Persuasive technology for health and wellness: State-of-the-art and emerging trends

The Role of Relevance in Shaping Perceptions of Sleep Hygiene Games Among University Students: Mixed Methods Study

BACKGROUND

Sleep games are an emerging topic in the realm of serious health game research. However, designing features that are both enjoyable and effective at engaging users, particularly university students, to develop healthy sleep habits remains a challenge.

OBJECTIVE

This study aims to investigate user preferences for 3 sleep game prototypes, that is, Hero's Sleep Journey, Sleep Tamagotchi, and Sleepland, and to explore their popularity and perceived utility in promoting sleep health.

METHODS

A mixed methods approach was used in this study. Quantitative and qualitative data were collected through a co-design workshop involving 47 university students. Participants were presented with storyboard cards of game features and were asked to provide an overall rating on each game, as well as ratings for individual features. They were also encouraged to provide free-form comments on the features and suggest improvements. In addition, participants were asked to express their preferences among the 3 games regarding which game they would most like to play and which one they found most useful for promoting sleep health.

RESULTS

Surprisingly, while Hero's Sleep Journey was the most popular choice among participants, Sleep Tamagotchi was perceived as the most beneficial for improving sleep health. Relevance emerged as an overarching theme in the qualitative data analysis, with 3 interconnected dimensions: psychological relevance to users' personal lives, logical relevance to sleep health, and situational relevance to users' circumstantial context. We discussed how the 3 dimensions of relevance address the autonomy and relatedness constructs outlined in the self-determination theory and proposed 3 design recommendations.

CONCLUSIONS

Our serious sleep game prototypes demonstrated the potential to engage university students to develop healthy sleep hygiene. Future sleep game designs should aim to create a sense of relevance to users' personal lives, sleep health goals, and situational contexts. Rather than a one-size-fits-all approach, it is essential to develop a wide range of game genres and features to cater to diverse users. Aligning game features with sleep health goals and educating users on the design rationale through sleep knowledge are also important aspects. Furthermore, allowing users to customize their game experience and manage technology boundaries is necessary to nurture a sense of control and autonomy in the process of forming good sleep hygiene.

Can technology be good for health? Investigating health-promoting strategies in the private sector

Introduction

This research investigates what might motivate tech companies and impact-driven investors to adopt a health-promoting strategy in their product development and capital allocation strategies.

Methods

Participants were recruited for semi-structured interviews through purposive and snowball sampling. From 83 outreach attempts, thematic saturation required 19 completed interviews out of the 46 consumer technology executives and impact-focused investors who responded. Interviews were analyzed using grounded theory-based content analysis.

Results

Seven coding categories resulted from inductive coding, with 83 sub-codes. The primary themes were: product-based health impact is magnified when matched to user demographics (making an equity mindset important); stakeholders are eager for reliable health metrics, especially those that hold across industry verticals; when capturing health impact, it is critical to include positive (i.e., economically beneficial) externalities. These results allowed for the creation of a logic model with a recommended theory of change for the private sector to develop health strategy.

Discussion

Intentional integration of impact strategy with business priorities will allow teams to design products that promote health, driving buy-in and resource allocation while attracting investment and double returns. For policymakers, it is clear that tech policy and regulation for corporate reporting need to keep pace. These findings are limited by the purposive recruitment of participants, introducing potential bias and risk to generalizability.

Engagement analysis of a persuasive-design-optimized eHealth intervention through machine learning

The challenge of sustaining user engagement in eHealth interventions is a pressing issue with significant implications for the effectiveness of these digital health tools. This study investigates user engagement in a cognitive-behavioral therapy-based eHealth intervention for procrastination, using a dataset from a randomized controlled trial of 233 university students. Various machine learning models, including Decision Tree, Gradient Boosting, Logistic Regression, Random Forest, and Support Vector Machines, were employed to predict patterns of user engagement. The study adopted a two-phase analytical approach. In the first phase, all features of the dataset were included, revealing 'total_minutes'-the total time participants spent on the intervention and the eHealth platform-as the most significant predictor of engagement. This finding emphasizes the intuitive notion that early time spent on the platform and the intervention is a strong indicator of later user engagement. However, to gain a deeper understanding of engagement beyond this predominant metric, the second phase of the analysis excluded 'total_minutes'. This approach allowed for the exploration of the roles and interdependencies of other engagement indicators, such as 'number_intervention_answersheets'-the number of completed lessons, 'logins_first_4_weeks'-login frequency, and 'number_diary_answersheets'-the number of completed diaries. The results from this phase highlighted the multifaceted nature of engagement, showing that while 'total_minutes' is strongly correlated with engagement, indicating that more engaged participants tend to spend more time on the intervention, the comprehensive engagement profile also depends on additional aspects like lesson completions and frequency of platform interactions.

Design and rationale of the Engage-HF study: the impact of a gamified engagement toolkit on participation and engagement in a heart failure registry

Aims

Heart failure (HF) registries provide valuable insights into patient management and quality of care. However, healthcare professionals face challenges due to the administrative burden of participation in registries. This study aims to evaluate the impact of education through an engagement toolkit on HF nurse practitioners' participation rate and data completeness in a national registry: the Netherlands Heart Registration-Heart Failure (NHR-HF) registry.

Methods and results

Engage-HF is an observational study (intervention at the HF nurse level) with a pretest-posttest design within the participating hospitals. Between December 2022 and April 2024, 28 HF nurse practitioners from 12 hospitals will participate in a 24-week educational programme using the Engage-HF engagement toolkit. The main interaction platform in this toolkit is a gamified smartphone-based educational application called BrightBirds. The complete toolkit includes this educational application with weekly challenges, interactive posters, pop-ups, and alert messages, and a follow-up call at Week 4. The primary endpoints are the NHR-HF participation rates and data completeness at 1 and 6 months after using the toolkit. Additionally, we will analyse the experience of participants with the toolkit concerning their HF registry and knowledge of ESC 2021 HF guidelines.

Conclusion

The Engage-HF study is the first to explore the impact of education through a gamified engagement toolkit to boost participation rates in a HF registry (NHR-HF) and test participant knowledge of the ESC 2021 HF guidelines. This innovative approach addresses challenges in the rollout of healthcare registries and the implementation of guidelines by providing a contemporary support base and a time-efficient method for education.

Rethinking Health Recommender Systems for Active Aging: An Autonomy-Based Ethical Analysis

Health Recommender Systems are promising Articial-Intelligence-based tools endowing healthy lifestyles and therapy adherence in healthcare and medicine. Among the most supported areas, it is worth mentioning active aging. However, current HRS supporting AA raise ethical challenges that still need to be properly formalized and explored. This study proposes to rethink HRS for AA through an autonomy-based ethical analysis. In particular, a brief overview of the HRS' technical aspects allows us to shed light on the ethical risks and challenges they might raise on individuals' well-being as they age. Moreover, the study proposes a categorization, understanding, and possible preventive/mitigation actions for the elicited risks and challenges through rethinking the AI ethics core principle of autonomy. Finally, elaborating on autonomy-related ethical theories, the paper proposes an autonomy-based ethical framework and how it can foster the development of autonomy-enabling HRS for AA.

Investigating mobile persuasive design for mental wellness: A cross-domain analysis

BACKGROUND

Global mental health issues have increased the demand for digital mental health support. Mobile apps with persuasive technology play a vital role in enhancing mental well-being.

OBJECTIVE

Analysing and Comparing persuasive intervention design across various app categories, this study aims to inspire innovative design approaches for improving the persuasiveness of mental wellness apps during their development.

METHODS

We retrieved a total of 100 mobile apps from five distinct categories (20 for each): Mental wellness, Social media, Entertainment, Fitness & Physical health and News & Information from Apple Store and Google Play. Two researchers examined and coded the apps to identify the persuasive features employed within each category using the Persuasive Systems Design (PSD) Framework, while a third researcher participated in discussions to resolve discrepancies. Kendall's Rank Correlation Coefficient was performed to determine the relationship between persuasive features and effectiveness.

RESULTS

Trustworthiness (n = 81), Liking (n = 78), Surface credibility (n = 71), Reminders (n = 63), and Reduction (n = 57) were the most widely implemented persuasive features. Dialogue support and system credibility support features were heavily used across different app types, while social support features were less commonly employed, particularly in mental health apps. A positive correlation was found between Surface credibility, Trustworthiness, Liking, Reminders, Self-monitoring, Expertise features and apps' effectiveness.

CONCLUSION

Through a cross-domain analysis using the PSD framework to investigate persuasive feature implementations, the findings from this study offer design suggestions to create innovative and effective mobile apps promoting mental well-being.

Effective management of sedentary behavior among Indian university students: An empirical exploration into health-related behavior

BACKGROUND

The past few years have witnessed a notable rise in sedentary tendencies, unveiling a modern era of prolonged stillness and diminished physical engagement. This study sought to assess the feasibility of a digital health intervention (DHI) to reduce overall sedentary behavior among university students. The study also identifies distinct subgroups within Indian universities that exhibit a heightened propensity for engaging in unhealthy behaviors.

MATERIALS AND METHODS

The research design used was a quasi-experimental (pre-post) design. A total of 500 participants were selected using a simple randomized sampling method (250 belonging to the control group and 250 belonging to the experimental group). These participants actively engaged in the study for 2 weeks. The participants completed the Sedentary Behavior Questionnaire (SBQ) before the intervention to evaluate their level of sedentary behavior. To evaluate the impact of the intervention on subjectively measured sedentary behavior, statistical analyses were conducted using the paired-samples t-test and analysis of covariance (ANCOVA) with the post hoc Bonferroni test.

RESULTS

The findings demonstrated a significant t-value of sedentary behavior for the entire group, with t(249) = 4.88, P < .05. Furthermore, the F-value of 28.787 indicated a statistically significant difference in the sedentary behavior between the experimental and control groups. When considering female university students specifically, the t-value for sedentary behavior was significant at t(105) = 3.22, P < .05, and for male university students, the t-value for sedentary behavior was found to be significant at t(143) = 3.69, P < .05.

CONCLUSION

Smartphone-based health interventions targeting sedentary behavior reduction demonstrated promising outcomes in facilitating health behavior change among university students.

Benefits, Recruitment, Dropout, and Acceptability of the Strength Back Digital Health Intervention for Patients Undergoing Spinal Surgery: Nonrandomized, Qualitative, and Quantitative Pilot Feasibility Study

BACKGROUND

Patients undergoing spinal surgery report high levels of insecurity, pain, stress, and anxiety before and after surgery. Unfortunately, there is no guarantee that surgery will resolve all issues; postsurgical recovery often entails moderate to severe postoperative pain, and some patients undergoing spinal surgery do not experience (long-term) pain relief after surgery. Therefore, focusing on sustainable coping skills and resilience is crucial for these patients. A digital health intervention based on acceptance and commitment therapy (ACT) and positive psychology (PP) was developed to enhance psychological flexibility and well-being and reduce postsurgical pain.

OBJECTIVE

The objective of this study was 3-fold: to explore the potential benefits for patients undergoing spinal surgery of the digital ACT and PP intervention Strength Back (research question [RQ] 1), explore the feasibility of a future randomized controlled trial in terms of recruitment and dropout (RQ 2), and assess the acceptability of Strength Back by patients undergoing spinal surgery (RQ 3).

METHODS

We used a nonrandomized experimental design with an intervention group (n=17) and a control group (n=20). To explore the potential benefits of the intervention, participants in both groups filled out questionnaires before and after surgery. These questionnaires included measurements of pain intensity (Numeric Pain Rating Scale), pain interference (Multidimensional Pain Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), valued living (Engaged Living Scale), psychological flexibility (Psychological Inflexibility in Pain Scale), and mental well-being (Mental Health Continuum-Short Form). Semistructured interviews combined with log data and scores on the Twente Engagement With eHealth Technologies Scale were used to assess the acceptability of the intervention.

RESULTS

A significant improvement over time in emotional (V=99; P=.03) and overall (V=55; P=.004) well-being (Mental Health Continuum-Short Form) was observed only in the intervention group. In addition, the intervention group showed a significantly larger decline in pain intensity (Numeric Pain Rating Scale) than did the control group (U=75; P=.003). Of the available weekly modules on average 80% (12/15) was completed by patients undergoing spinal fusion and 67% (6/9) was completed by patients undergoing decompression surgery. A total of 68% (17/25) of the participants used the intervention until the final interview. Most participants (15/17, 88%) in the intervention group would recommend the intervention to future patients.

CONCLUSIONS

This pilot feasibility study showed that combining ACT and PP in a digital health intervention is promising for patients undergoing spinal surgery as the content was accepted by most of the participants and (larger) improvements in pain intensity and well-being were observed in the intervention group. A digital intervention for patients undergoing (spinal) surgery can use teachable moments, when patients are open to learning more about the surgery and rehabilitation afterward. A larger randomized controlled trial is now warranted.

A panoramic view of personalization based on individual differences in persuasive and behavior change interventions

Persuasive technologies are designed to change human behavior or attitude using various persuasive strategies. Recent years have witnessed increasing evidence of the need to personalize and adapt persuasive interventions to various users and contextual factors because a persuasive strategy that works for one individual may rather demotivate others. As a result, several research studies have been conducted to investigate how to effectively personalize persuasive technologies. As research in this direction is gaining increasing attention, it becomes essential to conduct a systematic review to provide an overview of the current trends, challenges, approaches used for developing personalized persuasive technologies, and opportunities for future research in the area. To fill this need, we investigate approaches to personalize persuasive interventions by understanding user-related factors considered when personalizing persuasive technologies. Particularly, we conducted a systematic review of 72 research published in the last ten years in personalized and adaptive persuasive systems. The reviewed papers were evaluated based on different aspects, including metadata (e.g., year of publication and venue), technology, personalization dimension, personalization approaches, target outcome, individual differences, theories and scales, and evaluation approaches. Our results show (1) increased attention toward personalizing persuasive interventions, (2) personality trait is the most popular dimension of individual differences considered by existing research when tailoring their persuasive and behavior change systems, (3) students are among the most commonly targeted audience, and (4) education, health, and physical activity are the most considered domains in the surveyed papers. Based on our results, the paper provides insights and prospective future research directions.

StudiCare procrastination - Randomized controlled non-inferiority trial of a persuasive design-optimized internet- and mobile-based intervention with digital coach targeting procrastination in college students

BACKGROUND

Academic procrastination is widespread among college students. Procrastination is strongly negatively correlated with psychological well-being, thus early interventions are needed. Internet- and mobile-based cognitive behavioral therapy (iCBT) could provide a low-threshold treatment option. Human guidance seems to be a decisive mechanism of change in iCBT. Persuasive design optimization of iCBT and guidance by a digital coach might represent a resource-saving alternative. The study evaluated the non-inferiority of a digital coach in comparison to human guidance with regard to the primary outcome procrastination.

METHODS

The iCBT StudiCare procrastination was optimized by principles of the Persuasive System Design (PSD). A total of 233 college students were randomly assigned to either StudiCare procrastination guided by a digital coach (intervention group, IG) or by a human eCoach (control group, CG). All participants were assessed at baseline, 4-, 8- and 12-weeks post-randomization. Symptom change and between-group differences were assessed with latent growth curve models and supported by effect size levels. The non-inferiority margin was set at Cohen's d = - 0.3.

RESULTS

The primary outcome procrastination measured by the Irrational Procrastination scale (IPS) significantly decreased across groups (γ = - 0.79, p < .001, Cohen's d = -0.43 to -0.89) from baseline to 12-weeks post-randomization. There were no significant differences between groups (γ = -0.03, p = .84, Cohen's d = -0.03 to 0.08). Regarding symptoms of depression, no significant time x group effect was found (γ = 0.26, p = .09; Cohen's d = -0.15 to 0.21). There was also no significant time x group effect on the improvement of symptoms of anxiety (γ = 0.25, p = .09). However, Cohen's ds were above the non-inferiority margin 8-weeks (Cohen's d = 0.51) and 12-weeks post-randomization (Cohen's d = 0.37), preferring the CG. Of the IG, 34% and of the CG, 36% completed 80% of the modules.

CONCLUSIONS

The PSD optimized version of StudiCare procrastination is effective in reducing procrastination. The digital coach was not inferior to human guidance. Guidance by a digital coach in iCBT against procrastination for college students could be a resource-saving alternative to human guidance.

TRIAL REGISTRATION

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trial Register (ID: DRKS00025209, 30/04/2021).

An emerging framework for digital mental health design with Indigenous young people: a scoping review of the involvement of Indigenous young people in the design and evaluation of digital mental health interventions

BACKGROUND

Indigenous young people worldwide possess unique protective factors that support wellbeing. However, they experience mental illness at higher rates than their non-indigenous counterparts. Digital mental health (dMH) resources can increase access to structured, timely, and culturally tailored mental health interventions by reducing structural and attitudinal barriers to accessing treatment. The involvement of Indigenous young people in dMH resource development is recommended, however, no guidelines exist on how this can best be facilitated.

METHODS

A scoping review examining processes to involve Indigenous young people in developing or evaluating dMH interventions was conducted. Studies reported between 1990 and 2023 involving Indigenous young people aged 12-24 years, originating from Canada, the USA, New Zealand, and Australia, in the development or evaluation of dMH interventions were eligible for inclusion. Following a three-step search process, four electronic databases were searched. Data were extracted, synthesized, and described under three categories: dMH intervention attributes, study design, and alignment with research best practice. Best practice recommendations for Indigenous research and participatory design principles derived from the literature were identified and synthesised. Included studies were assessed against these recommendations. Consultation with two Senior Indigenous Research Officers ensured Indigenous worldviews informed analysis.

RESULTS

Twenty-four studies describing eleven dMH interventions met inclusion criteria. Studies included formative, design, pilot, and efficacy studies. Overall, most included studies demonstrated a high degree of Indigenous governance, capacity building, and community benefit. All studies adapted their research processes to ensure that local community protocols were followed and most aligned these within an Indigenous research paradigm. Formal agreements regarding existing and created intellectual property and implementation evaluations were rare. Outcomes were the primary focus of reporting, with limited detailed descriptions of governance and decision-making processes or strategies for managing predictable tensions between co-design stakeholders.

CONCLUSIONS

This study identified recommendations for undertaking participatory design with Indigenous young people and evaluated the current literature against these criteria. Common gaps were evident in the reporting of study processes. Consistent, in-depth reporting is needed to allow assessment of approaches for this hard-to-reach population. An emergent framework, informed by our findings, for guiding the involvement of Indigenous young people in the design and evaluation of dMH tools is presented.

TRIAL REGISTRATION

Available via osf.io/2nkc6.

Exploring the Use of the Behavior Change Technique Taxonomy and the Persuasive System Design Model in Defining Parent-Focused eHealth Interventions: Scoping Review

BACKGROUND

Taxonomies and models are useful tools for defining eHealth content and intervention features, enabling comparison and analysis of research across studies and disciplines. The Behavior Change Technique Taxonomy version 1 (BCTTv1) was developed to decrease ambiguity in defining specific characteristics inherent in health interventions, but it was developed outside the context of digital technology. In contrast, the Persuasive System Design Model (PSDM) was developed to define and evaluate the persuasive content in software solutions but did not have a specific focus on health. Both the BCTTv1 and PSDM have been used to define eHealth interventions in the literature, with some researchers combining or reducing the taxonomies to simplify their application. It is unclear how well the taxonomies accurately define eHealth and whether they should be used alone or in combination.

OBJECTIVE

This scoping review explored how the BCTTv1 and PSDM capture the content and intervention features of parent-focused eHealth as part of a program of studies investigating the use of technology to support parents with therapy home programs for children with special health care needs. It explored the active ingredients and persuasive technology features commonly found in parent-focused eHealth interventions for children with special health care needs and how the descriptions overlap and interact with respect to the BCTTv1 and PSDM taxonomies.

METHODS

A scoping review was used to clarify concepts in the literature related to these taxonomies. Keywords related to parent-focused eHealth were defined and used to systematically search several electronic databases for parent-focused eHealth publications. Publications referencing the same intervention were combined to provide comprehensive intervention details. The data set was coded using codebooks developed from the taxonomies in NVivo (version 12; QSR International) and qualitatively analyzed using matrix queries.

RESULTS

The systematic search found 23 parent-focused eHealth interventions described in 42 articles from various countries; delivered to parents with children aged 1 to 18 years; and covering medical, behavioral, and developmental issues. The predominant active ingredients and intervention features in parent-focused eHealth were concerned with teaching parents behavioral skills, encouraging them to practice and monitor the new skills, and tracking the outcomes of performing the new skills. No category had a complete set of active ingredients or intervention features coded. The two taxonomies conceptually captured different constructs even when their labels appeared to overlap in meaning. In addition, coding by category missed important active ingredients and intervention features.

CONCLUSIONS

The taxonomies were found to code different constructs related to behavior change and persuasive technology, discouraging the merging or reduction of the taxonomies. This scoping review highlighted the benefit of using both taxonomies in their entirety to capture active ingredients and intervention features important for comparing and analyzing eHealth across different studies and disciplines.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi.org/10.15619/nzjp/47.1.05.

Integration of nurse-led virtual reviews with growth hormone device-linked patient adherence information: a mixed methods feasibility study

Introduction

Easypod-connect™ for childhood growth disorders is a unique connected system that enables transmission of injection adherence information for recombinant human growth hormone (r-hGH). Although this system has the potential to facilitate greater adherence, observational studies have shown declining adherence over prolonged periods when used without additional support. Supplemental nurse practitioner support has been envisaged but not investigated; in this study, we have undertaken feasibility analysis of nurse-led virtual reviews (NVR) in combination with easypod-connect™ in a single centre using quantitative and qualitative analyses.

Aims

We aimed to test feasibility by assessing compliance with NVR, height standard deviation score (SDS) gain, adherence improvement and patient opinions.

Methods

Patients using easypod™ r-hGH were recruited prospectively to a 12-month study with two telephone NVR appointments in addition to standard of care in-person hospital outpatient visits. A subset was recruited for a semi-structured interview for qualitative thematic analysis.

Results

Forty-three patients of median (range) age 10.7 (6.7, 15.2) were recruited for a period of 1.1 (0.7, 1.8) years. Thirty-three (76.7%) patients were fully compliant with NVR integration with easypod-connect™, establishing feasibility. Median (inter-quartile range, IQR) height SDS improved from -1.85 (-2.44, -1.37) to -1.48 (-2.14, -1.07) (p<0.001) while adherence remained similar in the majority from study start [96.5 (88.8, 100.0)] to end [99.0 (94.0, 100.0)]. Qualitative analysis identified themes supporting patient benefit: practicalities of appointments, perceived purpose and significance of virtual reviews, and the importance of optimising growth. Four patients complained of injection pain, of whom two switched to an alternative r-hGH device.

Conclusion

Our study has demonstrated the feasibility of nurse-led virtual review integration with easypod-connect™ in a mixed methods study, laying the foundation for research in larger groups over longer periods. Nurse practitioner supported application of easypod-connect™ offers the potential for improved growth outcomes in all r-hGH devices providing adherence information.

DiaFocus: A Personal Health Technology for Adaptive Assessment in Long-Term Management of Type 2 Diabetes

Type 2 diabetes (T2D) is a large disease burden worldwide and represents an increasing and complex challenge for all societies. For the individual, T2D is a complex, multi-dimensional, and long-term challenge to manage, and it is challenging to establish and maintain good communication between the patient and healthcare professionals. This article presents DiaFocus, which is a mobile health sensing application for long-term ambulatory management of T2D. DiaFocus supports an adaptive collection of physiological, behavioral, and contextual data in combination with ecological assessments of psycho-social factors. This data is used for improving patient-clinician communication during consultations. DiaFocus is built using a generic data collection framework for mobile and wearable sensing and is highly extensible and customizable. We deployed DiaFocus in a 6-week feasibility study involving 12 patients with T2D. The patients found the DiaFocus approach and system useful and usable for diabetes management. Most patients would use such a system, if available as part of their treatment. Analysis of the collected data shows that mobile sensing is feasible for longitudinal ambulatory assessment of T2D, and helped identify the most appropriate target users being early diagnosed and technically literate T2D patients.

Predictors of genetic risk recall among the participants of a randomized controlled precision prevention trial against melanoma

PURPOSE

Inherited variation in MC1R imparts low to moderate risk of melanoma. Research on genetic risk recall, factors predicting recall, and whether recall influences adoption of preventive behaviors is limited.

METHODS

Participants (n = 447) enrolled in a melanoma precision prevention trial were provided with MC1R risk information (average or higher) and after 6 and 12 months, were asked to recall their genetic risk. Predictors of recall were identified using backward stepwise selection. Intervention effects were reassessed after stratifying by recall.

RESULTS

Participants at higher risk were 2 to 3 times more likely to misremember or not recall than participants with average risk. Misremembering was almost exclusively observed among participants at higher risk. Among the participants with average risk, lower health numeracy and not completing the telephone follow-up were associated with not recalling or misremembering. Among the participants at higher risk, lower education was associated with not recalling and lower perceived comparative chance of developing melanoma was associated with misremembering. In general, participants at higher risk who correctly recalled had modestly stronger intervention effects on sun protection behaviors than those who misremembered or did not recall.

CONCLUSION

Future studies should examine different strategies to increase genetic risk recall, which may result in improved behavioral outcomes, especially among participants with lower education and health numeracy.

Fact or Fiction? The Development and Evaluation of a Tobacco Virtual Health Tool

The virtual setting is an important setting for health promotion as individuals increasingly go online for health information and support. Yet, users can have difficulty finding valid, trustworthy, and user-friendly health information online. In 2022, we launched an interactive Fact or Fiction Tobacco virtual health tool. The virtual health tool uses evidence-informed tailored content to engage users and refer them to local tobacco cessation resources. The present paper describes the development, user testing, and evaluation of this tool. The Fact or Fiction virtual health tool was designed by tobacco cessation and health marketing experts and informed by health behaviour theories of change. The tool captures data on who is seeking health information, the user's stage of readiness to quit tobacco products, and whether they act by accessing referred resources. In 2021, we conducted two phases of user testing prior to marketing the tool publicly. After 7 weeks of marketing, we collected data on user interactions with the tool and evaluated the reach of the tool. Results from user testing found the tool to be engaging, easy to use, and quick to complete. Adaptations were made to simplify and condense text and include additional animations. During the first seven weeks of the tool being live, it reached 2306 users, and 38.7% of those users were current or occasional tobacco users. Users were classified based on their intention to quit. Bivariate analysis found that the tool was successful in driving tobacco users towards action as 21.2% tobacco users who were looking to quit and 8.8% of tobacco users who were not looking to quit clicked on local tobacco cessation resources. This virtual health tool is reaching the targeted population and providing tailored information needed at each stage of the continuum of health behaviour change. Among tobacco users looking to quit, this virtual health tool acts as a quick referral to local tobacco cessation resources.

The influence of health information attention and app usage frequency of older adults on persuasive strategies in mHealth education apps

With the development of mobile communication technology, persuasive technology is widely used in mobile health. Using personalized persuasive strategies in mobile health education (MHE) apps can effectively improve users’ health literacy and health behaviors. The transtheoretical model explains the process of user behavior change. Different usage frequency of the app reflects changes in user behavior. However, few studies have examined how the perceived importance of persuasive strategies among older adults changes with increasing use frequency. In this study, we analyzed the sensitivity of 111 older adults in China to persuasive strategies in MHE apps. Thirteen persuasive strategies were selected for this study. A repeated measure analysis of variance (RM-ANOVA) was used to demonstrate the influence of gender, health information attention and frequency of use on the sensitivity of perceived persuasive strategies among older adults. The results revealed older adults with a high usage frequency of health apps were more receptive to persuasive strategies, especially in social comparison strategy. This result may help developers consider factors such as the frequency of use by older users when designing personalized persuasive strategies for MHE apps.

The behaviour change behind a successful pilot of hypoglycaemia reduction with HYPO-CHEAT

Background

Children with hypoglycaemia disorders, such as congenital hyperinsulinism (CHI), are at constant risk of hypoglycaemia (low blood sugars) with the attendant risk of brain injury. Current approaches to hypoglycaemia detection and prevention vary from fingerprick glucose testing to the provision of continuous glucose monitoring (CGM) to machine learning (ML) driven glucose forecasting. Recent trends for ML have had limited success in preventing free-living hypoglycaemia, due to a focus on increasingly accurate glucose forecasts and a failure to acknowledge the human in the loop and the essential step of changing behaviour. The wealth of evidence from the fields of behaviour change and persuasive technology (PT) allows for the creation of a theory-informed and technologically considered approach.

Objectives

We aimed to create a PT that would overcome the identified barriers to hypoglycaemia prevention for those with CHI to focus on proactive prevention rather than commonly used reactive approaches.

Methods

We used the behaviour change technique taxonomy and persuasive systems design models to create HYPO-CHEAT (HYpoglycaemia-Prevention-thrOugh-Cgm-HEatmap-Assisted-Technology): a novel approach that presents aggregated CGM data in simple visualisations. The resultant ease of data interpretation is intended to facilitate behaviour change and subsequently reduce hypoglycaemia.

Results

HYPO-CHEAT was piloted in 10 patients with CHI over 12 weeks and successfully identified weekly patterns of hypoglycaemia. These patterns consistently correlated with identifiable behaviours and were translated into both a change in proximal fingerprick behaviour and ultimately, a significant reduction in aggregated hypoglycaemia from 7.1% to 5.4% with four out of five patients showing clinically meaningful reductions in hypoglycaemia.

Conclusions

We have provided pilot data of a new approach to hypoglycaemia prevention that focuses on proactive prevention and behaviour change. This approach is personalised for individual patients with CHI and is a first step in changing our approach to hypoglycaemia prevention in this group.

Design, development, utility and usability testing of the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians and patients with metabolic syndrome

Objective

This study aimed to design, develop, assess and refine the EMPOWER-SUSTAIN Self-Management Mobile App© among primary care physicians (PCP) and patients with metabolic syndrome (MetS) in primary care.

Methodology

Using the software-development-life-cycle (SDLC) iterative model, storyboard and wireframe were drafted; and a mock prototype was designed to illustrate the content and function graphically. Subsequently, a working prototype was developed. Qualitative studies using the 'think-aloud' and cognitive-task-analysis methods were conducted for the utility and usability testing. Topic guide was based on the 10-Nielsen's-Heuristic-Principles. Utility testing was conducted among PCP in which they 'thought-aloud' while performing tasks using the mobile app. Usability testing was conducted among MetS patients after they were given the app for 3 weeks. They 'thought-aloud' while performing tasks using the app. Interviews were audio- and video-recorded, and transcribed verbatim. Thematic content analysis was performed.

Result

Seven PCP and nine patients participated in the utility and usability testing, respectively. Six themes (efficiency of use, user control and freedom, appearance and aesthetic features, clinical content, error prevention, and help and documentation) emerged. PCP found the mobile app attractive and relevant sections were easy to find. They suggested adding 'zoom/swipe' functions and some parts needed bigger fonts. Patients commented that the app was user-friendly, has nice interface, and straightforward language. It helped them understand their health better. Based on these findings, the mobile app was refined.

Conclusion

This app was produced using a robust SDLC method to increase users' satisfaction and sustainability of its use. It could potentially improve self-management behaviour among MetS patients in primary care.

The Intersection of Persuasive System Design and Personalization in Mobile Health: Statistical Evaluation

Background

Persuasive technology is an umbrella term that encompasses software (eg, mobile apps) or hardware (eg, smartwatches) designed to influence users to perform preferable behavior once or on a long-term basis. Considering the ubiquitous nature of mobile devices across all socioeconomic groups, user behavior modification thrives under the personalized care that persuasive technology can offer. However, there is no guidance for developing personalized persuasive technologies based on the psychological characteristics of users.

Objective

This study examined the role that psychological characteristics play in interpreted mobile health (mHealth) screen perceived persuasiveness. In addition, this study aims to explore how users’ psychological characteristics drive the perceived persuasiveness of digital health technologies in an effort to assist developers and researchers of digital health technologies by creating more engaging solutions.

Methods

An experiment was designed to evaluate how psychological characteristics (self-efficacy, health consciousness, health motivation, and the Big Five personality traits) affect the perceived persuasiveness of digital health technologies, using the persuasive system design framework. Participants (n=262) were recruited by Qualtrics International, Inc, using the web-based survey system of the XM Research Service. This experiment involved a survey-based design with a series of 25 mHealth app screens that featured the use of persuasive principles, with a focus on physical activity. Exploratory factor analysis and linear regression were used to evaluate the multifaceted needs of digital health users based on their psychological characteristics.

Results

The results imply that an individual user’s psychological characteristics (self-efficacy, health consciousness, health motivation, and extraversion) affect interpreted mHealth screen perceived persuasiveness, and combinations of persuasive principles and psychological characteristics lead to greater perceived persuasiveness. The F test (ie, ANOVA) for model 1 was significant (F9,6540=191.806; P<.001), with an adjusted R2 of 0.208, indicating that the demographic variables explained 20.8% of the variance in perceived persuasiveness. Gender was a significant predictor, with women having higher perceived persuasiveness (P=.008) relative to men. Age was a significant predictor of perceived persuasiveness with individuals aged 40 to 59 years (P<.001) and ≥60 years (P<.001). Model 2 was significant (F13,6536=341.035; P<.001), with an adjusted R2 of 0.403, indicating that the demographic variables self-efficacy, health consciousness, health motivation, and extraversion together explained 40.3% of the variance in perceived persuasiveness.

Conclusions

This study evaluates the role that psychological characteristics play in interpreted mHealth screen perceived persuasiveness. Findings indicate that self-efficacy, health consciousness, health motivation, extraversion, gender, age, and education significantly influence the perceived persuasiveness of digital health technologies. Moreover, this study showed that varying combinations of psychological characteristics and demographic variables affected the perceived persuasiveness of the primary persuasive technology category.

Uncovering the Heterogeneity in Fitness App Use: A Latent Class Analysis of Chinese Users

This study examines fitness app use patterns and their correlates among Chinese users from the perspectives of uses and gratification theory and self-determination theory. Our sample comprised 632 users of WeRun, the fitness plugin of WeChat, the largest Chinese mobile social networking app; participants completed an online survey and provided self-tracked physical activity data, which were subjected to latent class analysis. Based on the four-class latent class model (which yielded the best model fit and the most interpretable results), 30.5%, 27.5%, 24.7%, and 17.3% of the users were categorized as light users, reward-oriented users, lifestyle-oriented users, and interaction-oriented users, respectively. Moreover, class membership was associated with gender, age, education, income, life satisfaction, autonomy, and platform-based motivations. There is a significant heterogeneity in fitness app use and exercise behaviors. Platform-based motivations and autonomy are important classification factors, as users are looking for specific kinds of gratification from their use of fitness apps. Demographics and individual characteristics are also explanatory factors for class membership. The study findings suggest that fitness app designers should segment users based on motivation and gratification.

Translating Promoting Factors and Behavior Change Principles Into a Blended and Technology-Supported Intervention to Stimulate Physical Activity in Children With Asthma (Foxfit): Design Study

Background

Children with asthma can decrease the impact of their disease by improving their physical activity (PA). However, health care providers lack interventions for children with asthma that effectively increase their PA levels and achieve behavior change. A technology-supported approach can positively influence PA and physical functioning in children.

Objective

The aims of this study were to develop a technology-supported intervention that facilitates health care providers in promoting PA for children (aged 8 to 12 years) with asthma and to systematically describe this developmental process.

Methods

Intervention mapping (IM) was applied to develop a blended and technology-supported intervention in cocreation with children with asthma, their parents, and health care providers. In accordance with the IM framework, the following steps were performed: conduct a needs assessment; define the intervention outcome, performance objectives, and change objectives; select theory-based intervention methods and strategies; create components of the intervention and conduct pilot tests; create an implementation plan; and create an evaluation plan.

Results

We developed the blended intervention Foxfit that consists of an app with a PA monitor for children (aged 8 to 12 years) with asthma and a web-based dashboard for their health care provider. The intervention focuses on PA in everyday life to improve social participation. Foxfit contains components based on behavior change principles and gamification, including goal setting, rewards, action planning, monitoring, shaping knowledge, a gamified story, personal coaching and feedback, and a tailored approach. An evaluation plan was created to assess the intervention’s usability and feasibility for both children and health care providers.

Conclusions

The IM framework was very useful for systematically developing a technology-supported intervention and for describing the translational process from scientific evidence, the needs and wishes of future users, and behavior change principles into this intervention. This has led to the technology-supported intervention Foxfit that facilitates health care providers in promoting PA in children with asthma. The structured description of the development process and functional components shows the way behavior change techniques are incorporated in the intervention.

Trial Registration

International Clinical Trial Registry Platform NTR6658; https://tinyurl.com/3rxejksf

Socially-Oriented Persuasive Game to Promote Disease Awareness and Prevention

Persuasive games are widely implemented in the health domain to promote desirable behaviour change. Previous research shows that using persuasive games employing various strategies results in increased motivation and awareness that led to a positive change in behaviour. This paper investigates the efficacy of a competition-based persuasive game at creating awareness and motivating people to adhere to COVID-19 precautionary measures. To achieve this goal, we developed and evaluated a competition-based persuasive game to promote the awareness and adoption of COVID-19 precautionary measures. The results of our pretest and posttest study ( $N=67$ ) followed by a semistructured interview of 18 participants show the efficacy of the game with respect to promoting a positive change in attitude, intention, self-efficacy, knowledge, and promoting motivation and positive player experience among participants. The qualitative results provide insight into how and why persuasive games promote desirable behaviour. The paper contributes to the knowledge of how emerging technologies in the form of persuasive games can be designed and used to contribute to solving problems in our society.

Attribute Framework Validation for Wellness Tourism within the Context of Thailand

Background: Research on the theoretical integration of attributes of wellness tourism in the form of the physical, mental, spiritual, and environmental (PMSE) attribute framework and the effect of cultural differences on the framework validation has not been conducted before. Objectives: This study developed and validated the key underlying attributes of the wellness tourism experience framework within the Thailand context. Methods: From reviewing the related literature to identify potential sub attributes under the four dimensions of the PMSE framework, themes were developed using a theory- and prior research-driven method within different cultural contexts. The fitness of the PMSE attribute framework model within the context of Thailand wellness tourism was confirmed through a survey design with a quantitative approach from the generalities of the sample groups. The entire dataset was statistically tested with descriptive statistics and confirmatory factor analysis (CFA). Results and Conclusions: After adjustments, the four-factors with a 28-item model substantiated the data. The results validated that the mental experience dimension accounted for the most variance, with an indicator value of 0.99 in the framework, predicting the effective wellness tourism experience better than the other attributes. Experience design should involve the participation of all stakeholders in the wellness tourism system in terms of managerial contribution. Recommendations for the planning of wellness experiences concerning each four-factor will be investigated in future studies.

Persuasive Technology in an mHealth App Designed for Pelvic Floor Muscle Training Among Women: Systematic Review

BACKGROUND

Pelvic floor muscle training (PFMT) is one of the first-line treatments for stress urinary incontinence among pregnant women. Mobile health (mHealth) technology is potentially effective for delivering PFMT to pregnant women. Persuasive technology in the development of such mobile apps may facilitate behavior change by improving adherence to the exercises. The Capability, Opportunity, and Motivation-Behavior (COM-B) model is potentially useful in selecting the appropriate interventions to be incorporated into the apps.

OBJECTIVE

This review of mHealth apps for PFMT aims to describe the principles of persuasion used for each app and to propose mHealth app design features based on the COM-B model.

METHODS

A systematic literature search was conducted to answer three main research questions: what are the available mHealth apps for PFMT in the published literature, what persuasive strategies were used in their studies how were they mapped to the COM-B model, and how effective were the selected persuasive strategies for PFMT adherence? We searched PubMed, CINAHL, Web of Science, Scopus, and local Malaysian databases such as MyCite and MyMedR for articles reporting mHealth apps used for the delivery of PFMT. We included original articles reporting experimental and cross-sectional studies, including pilot or feasibility trials. Systematic and narrative reviews were excluded. Narrative and thematic syntheses were conducted on the eligible articles based on the research questions. The Cochrane risk of bias tool and the Risk of Bias Assessment Tool for Non-randomized Studies were used to assess study bias.

RESULTS

Of the 169 records from the initial search, 10 (5.9%) articles meeting the selection criteria were included in this review. There were 8 mHealth apps designed for the delivery of PFMT. The Tät, which used 3 categories of persuasive system design, improved PFMT adherence and was cost-effective. Only 1 app, the iBall app, used all categories of persuasive system design, by including social support such as "competition" in its design. The Diário Saúde app was the only app developed using operant conditioning. All apps incorporated Tailoring and Expertise as part of their PSD strategies. Only 3 apps, the Diário Saúde, Tät, and Pen Yi Kang demonstrated improved PFMT adherence.

CONCLUSIONS

Persuasive technology used in mobile apps may target desired behavior change more effectively. The persuasive system design can be mapped to the COM-B model to explain its effectiveness on behaviour change outcomes.

Personality-targeted persuasive gamified systems: exploring the impact of application domain on the effectiveness of behaviour change strategies

Persuasive gamified systems for health are interventions that promote behaviour change using various persuasive strategies. While research has shown that these strategies are effective at motivating behaviour change, there is little knowledge on whether and how the effectiveness of these strategies vary across multiple domains for people of distinct personality traits. To bridge this gap, we conducted a quantitative study with 568 participants to investigate (a) whether the effectiveness of the persuasive strategies implemented vary within each domain (b) whether the effectiveness of various strategies vary across two distinct domains, (c) how people belonging to different personality traits respond to these strategies, and (d) if people high in a personality trait would be influenced by a persuasive strategy within one domain and not in the other. Our results show that there are significant differences in the effectiveness of various strategies across domains and that people's personality plays a significant role in the perceived persuasiveness of different strategies both within and across distinct domains. The Reward strategy (which involves incentivizing users for achieving specific milestones towards the desired behaviour) and the Competition strategy (which involves allowing users to compete with each other to perform the desired behaviour) were effective for promoting healthy eating but not for smoking cessation for people high in Conscientiousness. We provide design suggestions for developing persuasive gamified interventions for health targeting distinct domains and tailored to individuals depending on their personalities.

A Systematic and Comparative Review of Behavior Change Strategies in Stress Management Apps: Opportunities for Improvement

Stress is one of the significant triggers of several physiological and psychological illnesses. Mobile health apps have been used to deliver various stress management interventions and coping strategies over the years. However, little work exists on persuasive strategies employed in stress management apps to promote behavior change. To address this gap, we review 150 stress management apps on both Google Play and Apple's App Store in three stages. First, we deconstruct and compare the persuasive/behavior change strategies operationalized in the apps using the Persuasive Systems Design (PSD) framework and Cialdini's Principles of Persuasion. Our results show that the most frequently employed strategies are personalization, followed by self-monitoring, and trustworthiness, while social support strategies such as competition, cooperation and social comparison are the least employed. Second, we compare our findings within the stress management domain with those from other mental health domains to uncover further insights. Finally, we reflect on our findings and offer eight design recommendations to improve the effectiveness of stress management apps and foster future research.

Persuasive Technologies and Social Interactions in Professional Environments: Embedded Qualitative Case Study

BACKGROUND

Although previous studies have highlighted the impact of interactions on the web in the context of patient-health care professional (HCP) dyads, this paper extends that context to a triad that includes the role of employers and associated settings with social groups.

OBJECTIVE

This study aims to evaluate how the interactions between individuals and the social use of the platform affect individuals' use of persuasive technology and, in turn, their work environment actions and responses, by implementing a persuasive technology health and wellness platform in a work environment.

METHODS

For 8 months, we deployed a persuasive technology platform with different combinations of health-related features and content in 1 embedded case design with 8 fire stations for a small Canadian city (total number of participant firefighters, n=141) assigned to 1 of 2 treatments-interactive or static webpages. We used text-based content analysis techniques for outcome measures, drawn from a total of 29 participant exit interviews. In addition, medical assessments were conducted at baseline, midpoint, and end point by 7 HCPs and 1 researcher (BM), who also served as the data steward and managed the study.

RESULTS

Our results reveal that group, social, and work influences introduce new elements to the use of persuasive technology, which interact to foster higher levels of individual success. The platform in our study served as part of a larger social system, providing information that facilitated new behaviors at work and home. The 8-month group programs centered on exercise, nutrition, and smoking cessation. Groups of participants coached by certified professionals showed significant increases in sodium awareness, levels of actual exercise, and consistency of activities. As a result of the study, of 141 people, 15 (10.6%) were notified of serious medical health issues and 29 (20.6%) underwent blood work assessments and a privacy shield (protected by federal law) was enacted to protect employees from losing their employment based on any health concerns disclosed.

CONCLUSIONS

The persuasive technology platform, in combination with self-management and professional management and social interactions, significantly altered work management behaviors. Interactions among individual outcomes, group influences, and social situations strongly influenced individuals' behaviors in their work and home environments. Three things further improved the positive results that we observed: privacy shields (which allowed employees to reveal health concerns without fear of professional consequences), individual private activities aligned with group activities, and integration between HCP work with localized, organizational work roles.

Determining Priorities in the Aboriginal and Islander Mental Health Initiative for Youth App Second Phase Participatory Design Project: Qualitative Study and Narrative Literature Review

Background

Digital mental health tools can promote access to culturally safe early intervention mental health services for Aboriginal and Torres Strait Islander young people. Participatory design methodology facilitates user engagement in the co-design of digital resources. However, several challenges have been identified that limit the methodological rigor of this approach.

Objective

This paper aims to present an in-depth account of the second phase of participatory design in the development of the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app.

Methods

A first idea storyboard, generated from a formative phase of the AIMhi-Y project, was refined through a series of youth co-design workshops and meetings. A narrative review of the literature, 6 service provider interviews, and engagement with an expert reference group also informed the design process. Generative design activities, storyboarding, discussions, and voting strategies were used.

Results

The participatory design process identified the app features preferred by young people and service providers and assessed their alignment with current recommendations from the scientific literature. Findings from the co-design process are presented across 9 app characteristic domains. Integration of findings into app design proved complex. Although most preferred features identified by young people were included to some degree, other inclusions were restricted by budget, time, and the need to integrate best practice recommendations. A process of prioritization was required.

Conclusions

Participatory design is often cited in the development of digital mental health resources; however, methods are diverse and often lack detailed descriptions. This study reports the outcomes and strategies used to determine priorities in the second phase of the development of the AIMhi-Y app. We provide an example and the key learnings to inform others seeking to use participatory design with a similar cohort.

Digital Companion Choice to Support Teachers' Stress Self-management: Systematic Approach Through Taxonomy Creation

BACKGROUND

There are thousands of digital companions designed for emotional well-being and stress, including websites, wearables, and smartphone apps. Although public evaluation frameworks and ratings exist, they do not facilitate digital companion choice based on contextual or individual information, such as occupation or personal management strategies.

OBJECTIVE

The aim of this study is to establish a process for creating a taxonomy to support systematic choice of digital companions for teachers' stress self-management.

METHODS

We used a 4-step study design. In step 1, we identified the dimension of stress self-management and strategic classifications. In step 2, we identified the dimension of the digital techniques and conceptual descriptions. In step 3, we created 6 criteria for the inclusion of digital companions. In step 4, we used the taxonomy framework created by steps 1 and 2 and populated it with digital companions for stress self-management, as identified in step 3.

RESULTS

First, in the dimension of stress self-management, we identified four classes of strategies: educational, physiological, cognitive, and social. Second, in the digital techniques dimension, we derived four conceptual descriptions for the digital companions' mechanisms of action: fostering reflection, suggesting treatment, peer-to-peer support, and entertainment. Third, we created six criteria for digital companion inclusion in the taxonomy: suitability, availability, evaluation, security, validity, and cost. Using the taxonomy framework and criteria, we populated it with digital companions for stress management ahead of presentation to teachers in a stress study workshop.

CONCLUSIONS

The elements of our approach can be generalized as principles for the creation of taxonomies for other occupations or conditions. Taxonomies such as this could be a valuable resource for individuals to understand which digital companion could be of help in their personal context.

Mental Health and Time Management Behavior among Students During COVID-19 Pandemic: Towards Persuasive Technology Design

The study explored the impact of the COVID-19 pandemic on students’ mental health in higher education while capturing their perceptions and attitudes towards time management. The aim was to examine relationships between stress, anxiety, and specific time management-related factors. Considering possible differences between genders and degree levels, we developed five structural equation models (SEMs) to delineate these relationships. Results of a large-scale study of 502 participants show that students suffered from stress and two types of COVID-19-related anxiety: disease and consequences. Students’ preference for organization was the only factor that significantly promoted their perceived control over time, which contributes to reducing stress, hence anxiety. However, female students reported higher stress and anxiety levels than male students. Graduate students reported higher anxiety levels related to the consequences of the pandemic compared to undergrads. To promote students’ preference for organization, we map the three categories of organization to corresponding persuasive strategies which could be used in the design of persuasive interventions. This creates an opportunity for developing technological interventions to improve students’ perceived control over time, thus reduce stress and anxiety.

Social+Me: a persuasive application to increase communication between students and their support networks in Southern Chile

Technology can improve university students' communication, helping them maintain relationships. Although there are many available technological tools, students face challenges-e.g., living far from home, failing grades, depression-that may isolate them from their networks. Most research into these topics has been conducted in countries in which students leave their parents' home while at university, which is not the case for most students in southern Chile. In this context that has been seldom studied, this paper presents two studies, focusing on two research questions: (1) How do university students in southern Chile communicate? (2) Can a mobile application persuade university students to increase their communication patterns? To answer these questions, we conducted a survey with 90 students in southern Chile, and then developed a persuasive application called Social+Me, aimed at monitoring communication with students' support networks and persuading them to keep in touch. We conducted a preliminary evaluation of Social+Me, and the application was well received by participants, who felt that it improved their communication with their social network. The main impact of our study lies in applying persuasive technologies to the communicative practice of university students to prevent students from feeling isolated or unsupported.

Harnessing Artificial Intelligence for Health Message Generation: The Folic Acid Message Engine

Background

Communication campaigns using social media can raise public awareness; however, they are difficult to sustain. A barrier is the need to generate and constantly post novel but on-topic messages, which creates a resource-intensive bottleneck.

Objective

In this study, we aim to harness the latest advances in artificial intelligence (AI) to build a pilot system that can generate many candidate messages, which could be used for a campaign to suggest novel, on-topic candidate messages. The issue of folic acid, a B-vitamin that helps prevent major birth defects, serves as an example; however, the system can work with other issues that could benefit from higher levels of public awareness.

Methods

We used the Generative Pretrained Transformer-2 architecture, a machine learning model trained on a large natural language corpus, and fine-tuned it using a data set of autodownloaded tweets about #folicacid. The fine-tuned model was then used as a message engine, that is, to create new messages about this topic. We conducted a web-based study to gauge how human raters evaluate AI-generated tweet messages compared with original, human-crafted messages.

Results

We found that the Folic Acid Message Engine can easily create several hundreds of new messages that appear natural to humans. Web-based raters evaluated the clarity and quality of a human-curated sample of AI-generated messages as on par with human-generated ones. Overall, these results showed that it is feasible to use such a message engine to suggest messages for web-based campaigns that focus on promoting awareness.

Conclusions

The message engine can serve as a starting point for more sophisticated AI-guided message creation systems for health communication. Beyond the practical potential of such systems for campaigns in the age of social media, they also hold great scientific potential for the quantitative analysis of message characteristics that promote successful communication. We discuss future developments and obvious ethical challenges that need to be addressed as AI technologies for health persuasion enter the stage.

Persuasive Apps for Sustainable Waste Management: A Comparative Systematic Evaluation of Behavior Change Strategies and State-of-the-Art

With the proliferation of ubiquitous computing and mobile technologies, mobile apps are tailored to support users to perform target behaviors in various domains, including a sustainable future. This article provides a systematic evaluation of mobile apps for sustainable waste management to deconstruct and compare the persuasive strategies employed and their implementations. Specifically, it targeted apps that support various sustainable waste management activities such as personal tracking, recycling, conference management, data collection, food waste management, do-it-yourself (DIY) projects, games, etc. The authors who are persuasive technology researchers retrieved a total of 244 apps from App Store and Google Play, out of which 148 apps were evaluated. Two researchers independently analyzed and coded the apps and a third researcher was involved to resolve any disagreement. They coded the apps based on the persuasive strategies of the persuasive system design framework. Overall, the findings uncover that out of the 148 sustainable waste management apps evaluated, primary task support was the most employed category by 89% (n = 131) apps, followed by system credibility support implemented by 76% (n = 112) apps. The dialogue support was implemented by 71% (n = 105) apps and social support was the least utilized strategy by 34% (n = 51) apps. Specifically, Reduction (n = 97), personalization (n = 90), real-world feel (n = 83), surface credibility (n = 83), reminder (n = 73), and self-monitoring (n = 50) were the most commonly employed persuasive strategies. The findings established that there is a significant association between the number of persuasive strategies employed and the apps’ effectiveness as indicated by user ratings of the apps. How the apps are implemented differs depending on the kind of sustainable waste management activities it was developed for. Based on the findings, this paper offers design implications for personalizing sustainable waste management apps to improve their persuasiveness and effectiveness.

Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial

BACKGROUND

As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life.

OBJECTIVE

The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes.

METHODS

A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre- and post-psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data.

RESULTS

In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received.

CONCLUSIONS

Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life.

Understanding Preferences for Lifestyle-Focused Visual Text Messages in Patients With Cardiovascular and Chronic Respiratory Disease: Discrete Choice Experiment

Background

Supporting healthy lifestyle changes is a key aim of cardiovascular and pulmonary rehabilitation programs. SMS text messaging programs have demonstrated effectiveness in cardiovascular disease risk reduction, weight loss, increasing physical activity, and smoking cessation. The optimization of SMS text messaging programs may deliver greater population benefits as mobile phone use becomes ubiquitous. Visual messaging (ie, image-based messages) has the potential to communicate health messages via digital technology and result in enhanced engagement.

Objective

This study aims to determine and understand patient preferences for lifestyle-focused visual text messages that support cardiovascular and pulmonary rehabilitation.

Methods

A discrete choice experiment was conducted in a 4-stage iterative process to elicit patient preferences for visual message features. Attribute and level development yielded 3 attributes (purpose, image type, and web address), and 16 choice sets were subsequently constructed according to a full factorial design. Patients participating in cardiovascular and pulmonary rehabilitation were surveyed (on the web) for their preferences regarding the visual message choice sets. Respondents were asked to choose among 16 pairs of visual messages regarding key lifestyle behaviors, namely, physical activity and nutrition. The data were analyzed using a conditional logit model.

Results

There was a total of 1728 observations from 54 unique respondents. Two factors that were associated with patient preference were gain-framed purpose compared with no purpose (odds ratio [OR] 1.93, 95% CI 1.40-2.65) and real images compared with cartoon images (OR 1.26, 95% CI 1.04-1.54). A loss-framed purpose was less preferred than no purpose (OR 0.55, 95% CI 0.42-0.74). Overall, patients preferred positive images that were colorful and engaged with text that supported the image and had a preference for images of real people rather than cartoons.

Conclusions

A discrete choice experiment is a scientific method for eliciting patient preferences for a visual messaging intervention that is designed to support changes in lifestyle behaviors. SMS text messaging programs that use visual aids may result in greater patient satisfaction by using a gain frame, using real images, and avoiding a loss frame. Further research is needed to explore the feasibility of implementation and the health and behavioral outcomes associated with such visual messaging programs.

Conceptual validation of an innovative remote pulmonary rehabilitation solution for Chronic Obstructive Pulmonary Disease

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in the world. Pulmonary rehabilitation (PR) reduces COPD hospitalisations, although its use is low. Telerehabilitation is effective; however, in Chile the development of remote PR technology is incipient. Therefore, the aim of the study was to validate conceptual aspects of an innovative remote PR solution for COPD.

METHODS

This mixed study used a nonprobabilistic sample of PR professionals and people with COPD (PwCOPD) from Santiago. The perception of a conceptual solution for PR through a semi-structured interview was determined. Professionals were also asked about willingness to use technology using a questionnaire designed and validated in 75 professionals in this study. The study was approved by the Ethics Committee and data were collected after informed consent.

RESULTS

Twenty-two participants were recruited, of which 14 were professionals and eight were PwCOPD. Among professionals and patients, the willingness to use the solution is positive because it would reduce visits and improve self-management, although it should include a remote/in-person combination, training, and user-friendly interface. Most of the professionals were willing to use technology for pulmonary rehabilitation.

CONCLUSIONS

The development of telehealth technologies should consider the expectations of patients and professionals and may incorporate elements of persuasive technologies in the design. The results could contribute to the development of digital solutions for remote PR in PwCOPD.

Effects of technology-based physical activity interventions for women after bariatric surgery: study protocol for a three-arm randomised controlled trial

INTRODUCTION

A recent meta-analysis provided proof of efficacy for mobile technology to increase physical activity or weight loss in the short term. Videoconferencing may also be effective, especially as it reduces the barriers related to face-to-face physical activity interventions. Both technologies seem particularly interesting for bariatric surgery management, but their long-term effects on physical activity maintenance are unknown. Moreover, the mechanisms underlying their effectiveness, such as technology acceptability and motivational processes, have not been examined.The objectives of this study are to determine the effects of two technology-based (mobile technology and videoconferencing) physical activity programmes after bariatric surgery compared with standard care and to assess the contribution of acceptability and motivational mechanisms in explaining these effects on physical activity, physiological measures and health indicators.

METHODS AND ANALYSIS

One hundred and twenty young women who have undergone bariatric surgery in the last 3-6 months will be included. The volunteers will be randomly assigned to one of three arms: CONTROL (standard care), ACTI-MOBIL (mobile technology) or ACTI-VISIO (videoconferencing). The primary outcome is the distance travelled during a 6 min walk test relativised according to Capadaglio's theoretical distance. Secondary outcomes are behavioural measures of physical activity, physiological measures, health indicators, technology acceptability and motivational concepts. Data will be collected at baseline (T0), 3 months (T3) and 6 months (T6). The technology groups will receive a physical activity programme for 12 weeks (between T0 and T3). A mixed model approach will be used to analyse the change in outcomes over time for each group.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the French East 1 Protection of Persons Ethics Committee (number: 2020.A00172-37) and the French National Commission for Information Technology and Civil Liberties (number: UCA-R20-034). The results will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04478331.

Intelligent Cognitive Assistants for Attitude and Behavior Change Support in Mental Health: State-of-the-Art Technical Review

Intelligent cognitive assistant (ICA) technology is used in various domains to emulate human behavior expressed through synchronous communication, especially written conversation. Due to their ability to use individually tailored natural language, they present a powerful vessel to support attitude and behavior change. Behavior change support systems are emerging as a crucial tool in digital mental health services, and ICAs exceed in effective support, especially for stress, anxiety and depression (SAD), where ICAs guide people’s thought processes and actions by analyzing their affective and cognitive phenomena. Currently, there is no comprehensive review of such ICAs from a technical standpoint, and existing work is conducted exclusively from a psychological or medical perspective. This technical state-of-the-art review tried to discern and systematize current technological approaches and trends as well as detail the highly interdisciplinary landscape of intersections between ICAs, attitude and behavior change, and mental health, focusing on text-based ICAs for SAD. Ten papers with systems, fitting our criteria, were selected. The systems varied significantly in their approaches, with the most successful opting for comprehensive user models, classification-based assessment, personalized intervention, and dialogue tree conversational models.

Gamification for Family Engagement in Lifestyle Interventions: A Systematic Review

The majority of chronic conditions that plague the USA are modifiable by lifestyle change. Lifestyle interventions that incorporate family members for social support and that use game design elements to engage family members have the potential to improve upon traditional interventions, which have largely been unsustainable. Determining the populations where family member support in a lifestyle intervention are present and the extent of gamification of lifestyle intervention components that engage these family members is an important and underexplored area of work. A systematic review of lifestyle interventions involving family members were reviewed for game design elements using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Game design elements related to engaged learning and motivational affordances from previous literature were included. Sixty-one studies met inclusion criteria. These studies reported on 50 independent interventions that were reviewed. Thirty-one of these interventions addressed lifestyle in those with a chronic condition, and 19 addressed lifestyle in those at high risk for chronic conditions. The majority of the lifestyle interventions included at least one game design element, yet overall there were limited elements utilized together. Compared with successful gamified programs that have greatly impacted a population's health behaviors, there were relatively a limited number of elements reported, particularly those that support social relatedness, such as meaningful storylines. Meaningfulness of the game design elements chosen and their arrangement was not apparent. Technology was under-utilized as a potential modality for intervention component delivery. Developing products to train researchers to properly apply game design elements to intervention components, as well as test their effectiveness, are areas for future research.

Satisfied or Frustrated? A Qualitative Analysis of Need Satisfying and Need Frustrating Experiences of Engaging With Digital Health Technology in Chronic Care

Introduction: Digital health technologies such as self-monitoring devices and apps are becoming increasingly important as tools to promote healthy habits and support individuals in their self-care. There is still a scarcity of research that builds on motivational theory to better understand the functioning of digital health technologies. The self-determination theory (SDT) is a macro theory of motivation that delineates three basic psychological needs that are linked to different types of motivation and lead to well-being when satisfied and illbeing when frustrated.

Objective: To explore how the use of a digital tool for self-monitoring and communication with healthcare satisfies or frustrates basic psychological needs across four spheres of user experience: interface, task, behavior, and life.

Methods: The study was conducted in a Swedish primary care setting with individuals who participated in a pilot study of a digital health intervention for self-monitoring in chronic care management. Data from a follow-up survey with participants 7 months after recruitment were analyzed using a thematic approach mixing inductive and deductive analysis. The unit of analysis is based on a total of 642 individual answers to seven open-ended questions, from 121 respondents.

Results: The analysis identified positive and negative influences of self-monitoring and digital communication with healthcare on all three psychological needs. Three main findings are that: (1) data covered all four spheres of user experiences, but most user experiences concerned the behavior and task spheres; (2) satisfaction and frustration of competence needs was more prominent than influences on other needs; (3) the same experience may be perceived as both need frustrating and need satisfying, which suggests a tension that reflects individual differences.

Conclusion: Designers of digital health technologies need to take into account basic psychological needs within all spheres of user experience, from interface to life in general. Because some features may be simultaneously experienced as satisfying and frustrating by different users, these types of tools need to be flexible to accommodate for variation of user experiences. Careful design considerations that take motivational theory into account would contribute to the transformation of care for individuals with chronic conditions.

Does Health Information Technology Promote Healthy Behaviors? The Mediating Role of Self-Regulation

Health information technology (health IT) has the potential to facilitate the self-regulation of fruit and vegetable intake (FVI) and physical activity (PA). This study explores whether using health IT for self-regulation mediates the relationship between sociodemographic factors and health behaviors including FVI and PA among U.S. adults. Bayesian mediation analysis was used to analyze a nationally representative sample of the U.S. adults (N = 3285) from Cycle 1 of the 2017 Health Information National Trends Survey (HINTS). The 95% credibility intervals (CI) were calculated for each sociodemographic factor and the mediator using health IT for self-regulation in relation to FVI and PA. About 58% of the participants used at least one type of health IT for self-regulation. Age was negatively associated with using health IT for self-regulation, whereas being a female and having a higher income and education were positively associated with it. Using health IT for self-regulation partially mediated the positive relationships between income, education, and FVI, but it is unrelated to PA. The findings support the efficacy of using health IT to regulate healthier eating. Nevertheless, the digital divide is a critical issue to consider when applying health IT to promote behavior change.

Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial

BACKGROUND

Syringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings.

OBJECTIVE

The aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients.

METHODS

Using a social network-based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants' selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual's readiness to change each behavior was also examined.

RESULTS

From 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey.

CONCLUSIONS

Implementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/resprot.4830.