing interventions, programmes or innovations to improve health. Identifying different types of approach, and synthesising the range of actions taken within this endeavour, can inform future intervention development.

Methods

This study is a systematic methods overview of approaches to intervention development. Approaches were considered for inclusion if they described how to develop or adapt an intervention in a book, website or journal article published after 2007, or were cited in a primary research study reporting the development of a specific intervention published in 2015 or 2016. Approaches were read, a taxonomy of approaches was developed and the range of actions taken across different approaches were synthesised.

Results

Eight categories of approach to intervention development were identified. (1) Partnership, where people who will use the intervention participate equally with the research team in decision-making about the intervention throughout the development process. (2) Target population-centred, where the intervention is based on the views and actions of the people who will use it. (3) Evidence and theory-based, where the intervention is based on published research evidence and existing theories. (4) Implementation-based, where the intervention is developed with attention to ensuring it will be used in the real world. (5) Efficiency-based, where components of an intervention are tested using experimental designs to select components which will optimise efficiency. (6) Stepped or phased, where interventions are developed with an emphasis on following a systematic set of processes. (7) Intervention-specific, where an approach is constructed for a specific type of intervention. (8) Combination, where existing approaches to intervention development are formally combined. The actions from approaches in all eight categories were synthesised to identify 18 actions to consider when developing interventions.

Conclusions

This overview of approaches to intervention development can help researchers to understand the variety of existing approaches, and to understand the range of possible actions involved in intervention development, prior to assessing feasibility or piloting the intervention. Findings from this overview will contribute to future guidance on intervention development.

Trial registration

PROSPERO CRD42017080553.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0425-6) contains supplementary material, which is available to authorized users.

Behavioral Theory: The Missing Ingredient for Digital Health Tools to Change Behavior and Increase Adherence

Behavioral theory is an important factor for designing digital health tools for diabetes to increase adherence to treatment. Many digital health products have not incorporated this method for achieving behavior change. This oversight might explain the disappointing outcomes of many products in this class. Four theories reported to be capable of enhancing the performance of digital health tools for diabetes include (1) Integrate, Design, Assess, and Share (IDEAS); (2) the Behaviour Change Wheel; (3) the Information-Motivation-Behavioral skills (IMB) model; and (4) gamification. Well-designed digital health tools are most likely to be effective if they are deployed in a patient-centered care setting established upon principles of sound behavioral theory. Behavioral theory can increase the effectiveness of digital tools and promote a receptive environment for their use.