Customization in mobile health apps: explaining effects on physical activity intentions by the need for autonomy

An Artificial Intelligence-Based App for Self-Management of Low Back and Neck Pain in Specialist Care: Process Evaluation From a Randomized Clinical Trial

BACKGROUND

Self-management is endorsed in clinical practice guidelines for the care of musculoskeletal pain. In a randomized clinical trial, we tested the effectiveness of an artificial intelligence-based self-management app (selfBACK) as an adjunct to usual care for patients with low back and neck pain referred to specialist care.

OBJECTIVE

This study is a process evaluation aiming to explore patients' engagement and experiences with the selfBACK app and specialist health care practitioners' views on adopting digital self-management tools in their clinical practice.

METHODS

App usage analytics in the first 12 weeks were used to explore patients' engagement with the SELFBACK app. Among the 99 patients allocated to the SELFBACK interventions, a purposive sample of 11 patients (aged 27-75 years, 8 female) was selected for semistructured individual interviews based on app usage. Two focus group interviews were conducted with specialist health care practitioners (n=9). Interviews were analyzed using thematic analysis.

RESULTS

Nearly one-third of patients never accessed the app, and one-third were low users. Three themes were identified from interviews with patients and health care practitioners: (1) overall impression of the app, where patients discussed the interface and content of the app, reported on usability issues, and described their app usage; (2) perceived value of the app, where patients and health care practitioners described the primary value of the app and its potential to supplement usual care; and (3) suggestions for future use, where patients and health care practitioners addressed aspects they believed would determine acceptance.

CONCLUSIONS

Although the app's uptake was relatively low, both patients and health care practitioners had a positive opinion about adopting an app-based self-management intervention for low back and neck pain as an add-on to usual care. Both described that the app could reassure patients by providing trustworthy information, thus empowering them to take actions on their own. Factors influencing app acceptance and engagement, such as content relevance, tailoring, trust, and usability properties, were identified.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04463043; https://clinicaltrials.gov/study/NCT04463043.

Virtual fitness buddy ecosystem: a mixed reality precision health physical activity intervention for children

6-11-year-old children provide a critical window for physical activity (PA) interventions. The Virtual Fitness Buddy ecosystem is a precision health PA intervention for children integrating mixed reality technology to connect people and devices. A cluster randomized, controlled trial was conducted across 19 afterschool sites over two 6-month cohorts to test its efficacy in increasing PA and decreasing sedentary behavior. In the treatment group, a custom virtual dog via a mixed reality kiosk helped children set PA goals while sharing progress with parents to receive feedback and support. Children in the control group set PA goals using a computer without support from the virtual dog or parents. 303 children had 8+ hours of PA data on at least one day of each of the 3 intervention time intervals. Conversion of sedentary time was primarily to light-intensity PA and was strongest for children with low baseline moderate-to-vigorous PA than children above 45 min of baseline moderate-to-vigorous PA. Findings suggest that the VFB ecosystem can promote sustainable PA in children and may be rapidly diffused for widespread public health impact.

Effects of Technology Use on Self-Reported Physical Activity: A Behavioral Change Perspective

Previous research finds initial evidence that affordances of interactivity, agency, and modality can help increase physical activity (PA). However, the cross-sectional nature of these studies provides a snapshot of behavior but does not assess the impact of affordances of technology on change in PA behavior. In this study, we bridge this gap and test if features of technology that afford interactivity, agency, and choice of modality will be associated with an increase in PA across time. Guided by the Motivational Technology Model (MTM), we scraped 784 user profiles from the BodySpace App (a social weightlifting smartphone application) at baseline and after 70 days and establish the relationship between the use of features that afford interactivity, agency, and modality and behavioral change. Theoretical and methodological implications are discussed.

Effectiveness of a tailored communication intervention to improve physical activity in hypertensive patients: a twelve-month randomized controlled trial

BACKGROUND

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally. Arterial hypertension is one of the main cardiovascular risk factors. Despite this, individuals with hypertension often fail to follow medical advice to counteract cardiovascular risks. A physically active lifestyle is one of the most challenging behaviors to adopt. This study aimed to preliminarily investigate the effectiveness of a tailored print message intervention to increase physical activity in patients with arterial hypertension.

METHODS

A sample of 188 patients with hypertension (mean age = 63 years; SD = 10.9; 50% men) participated in a theory-based tailored health communication intervention. Participants were randomly assigned to three parallel groups: (1) the tailored group, which received tailored health brochures; (2) the non-tailored group, which received non-tailored health brochures; or (3) the usual care group, which received no informative print materials. The longitudinal physical activity trajectories (baseline, 6- and 12-month follow-ups) were examined using repeated measures ANOVA and growth curve models.

RESULTS

At the baseline, 38.8% of patients achieved the target physical activity. This percentage rose to 43.0% at 6-month follow-up and 46.0% at 12-month follow-up. The descriptive statistics divided in function of the experimental group suggested differences in the longitudinal trend of the mean physical activity depending on the experimental group. However, statistical significance using repeated measures ANOVA did not support this observation. The analysis of the growth curves suggested that the tailored group showed a progressive increase in physical activity over twelve months (the model that best described the longitudinal trajectory was a linear growth model). The non-tailored group showed an increase in physical activity six months after the beginning of the intervention, followed by a decrease (free time score model). The usual care group did not change over time (no-growth model).

CONCLUSIONS

Findings suggest the effectiveness of the tailored intervention proposed. However, further investigations and empirical confirmations are required.

TRIAL REGISTRATION

ISRCTN13415993 ( https://doi.org/10.1186/ISRCTN13415993 ). Registration date: 08/04/2019.

Informing Patient-Provider Engagement for Shared Decision Making Through Mobile Health Applications

Objective

The study utilized a cross-sectional dataset to identify demographic and health factors associated with patient utilization of mHealth applications for engaging with healthcare providers. The focus was on adults with chronic health conditions as the primary app user group. The goal was to reveal specific barriers and facilitators to app adoption among smartphone users, with the aim of highlighting opportunities for upgrades that promote patient empowerment as a prerequisite for shared decision-making (SDM).

Methods

Data from the Health Information National Trends Survey (HINTS 5, Cycle 4, 2020) with 3865 respondents (≥18 years old) stratified analyses and weighted logistic regression were used.

Results

The study found that individuals having a wellness app on a smartphone increased the likelihood (OR 2.68, CI: 2.02-3.56, p-value < 0.0001) of discussing health conditions with providers. Furthermore, individuals with multiple chronic health conditions were more likely (OR 1.93, CI 1.26-2.95, p-value < 0.01) to use apps to use mobile health applications to engage with healthcare providers. Other significant variables affecting app usage such as race, marital status, and educational level.

Conclusion

Due to difficulties obtaining in-person healthcare, the COVID-19 epidemic forced a swift deployment of mHealth technologies. Even in the absence of a crisis, mobile health applications continue to be crucial for improving patient-provider engagement and developing novel approaches to healthcare delivery. During the pandemic, people with numerous chronic diseases used apps to stay in touch with doctors and maintain their reliance on these platforms. Nonetheless, different smartphone users continue to use mHealth application in different ways. The findings revealing barriers in mHealth app adoption among certain patient subgroups suggest opportunities for developers, in collaboration with users and providers, to enhance inclusion and acceptability when upgrading mHealth application platforms.

Digital applications as a means for promotion of healthy behaviours among Albanian children

Digital applications can be effective tools for strengthening school-based health education programs as they can provide valuable health information to children through interactive videos, quizzes and games. We aimed at assessing the change in the prevalence of healthy behaviours among children exposed to digital applications (intervention) employed for promoting healthy behaviours. We conducted a cross-sectional study before the intervention in March 2022 including a representative sample of 1500 Albanian schoolchildren (≈54% girls) aged 12-15 years. In June 2022, after 4-month exposure to digital applications aimed at promoting healthy behaviours (intervention), we carried out a second cross-sectional study in the same sample of schoolchildren. In both survey rounds, an anonymous and structured self-administered questionnaire inquired children about a range of behavioural practices including nutrition, oral health, physical activity and hygiene practices. After the intervention, overall, there was evidence of a significant increase in the prevalence of all healthy behavioural practices measured: ~9% for breakfast consumption and/or environmental protection, 12% for toothbrushing, 14% for handwashing, 15% for leisure time physical exercise and 24% for adequate fruit and vegetable intake (all p < 0.001). Engagement in healthy behaviours only after the intervention was higher among rural children (from 18% for breakfast consumption to 37% for handwashing and/or adequate fruit and vegetable intake) and especially those pertinent to Roma/Egyptian communities (from 18% for breakfast consumption to 46% for adequate fruit and vegetable intake), except for engagement in safe environmental protection which was more prevalent among urban residents (28% vs. 15% among rural children) and ethnic Albanian children (24% vs. 13% among Roma/Egyptian children). Our findings from Albania indicate that digital applications can be useful for strengthening school-based health promotion programs.

Incorporating new ways of doing by learning from everyday experiences and interactions using a multifactorial mHealth app

Background

Digital health innovations can support the prevention and management of risk factors for cardiovascular diseases, such as stroke. However, little is known about people's everyday experiences of digitally augmented stroke-prevention programmes combining onsite group sessions including peers and healthcare professionals with interaction and support from a multifactorial mHealth app.

Objective

The aim of this study was to explore how people with stroke risk experienced interaction with a multifactorial mHealth app as support in the make my day stroke-prevention programme.

Methods

Repeated interviews and observations with 12 adults with moderate to high stroke risk were analysed using a constant comparative method informed by constructive grounded theory.

Results

Incorporating new ways of doing into everyday life involves a process through which participants learn from both being and doing in different environments (e.g., digital, physical and social). Digital self-monitoring combined with seemingly trivial everyday experiences played central roles in the process of increasing awareness of health and stroke risks, and providing tools to support increased self-reflection on everyday behaviours. Adoption of positive health behaviours in everyday life was supported or hindered by how easy to use and personally relevant the mHealth app was perceived to be.

Conclusions

An experience-based group programme together with a personally relevant multifactorial mHealth app can be supportive in stroke prevention to increase general health literacy and stroke risk literacy, and promote the incorporation of new ways of doing in everyday life. Routines of doing digital self-monitoring and health-promoting activities were however strongly influenced by different environments in which choices are presented. It is therefore important to explore how both self-monitoring and health-promoting activities can be incorporated into everyday routines for different individuals. Research should also explore how personally relevant mHealth can be developed and integrated into prevention practices in primary healthcare.

Environmental scan of mobile apps for promoting sexual and reproductive health of adolescents in low- and middle-income countries

Background

Adolescence is a period of emotional, mental, and physical change. To increase health seeking behaviors, reduce risky sexual behavior, and improve sexual and reproductive health (SRH) knowledge, adolescents require support and access to SRH services. Providing evidence-informed SRH knowledge to adolescents in low- and middle-income countries (LMICs) can be a challenge as they face unique barriers such as lack of confidentiality, fear of refusal, and stigma from cultural norms. Increasing availability of mobile apps necessitates a comprehensive evaluation of the quality and classification of these SRH mobile applications so that accurate and evidence-based information is reaching its users. Failure to provide SRH services can have damaging effects throughout their development.

Objective

Provide an overview of current adolescent SRH (ASRH) mobile applications targeting adolescents in LMICs by evaluating their quality and classifying their characteristics.

Methods

21 search terms related to ASRH mobile apps was developed. These terms were searched in the Apple IOS store and Google Play stores. Inclusion and exclusion criteria were used to screen these apps. Resulting apps were assessed using the Mobile App Rating Scale (MARS) tool. Data extracted was used to rank order each app and identify any gaps in quality.

Results

Search strategy yielded 2,165 mobile apps. Of these, only 8 were assessed using the MARS tool. Functionality subdomain scored highest at 4.6, while Information scored lowest at 2.5. None of the assessed apps contained information on the MARS items: Evidence base and Goals. Too Shy to Ask had the highest individual app mean score of 4.1, while e-SRHR scored lowest at 2.3.

Conclusions

The goal of this study is to classify and rate the quality of mobile apps designed to promote ASRH behaviors and knowledge in LMICs. Numerous apps were reviewed and all of them failed to provide evidence-based and goal oriented SRH information. Strengths include ease of use, navigation, and gestural designs. Weaknesses include evidence base, goals, willingness to pay, customization, and interactivity. These findings can be potentially used to guide future app development and educate decision makers responsible for policy changes.

The problem with the internet: An affordance-based approach for psychological research on networked technologies

The internet is often viewed as the source of a myriad of benefits and harms. However, there are problems with using this notion of "the internet" and other high-level concepts to explain the influence of communicating via everyday networked technologies on people and society. Here, we argue that research on social influence in computer-mediated communication (CMC) requires increased precision around how and why specific features of networked technologies interact with and impact psychological processes and outcomes. By reviewing research on the affordances of networked technologies, we demonstrate how the relationship between features of "the internet" and "online behaviour" can be determined by both the affordances of the environment and the psychology of the user and community. To achieve advances in this field, we argue that psychological science must provide nuanced and precise conceptualisations, operationalisations, and measurements of "internet use" and "online behaviour". We provide a template for how future research can become more systematic by examining how and why variables associated with the individual user, networked technologies, and the online community interact and intersect. If adopted, psychological science will be able to make more meaningful predictions about online and offline outcomes associated with communicating via networked technologies.

A personalized mobile app for physical activity: An experimental mixed-methods study

Objectives

To investigate the feasibility of the be.well app and its personalization approach which regularly considers users’ preferences, amongst university students.

Methods

We conducted a mixed-methods, pre-post experiment, where participants used the app for 2 months. Eligibility criteria included: age 18–34 years; owning an iPhone with Internet access; and fluency in English. Usability was assessed by a validated questionnaire; engagement metrics were reported. Changes in physical activity were assessed by comparing the difference in daily step count between baseline and 2 months. Interviews were conducted to assess acceptability; thematic analysis was conducted.

Results

Twenty-three participants were enrolled in the study (mean age = 21.9 years, 71.4% women). The mean usability score was 5.6 ± 0.8 out of 7. The median daily engagement time was 2 minutes. Eighteen out of 23 participants used the app in the last month of the study. Qualitative data revealed that people liked the personalized activity suggestion feature as it was actionable and promoted user autonomy. Some users also expressed privacy concerns if they had to provide a lot of personal data to receive highly personalized features. Daily step count increased after 2 months of the intervention (median difference = 1953 steps/day, p-value <.001, 95% CI 782 to 3112).

Conclusions

Incorporating users’ preferences in personalized advice provided by a physical activity app was considered feasible and acceptable, with preliminary support for its positive effects on daily step count. Future randomized studies with longer follow up are warranted to determine the effectiveness of personalized mobile apps in promoting physical activity.

An Autonomy-Supportive Online Decision Aid to Assist Smokers in Choosing Evidence-Based Cessation Assistance: Development Process and Protocol of a Randomized Controlled Trial

BACKGROUND

Decision aids (DAs) may be used to facilitate an autonomous, informed decision to cease smoking and promote the uptake of evidence-based cessation assistance (ie, behavioral support, nicotine replacement therapy, or prescription medication). However, knowledge is lacking regarding their effective elements and (cost-)effectiveness.

OBJECTIVE

We describe the development process of an online DA (called "VISOR") that helps smokers to choose evidence-based cessation assistance. Additionally, we provide a description of the protocol of an ongoing randomized controlled trial in which the DA containing an explicit value clarification method (VCM) and tailored advice is compared with a DA without an explicit VCM and tailored advice.

METHODS

The development of "VISOR" was based on the International Patient Decision Aid Standards guidelines. Viewpoints of end users (collected through 20 interviews with smokers) and clinical and scientific experts (assessed using 2 Delphi studies with 24 scientists and 38 clinicians) were assessed regarding cessation tool decision making and preferred DA content. These findings, together with principles from the Self-Determination Theory, served as input for the development of the online DA. A first DA prototype was alpha-tested in September 2019 and beta-tested for usability in December 2019; feedback was incorporated and resulted in a final version. The final DA contains (1) an information section, (2) an optional knowledge quiz, (3) a brief smoking assessment, (4) intuitive decision, (5) intermediate advice, (6) an explicit VCM, (7) tailored advice, and (8) access information. A randomized controlled trial is currently being conducted to assess the DA's (cost-)effectiveness compared to a DA that does not include the explicit VCM and the tailored advice; specifically, the DA's effect on smoking abstinence, uptake of evidence-based cessation assistance, smoking abstinence mediated through uptake of evidence-based cessation assistance, and decisional conflict are investigated. Participants are randomly allocated to receive access to 1 of the 2 DAs and are asked to complete 5 questionnaires (including the baseline questionnaire) over a period of 12 months. To evaluate the effects of the DA on the outcome measures, logistic and linear regression analyses as well as mediation analyses will be carried out. An economic evaluation will be performed to assess the cost-effectiveness.

RESULTS

Data regarding the effect of the VISOR DA are currently being collected, and data collection is expected to be concluded in 2021.

CONCLUSIONS

By making use of an iterative process that integrated different stakeholders' perspectives (including end users), we were able to systematically design an evidence-based DA. The study will contribute to the current knowledge regarding smoking cessation DA application, the added value of explicit VCMs, and the effect of behavioral and informed decision-making outcomes.

TRIAL REGISTRATION

Netherlands Trial Register NL8270; https://www.trialregister.nl/trial/8270.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21772.