Persuasive features in web-based alcohol and smoking interventions: a systematic review of the literature

"Keep It Short and Simple": Perceptions of patients and healthcare professionals on the use of a mobile health app in the care for patients undergoing radical prostatectomy

Background

Patients undergoing radical prostatectomy for localised prostate cancer generally have good long-term survival rates. However, late recurrences can occur and require lifelong follow-up.

Objective

This research aims to investigate different stakeholders' perceptions on the use of mobile health (mHealth) applications for prostate cancer follow-up after radical prostatectomy.

Methods

A cross-sectional qualitative study was conducted to explore stakeholders' perceptions of an mHealth application for follow-up after radical prostatectomy. Urologists, nurses, and patients treated with radical prostatectomy were interviewed, and data were transcribed and analysed using thematic analysis according to Qualitative Analysis Guide of Leuven. Recommended features for an ideal mHealth application were grouped according to the Persuasive Systems Design model.

Results and Limitations

A total of 30 stakeholders, consisting of nurse specialists (n = 7), urologists (n = 8), and patients (n = 15), were interviewed. Expected benefits and barriers were mentioned and grouped in five overarching themes: healthcare optimisation, disease management, app compliance, legal and organisational requirements, and patient-mHealth interaction. Stakeholders provided a multitude of suggestions for an ideal mHealth app. Yet, not all types of stakeholders were interviewed, and patient selection limited generalisability of findings.

Conclusions

Stakeholders indicate that an mHealth app in the care for post-prostatectomy patients can improve patient care and promote disease management but consider app compliance as a major challenge.

Patient Summary

We interviewed patients, nurses, and urologists about using an mHealth application for follow-up after radical prostatectomy. The participants agreed that an mHealth app could improve care optimisation and disease management, but some concerns and barriers were expressed. This resulted in a list of recommended features for an ideal app.

Effective Behavior Change Techniques in Digital Health Interventions for the Prevention or Management of Noncommunicable Diseases: An Umbrella Review

BACKGROUND

Despite an abundance of digital health interventions (DHIs) targeting the prevention and management of noncommunicable diseases (NCDs), it is unclear what specific components make a DHI effective.

PURPOSE

This narrative umbrella review aimed to identify the most effective behavior change techniques (BCTs) in DHIs that address the prevention or management of NCDs.

METHODS

Five electronic databases were searched for articles published in English between January 2007 and December 2022. Studies were included if they were systematic reviews or meta-analyses of DHIs targeting the modification of one or more NCD-related risk factors in adults. BCTs were coded using the Behavior Change Technique Taxonomy v1. Study quality was assessed using AMSTAR 2.

RESULTS

Eighty-five articles, spanning 12 health domains and comprising over 865,000 individual participants, were included in the review. We found evidence that DHIs are effective in improving health outcomes for patients with cardiovascular disease, cancer, type 2 diabetes, and asthma, and health-related behaviors including physical activity, sedentary behavior, diet, weight management, medication adherence, and abstinence from substance use. There was strong evidence to suggest that credible source, social support, prompts and cues, graded tasks, goals and planning, feedback and monitoring, human coaching and personalization components increase the effectiveness of DHIs targeting the prevention and management of NCDs.

CONCLUSIONS

This review identifies the most common and effective BCTs used in DHIs, which warrant prioritization for integration into future interventions. These findings are critical for the future development and upscaling of DHIs and should inform best practice guidelines.

Factors Reducing the Use of a Persuasive mHealth App and How to Mitigate Them: Thematic Analysis

BACKGROUND

Studies on which persuasive features may work for different users in health contexts are rare. The participants in this study were microentrepreneurs. We built a persuasive mobile app to help them to recover from work. Representatives of this target group tend to be very busy due to work, which was reflected in their use of the app during the randomized controlled trial intervention. Microentrepreneurs also often have dual roles; they are professionals in their line of work as well as entrepreneurs managing their own business, which may add to their workload.

OBJECTIVE

This study aimed to present users' views on the factors that hinder their use of the mobile health app that we developed and how these factors could be mitigated.

METHODS

We interviewed 59 users and conducted both data-driven and theory-driven analyses on the interviews.

RESULTS

Factors reducing app use could be divided into 3 categories: use context (problem domain-related issues, eg, the lack of time due to work), user context (user-related issues, eg, concurrent use of other apps), and technology context (technology-related issues, eg, bugs and usability). Due to the nature of the participants' entrepreneurship, which often interferes with personal life, it became clear that designs targeting similar target groups should avoid steep learning curves and should be easy (quick) to use.

CONCLUSIONS

Personalized tunneling-guiding the user through a system via personalized solutions-could help similar target groups with similar issues better engage with and keep using health apps because of the easy learning curve. When developing health apps for interventions, background theories should not be interpreted too strictly. Applying theory in practice may require rethinking approaches for adaptation as technology has evolved rapidly and continues to evolve.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03648593; https://clinicaltrials.gov/ct2/show/NCT03648593.

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.

Social features in internet-based programs to prevent alcohol consumption among adolescents: a scoping review

Alcohol consumption among adolescents is a social and public health issue. School-based programs are needed to prevent the onset of alcohol consumption during adolescence. Information and communication technologies offer new promising approaches to deliver preventive programs to these populations. The most traditional, successful programs use group dynamics within the classroom. However, the usefulness of social interaction features (SIF) within internet-based interventions remains unclear. The current scoping review aims to identify and evaluate the effectiveness of online and mobile psychosocial preventive interventions that use SIF, and that target adolescents. Web of Science, Scopus and Google Scholar were electronically searched for all articles published between January 2011 and December 2020. Articles reporting on school-based, web-based interventions for adolescents to prevent alcohol consumption and that encouraged any kind of interaction between users ('social interactions') were eligible for inclusion. Fourteen articles were included in the review. These articles assessed eight preventive programs. Six programs showed positive results on outcome variables. In two of them, it was possible to determine that their success was partially due to the SIF. SIF seem to be useful to enhance the receptivity and usefulness of web-based prevention programs, but the current evidence of their effectiveness is scarce. More evidence is required to assess the effectiveness of these features and to improve programs having the objective of preventing the consumption of alcohol among young people.

Scalability of an ACT-Based strategy for improving well-being in health care providers: A mix-method and preliminary evaluation of efficacy

The burden of the COVID-19 pandemic has been mainly carried by health care providers. Technology-Mediated Interventions (TMI) seem to be a feasible alternative to increase access to behavioral health resources in this population. However, scaling-up treatments into TMI requires developing user-friendly, accepted, and accessible formats. A two-stage study was conducted to assess scalability of an Acceptance and Commitment Therapy (ACT) based strategy (named FACE COVID) delivered using technology. First, a mix-method design connected qualitative and quantitative data from health providers and ACT experts by which changes were performed to enhance scalability. Second, a pretest-posttest study was conducted to preliminary evaluate the efficacy of FACE COVID intervention on well-being, psychological distress, and psychological flexibility. Results showed a positive impact on well-being, but not distress and psychological flexibility. While this intervention has promising results, changes in dose intensity, social support, and mental health literacy could improve retention as well as increase opportunities to target distress and psychological flexibility in future studies.

Evaluating the effectiveness of Internet-based communication for public health: a systematic review (Preprint)

Background

Communicating strategically is a key issue for health organizations. Over the past decade, health care communication via social media and websites has generated a great deal of studies examining different realities of communication strategies. However, when it comes to systematic reviews, there is fragmentary evidence on this type of communication.

Objective

The aim of this systematic review was to summarize the evidence on web institutional health communication for public health authorities to evaluate possible aim-specific key points based on these existing studies.

Methods

Guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, we conducted a comprehensive review across 2 electronic databases (PubMed and Web of Science) from January 1, 2011, to October 7, 2021, searching for studies investigating institutional health communication. In total, 2 independent researchers (AN and SS) reviewed the articles for inclusion, and the assessment of methodological quality was based on the Kmet appraisal checklist.

Results

A total of 78 articles were selected. Most studies (35/78, 45%) targeted health promotion and disease prevention, followed by crisis communication (24/78, 31%), general health (13/78, 17%), and misinformation correction and health promotion (6/78, 8%). Engagement and message framing were the most analyzed aspects. Few studies (14/78, 18%) focused on campaign effectiveness. Only 23% (18/78) of the studies had an experimental design. The Kmet evaluation was used to distinguish studies presenting a solid structure from lacking studies. In particular, considering the 0.75-point threshold, 36% (28/78) of the studies were excluded. Studies above this threshold were used to identify a series of aim-specific and medium-specific suggestions as the communication strategies used differed greatly.

Conclusions

Overall, the findings suggest that no single strategy works best in the case of web-based health care communication. The extreme variability of outcomes and the lack of a unitary measure for assessing the end points of a specific campaign or study lead us to reconsider the tools we use to evaluate the efficacy of web-based health communication.

Improving the Safety of Medicines via Digital Technology: An Assessment of the Scope and Quality of Risk Minimization Websites in the United States and United Kingdom

INTRODUCTION

EHealth holds tremendous promise for enhancing drug safety initiatives known as risk minimization programs. Little is known, however, regarding the scope and quality of existing risk minimization websites.

METHODS

Two publicly accessible repositories, REMS@FDA [1] and Electronic Medicines Compendium [2], were reviewed to identify all regulatorily approved risk minimization programs in the United States (US) and United Kingdom (UK) with websites. Website quality was evaluated using the Enlight Quality Assessment tool, a psychometrically validated instrument that addresses seven quality domains.

RESULTS

Ninety-three websites were identified: 59 for healthcare professionals (7 UK/52 US), and 34 for patients (5 UK/29 US). The websites functioned chiefly as archives for electronic copies of educational materials; a subset (31/93) had additional features. Mean quality ratings for Usability (mean 4.70, SD 0.59), Visual Design (mean 4.03, SD 0.87) and Content (mean 4.31, SD 0.82) were good. General Subjective Evaluation was fair (mean 3.15, SD 1.21). Mean scores for Therapeutic Alliance and Therapeutic Persuasiveness were poor (mean 2.62, SD 1.47; and mean 2.50, SD 1.48, respectively); those for User Engagement were very poor (mean 2.25, SD 1.03). No differences were found by target audience but several were identified based on region.

CONCLUSIONS

Risk minimization websites are easy to navigate and well organized. Few, however, incorporate eHealth design elements that facilitate user engagement, build therapeutic alliance and exert therapeutic persuasiveness. Such elements can enhance program uptake and effectiveness. Results highlight opportunities for improving the quality of risk minimization websites and their ability to bridge pharmaceutical and healthcare systems.

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.

Application of persuasive systems design principles to design a self-management application user interface for Hispanic informal dementia caregivers: user preferences and perceptions

OBJECTIVE

We designed an mHealth application (app) user interface (UI) prototype informed by participatory design sessions, persuasive systems design (PSD) principles, and Lorig and Holman's self-management behavior framework to support self-management activities of Hispanic informal dementia caregivers and assessed their perceptions and preferences regarding features and functions of the app.

MATERIALS AND METHODS

Our observational usability study design employed qualitative methods and forced choice preference assessments to identify: (1) the relationship between user preferences for UI features and functions and PSD principles and (2) user preferences for UI design features and functions and app functionality. We evaluated 16 pairs of mHealth app UI prototype designs. Eight paper-based paired designs were used to assess the relationship between PSD principles and caregiver preferences for UI features and functions to support self-management. An Apple iPad WIFI 32GB was used to display another 8 paired designs and assess caregiver preferences for UI functions to support the self-management process.

RESULTS

Caregivers preferred an app UI with features and functions that incorporated a greater number of PSD principles and included an infographic to facilitate self-management. Moreover, caregivers preferred a design that did not depend on manual data entry, opting instead for functions such as drop-down list, drag-and-drop, and voice query to prioritize, choose, decide, and search when performing self-management activities.

CONCLUSION

Our assessment approaches allowed us to discern which UI features, functions, and designs caregivers preferred. The targeted application of PSD principles in UI designs holds promise for supporting personalized problem identification, goal setting, decision-making, and action planning as strategies for improving caregiver self-management confidence.

Prospective trial registration and publication rates of randomized clinical trials in digital health: A cross-sectional analysis of global trial registries

Objectives

We sought to examine the prevalence of prospective registration and publication rates in digital health trials.

Materials and Methods

We included 417 trials that enrolled participants in 2012 and were registered in any of the 17 WHO data provider registries. The evaluation of the prospective trial registration was based on the actual difference between the registration and enrollment dates. We identified existing publications through an automated PubMed search by every trial registration number as well as a pragmatic search in PubMed and Google based on extracted metadata from the trial registries.

Results

The prospective registration and publication rates were at (38.4%) and (65.5%), respectively. We identified a statistically significant ( p < 0.001) “Selective Registration Bias” with 95.7% of trials published within a year after registration, were registered retrospectively. We reported a statistically significant relationship ( p = 0.003) between prospective registration and funding sources, with industry-funded trials having the lowest compliance with prospective registration at (14.3%). The lowest non-publication rates were in the Middle East (26.7%) and Europe (28%), and the highest were in Asia (56.5%) and the U.S. (42.5%). We found statistically significant differences ( p < 0.001) between trial location and funding sources with the highest percentage of industry-funded trials in Asia (17.4%) and the U.S. (3.3%).

Conclusion

The adherence of investigators to the best practices of trial registration and result dissemination is still evolving in digital health trials. Further research is required to identify contributing factors and mitigation strategies to low compliance rate with trial publication and prospective registration in digital health trials.

Use of YouTube as a Source of Information for Quitting or Cutting Down Alcohol

Background: Although research has been done on considering YouTube for dissuading and encouraging unhealthy behaviours such as smoking, less focus has been placed on its role in quitting or cutting down alcohol. This study aims to analyse the alcohol cessation videos available and accessible on YouTube to gain a more in-depth insight into the ways that YouTube as a platform is being used to persuade with relation to alcohol cessation.

Methods: We systematically searched for content on YouTube related to alcohol cessation and these videos were analysed and evaluated for the format, themes, specific alcohol cessation advice, and uploader.

Results: The results demonstrated that the collected alcohol cessation videos included a fairly even presence of the themes of discussing the negative impacts of alcohol and the benefits of quitting or staying away from it. At the same time, however, we found the videos were not sourced from professional institutions, such as government or anti-alcohol misuse non-government organisations.

Conclusion: More research is needed to investigate utilising YouTube to support those looking to quit or cut down alcohol.

Usability of a Technology-Based Bystander Bullying Intervention for Middle School Students in Rural, Low-Income Communities: Mixed Methods Study

BACKGROUND

Students who are targets of bullying and who witness bullying are at high risk for negative mental health outcomes. Bystander training is essential to reduce bullying and the negative associated consequences for targets and bystanders. Resources necessary for program delivery, however, pose significant barriers for schools, particularly those in rural, low-income communities. Technology-based programs can reduce health disparities for students in these communities through cost-effective, easy-to-disseminate programming.

OBJECTIVE

The aim of this study is to conduct usability testing of a bystander bullying web app prototype, STAC-T (technology-based STAC, which stands for the 4 bystander strategies Stealing the Show, Turning it Over, Accompanying Others, and Coaching Compassion) as an initial step in the development of a full-scale STAC-T intervention. Objectives include assessing usability and acceptability of the STAC-T prototype, understanding school needs and barriers to program implementation, and assessing differences in usability between school personnel and students.

METHODS

A sample of 16 participants, including school personnel and students recruited from 3 middle schools in rural, low-income communities, completed usability testing followed by a qualitative interview. Descriptive statistics, 2-tailed independent sample t tests, and consensual qualitative research were used to assess usability and program satisfaction and to extract themes related to acceptability, feasibility, needs, barriers, and feedback for intervention development.

RESULTS

Usability testing indicated that the app was easy to use, acceptable, and feasible. Both school personnel (mean rating 89.6, SD 5.1) and students (mean rating 91.8, SD 7.0) rated the app well above the standard cutoff score for above-average usability (ie, 68), and both school personnel (mean rating 5.83, SD 0.41) and students (mean rating 6.10, SD 0.57) gave the app high user-friendliness ratings (0-7 scale, with 7 as high user-friendliness). The overall ratings also suggested that school personnel and students were satisfied with the program. Of the 6 school personnel who said they would recommend the program, 1 (17%), 4 (66%), and 1 (17%) rated the program as 3, 4, and 5 stars, respectively; 80% (8/10) of students said they would recommend the program; and 60% (6/10) and 40% (4/10) rated the program as 4 stars and 5 stars, respectively. Qualitative data revealed that school personnel and students found the STAC-T app to be useful, user-friendly, and relevant, while providing feedback related to the importance of digital learning activities that engage the user. Data from school personnel also indicated positive perceptions regarding program feasibility and probability of program adoption, with the most significant barrier being cost, suggesting the importance of considering the financial resources available to schools in rural, low-income communities when setting the price point for the full-scale STAC-T intervention.

CONCLUSIONS

This study provides support for the full-scale development of the STAC-T app and provides key information for revision to enhance used engagement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04681495; https://clinicaltrials.gov/ct2/show/NCT04681495.

The ideal mHealth-application for rheumatoid arthritis: qualitative findings from stakeholder focus groups

Background

Shifts in treatment strategies for rheumatoid arthritis (RA) have made ambulatory care more labour-intensive. These developments have prompted innovative care models, including mobile health (mHealth) applications. This study aimed to explore the perceptions of mHealth-inexperienced stakeholders concerning these applications in RA care.

Methods

We performed a qualitative study by focus group interviews of stakeholders including RA patients, nurses specialised in RA care and rheumatologists. The qualitative analysis guide of Leuven (QUAGOL), which is based on grounded theory principles, was used to thematically analyse the data. In addition, the Persuasive Systems Design (PSD) model was used to structure recommended app-features.

Results

In total, 2 focus groups with nurses (total n = 16), 2 with patients (n = 17) and 2 with rheumatologists (n = 25) took place. Six overarching themes emerged from the analysis. Efficiency of care and enabling patient empowerment were the two themes considered as expected benefits of mHealth-use in practice by the stakeholders. In contrast, 4 themes emerged as possible barriers of mHealth-use: the burden of chronic app-use, motivational aspects, target group aspects, and legal and organisational requirements. Additionally, recommendations for an ideal mHealth-app could be structured into 4 domains (Primary Task Support, Dialogue Support, Social Support and System Credibility) according to the PSD-framework. Most recommended features were related to improving ease of use (Task Support) and System Credibility.

Conclusions

Although mHealth-apps were expected to improve care efficiency and stimulate patient empowerment, stakeholders were concerned that mHealth-app use could reinforce negative illness behaviour. For mHealth-apps to be successful in practice, challenges according to stakeholders were avoiding long-term poor compliance, finding the target audience and tailoring a legal and organisational framework. Finally, the ideal mHealth-application should above all be trustworthy and easy to use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04624-8.

Theory Integration for Lifestyle Behavior Change in the Digital Age: An Adaptive Decision-Making Framework

Despite the growing popularity of digital health interventions, limitations of traditional behavior change theories and a lack of theory integration hinder theory-driven behavior change applications. In this paper, we aim to review theories relevant to lifestyle behavior change from the broader psychology literature and then integrate these theories into a new theoretical framework called adaptive decision-making to address two specific problems. First, our framework represents lifestyle behaviors at two levels-one of individual daily decisions (action level) and one of larger behavioral episodes (reflection level)-to more closely match the temporal characteristics of lifestyle behaviors and their associated digital data. Second, the framework connects decision-making theories and learning theories to explain how behaviors and cognitive constructs dynamically influence each other, making it a suitable scaffold for building computational models. We map common digital intervention techniques onto the behavioral and cognitive processes in the framework and discuss possible contributions of the framework to both theory development and digital intervention design.

Technology-Based Bullying Intervention for Rural Schools: Perspectives on Needs, Challenges, and Design

Bullying is a significant problem in the United States, with 26.7% of middle school students reporting bullying victimization. The majority of bullying programs are comprehensive, school-wide interventions that require significant resources for implementation, creating barriers and challenges for schools in rural and low-income communities. To increase access for these schools, we propose to translate a brief, bystander bullying intervention (STAC) into a technology-based format. Using consensual qualitative research (CQR), we aimed to understand the needs of school personnel and perceived challenges to program implementation to provide information on how to best serve middle schools in rural and low-income communities. We conducted interviews and focus groups with key school personnel at three middle schools in rural, low-income communities (N = 15). Participants indicated a strong interest in a technology-based bullying intervention and reported positive conditions for implementation including administrative support and technology-readiness. Participants identified program efficacy, flexibility of delivery, and parental involvement as important components of bullying prevention and identified implementation challenges, which included time, financial resources, and teacher buy-in. Perceived strengths of the STAC intervention included providing a clear definition of bullying, skills training and practice, and a certificate of completion. Feedback related to translating the intervention to a technology-based format included the use of virtual interaction and a hybrid virtual/in-person program, particularly for booster-sessions. Findings from this study support the need for the proposed technology-based STAC intervention and provide feedback on both the needs and challenges that need to be addressed for successful implementation in middle schools in rural and low-income communities.

Anesthesia in the modern world of apps and technology: Implications and impact on wellness

Recent decades have seen an unprecedented leap in digital innovation, with far-reaching implications in healthcare. Anesthesiologists have historically championed the adoption of new technologies. However, the rapid evolution of these technologies has outpaced attempts at studying their potential impact on healthcare providers' well-being. This document introduces several categories of workplace technologies commonly encountered by the anesthesiologist. We examine examples of novel technology and the impact of these digital interventions on the anesthesiologist's well-being. We also review popular personalized technology aimed at improving wellness and the impact on well-being examined. Finally, technology acceptance models are introduced to improve technology adoption, which, when appropriately applied, may minimize the negative impacts of technology on anesthesiologists' well-being. Incorporating quantitative, serial assessments of well-being as part of technology implementation are proposed as a future direction for examining the wellness impact of technology on anesthesiologists.

The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

BACKGROUND

Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses.

OBJECTIVE

This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses.

METHODS

A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance.

RESULTS

Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features.

CONCLUSIONS

More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

Patients' User Experience of a Blended Face-to-Face and Web-Based Smoking Cessation Treatment: Qualitative Study

Background

Blended web-based and face-to-face (F2F) treatment is a promising electronic health service because the strengths of one mode of delivery should compensate for the weaknesses of the other.

Objective

The aim of this study was to explore this compensation by examining patients’ user experience (UX) in a blended smoking cessation treatment (BSCT) in routine care.

Methods

Data on patients’ UX were collected through in-depth interviews (n=10) at an outpatient smoking cessation clinic in the Netherlands. A content analysis of the semantic domains was used to analyze patients’ UX. To describe the UX, the Hassenzahl UX model was applied, examining 4 of the 5 key elements of UX from a user’s perspective: (1) patients’ standards and expectations, (2) apparent character (pragmatic and hedonic attributes), (3) usage situation, and (4) consequences (appeal, emotions, and behavior).

Results

BSCT appeared to be a mostly positively experienced service. Patients had a positive-pragmatic standard and neutral-open expectation toward BSCT at the treatment start. The pragmatic attributes of the F2F sessions were mostly perceived as positive, whereas the pragmatic attributes of the web sessions were perceived as both positive and negative. For the hedonic attributes, there seemed to be a difference between the F2F and web sessions. Specifically, the hedonic attributes of the web sessions were experienced as mostly negative, whereas those of the F2F sessions were experienced as mostly positive. For the usage situation, the physical and social contexts were experienced positively, whereas the task and technical contexts were experienced negatively. Nevertheless, the consequential appeal of BSCT was positive. However, the consequential emotions and behavior varied, ultimately resulting in diverse combinations of consequential appeal, emotions, and behavior (positive, negative, and mixed).

Conclusions

This study provided insights into the UX of a blended treatment, and the results support the expectation that in a blended treatment, the strengths of one mode of delivery may compensate for the weaknesses of the other. However, in this certain setting, this is mainly achieved in only one way: F2F sessions compensated for the weaknesses of the web sessions. As a practical conclusion, this may mean that the web sessions, supported by the strengths of the F2F sessions, offer an interesting approach for further improving the blended treatment. Our theoretical findings reflect the relevance of the aspects of hedonism, such as fun, joy, or happiness in the UX, which were not mentioned in relation to the web sessions and were only scarcely mentioned in relation to the F2F sessions. Future research should further investigate the role of hedonistic aspects in a blended treatment and whether increased enjoyment of a blended treatment could increase treatment adherence and, ultimately, effectiveness.

The Effectiveness of Electronic Health Interventions for Promoting HIV-Preventive Behaviors Among Men Who Have Sex With Men: Meta-Analysis Based on an Integrative Framework of Design and Implementation Features

Background

The disproportionately high prevalence of HIV among men who have sex with men (MSM) is a global concern. Despite the increasing utilization of electronic health (eHealth) technology in the delivery of HIV prevention interventions, few studies have systematically explored its effectiveness and association with various intervention characteristics.

Objective

This study aimed to conduct a meta-analysis of the effectiveness of eHealth technology–based interventions for promoting HIV-preventive behaviors among MSM and to determine effectiveness predictors within a framework integrating design and implementation features.

Methods

A systematic literature search using terms related to eHealth technology, HIV, the MSM population, and an experimental study design was performed using 5 databases (ie, MEDLINE, PsycINFO, EMBASE, Web of Science, and ProQuest Dissertations & Theses) and other sources (eg, bibliographies of relevant reviews and JMIR Publications). First, primary meta-analyses were conducted to estimate the effectiveness of eHealth interventions (d₊) in changing 3 HIV-preventive behaviors among MSM: unprotected anal intercourse (UAI), HIV testing, and multiple sex partnership (MSP). Moderation analyses were then conducted to examine a priori effectiveness predictors including behavioral treatment components (eg, theory use, tailoring strategy use, navigation style, and treatment duration), eHealth technology components (eg, operation mode and modality type), and intervention adherence.

Results

A total of 46 studies were included. The overall effect sizes at end point were small but significant for all outcomes (UAI: d₊=−.21, P<.001; HIV testing: d₊=.38, P<.001; MSP: d₊=−.26, P=.02). The intervention effects on UAI were significantly larger when compared with preintervention groups than with concurrent groups. Greater UAI reductions were associated with the increased use of tailoring strategies, provision of feedback, and tunneling navigation in interventions with a concurrent group, whereas reductions were associated with the use of self-paced navigation in interventions with a preintervention group. Greater uptake of HIV testing was associated with longer treatment duration; computer-mediated communication; and the use of messaging, social media, or a combined technology modality. Higher intervention adherence consistently predicted larger effects on UAI and HIV testing.

Conclusions

This study provided empirical evidence for the effectiveness of eHealth interventions in promoting HIV-preventive behaviors among MSM. Features of treatment content and eHealth technology might best predict the intervention effects on UAI and HIV testing, respectively. Most importantly, intervention adherence tended to play an important role in achieving better effectiveness. The findings could help inform the development of efficacious interventions for HIV prevention in the future.

A Web-Based Alcohol Risk Communication Tool: Development and Pretesting Study

Background

Alcohol use is a major public health concern associated with an increased risk of morbidity and mortality. Health professionals in primary care commonly see patients with a range of alcohol-related risks and problems, providing an ideal opportunity for screening and brief intervention (BI).

Objective

This study aimed to develop a prototype for a Web-based tool for use by primary care health professionals (eg, doctors and nurses) to communicate alcohol harm risk to their patients and to engage with them regarding ways this risk could be reduced.

Methods

Following conceptualization and development of prototype wireframes, formative work and pretesting were undertaken. For the formative work, focus groups and key informant interviews were conducted with potential end users of the risk communication tool, including health professionals and consumers. The focus groups and interviews explored perceptions of alcohol risk communication and obtained feedback on the initial prototype. For pretesting, participants (primary care doctors and nurses) completed a Web-based survey followed by a period of pretesting before completion of a follow-up survey. The study was designed to gain feedback on the tool’s performance in real-world settings as well as its relevance, ease of use, and any suggested refinements.

Results

In the formative work stage, 11 key informants and 7 consumers participated in either focus groups or individual interviews. Participants were very positive about the prototype and believed that it would be useful and acceptable in practice. Key informants identified that the key point of difference with the tool was that it provided all the pieces in 1 place (ie, assessment, interpretation, and resources to support change). Participants provided feedback on how the tool could be improved, and these suggestions were incorporated into the prototype where possible. In the pretesting stage, 7 people (5 doctors and 2 primary care nurses) completed the pretesting. Participants reported that the tool provided a useful framework for an intervention, that it would be acceptable to patients, that it was easy to use, that they would be likely to use it in practice, and that there were no technical issues.

Conclusions

The alcohol risk communication tool was found to be acceptable and has the potential to increase the confidence of health professionals in assessing risk and providing BI.

Apps for Mental Health: An Evaluation of Behavior Change Strategies and Recommendations for Future Development

Mobile applications have shown promise in supporting people with mental health issues to adopt healthy lifestyles using various persuasive strategies. However, the extent to which mental health apps successfully employ various persuasive strategies remains unknown. Hence, it is important to understand the persuasive strategies integrated into mental health applications (apps) and how they are implemented to promote mental health. This paper aims to achieve three main objectives. First, we review 103 mental health apps and identify distinct persuasive strategies incorporated in them using the Persuasive Systems Design (PSD) model and Behavior Change Techniques (BCTs). We further classify the persuasive strategies based on the type of mental health issues the app is focused on. Second, we reveal the various ways that the persuasive strategies are implemented/operationalized in mental health apps to achieve their intended objectives. Third, we examine the relationship between apps effectiveness (measured by user ratings) and the persuasive strategies employed. To achieve this, two researchers independently downloaded and used all identified apps to identify the persuasive strategies using the PSD model and BCTs. Next, they also examine the various ways that these strategies are implemented in mental health apps. The results show that the apps employed 26 distinct persuasive strategies and a range of 1–10 strategies per app. Self-monitoring (n = 59), personalization (n = 55), and reminder (n = 49) were the most frequently employed strategies. We also found that anxiety, stress, depression, and general mental health issues were the common mental health issues targeted by the apps. Finally, we offer some design recommendations for designing mental health apps based on our findings.

Patterns of Cannabis Consumption, Social Networks, and Foraging

This study considered contextual factors (i.e., times, places, peers) associated with cannabis use. A total of 153 participants answered an anonymous online survey, completed the Cannabis Use Disorders Identification Test – Revised (CUDIT-R), and indicated their numbers of regular smoking partners, and times and places cannabis was normally purchased. Recent cannabis smokers had higher CUDIT-R scores and purchased cannabis from more places more often. Multiple regression considered subscales of the CUDIT-R. Greater cannabis consumption was associated with more smoking partners and purchases of cannabis at more times and places. Cannabis dependence was associated with cannabis purchases from more places and times and reports that there were more people prepared to do them favors. Harmful use was associated with more purchases at more locations. Patterns of cannabis foraging were compared with foraging behaviors previously observed for caffeine, nicotine, and alcohol. The data could inform the development and use of social media and location-aware services seeking to target risky substance use.

Potential Reduction of Symptoms With the Use of Persuasive Systems Design Features in Internet-Based Cognitive Behavioral Therapy Programs for Children and Adolescents With Anxiety: A Realist Synthesis

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) for children and adolescents is a persuasive system that combines 3 major components to therapy-therapeutic content, technological features, and interactions between the user and program-intended to reduce users' anxiety symptoms. Several reviews report the effectiveness of iCBT; however, iCBT design and delivery components differ widely across programs, which raise important questions about how iCBT effects are produced and can be optimized.

OBJECTIVE

The objective of this study was to review and synthesize the iCBT literature using a realist approach with a persuasive systems perspective to (1) document the design and delivery components of iCBT and (2) generate hypotheses as to how these components may explain changes in anxiety symptoms after completing iCBT.

METHODS

A multi-strategy search identified published and gray literature on iCBT for child and adolescent anxiety up until June 2019. Documents that met our prespecified inclusion criteria were appraised for relevance and methodological rigor. Data extraction was guided by the persuasive systems design (PSD) model. The model describes 28 technological design features, organized into 4 categories that help users meet their health goals: primary task support, dialogue support, system credibility support, and social support. We generated initial hypotheses for how PSD (mechanisms) and program delivery (context of use) features were linked to symptom changes (outcomes) across iCBT programs using realist and meta-ethnographic techniques. These hypothesized context-mechanism-outcome configurations were refined during analysis using evidence from the literature to improve their explanatory value.

RESULTS

A total of 63 documents detailing 15 iCBT programs were included. A total of six iCBT programs were rated high for relevance, and most studies were of moderate-to-high methodological rigor. A total of 11 context-mechanism-outcome configurations (final hypotheses) were generated. Configurations primarily comprised PSD features from the primary task and dialogue support categories. Several key PSD features (eg, self-monitoring, simulation, social role, similarity, social learning, and rehearsal) were consistently reported in programs shown to reduce anxiety; many features were employed simultaneously, suggesting synergy when grouped. We also hypothesized the function of PSD features in generating iCBT impacts. Adjunct support was identified as an important aspect of context that may have complemented certain PSD features in reducing users' anxiety.

CONCLUSIONS

This synthesis generated context-mechanism-outcome configurations (hypotheses) about the potential function, combination, and impact of iCBT program components thought to support desired program effects. We suggest that, when delivered with adjunct support, PSD features may contribute to reduced anxiety for child and adolescent users. Formal testing of the 11 configurations is required to confirm their impact on anxiety-based outcomes. From this we encourage a systematic and deliberate approach to iCBT design and evaluation to increase the pool of evidence-based interventions available to prevent and treat children and adolescents with anxiety.

Testing a Brief Web-based Intervention to Increase Recognition of Tobacco Constituents

Objective

We examined website formats to increase smokers' recognition of harmful and potentially harmful constituents (HPHCs) in cigarettes.

Methods

Adult, daily smokers (N = 279) were randomized to view a brief, single-page study website showing HPHC names and uses. The intervention site was tailored + interactive, labeled by cigarette brand/subbrand showing color imagery and pop-up boxes; the generic + static website (control) was unbranded in greyscale. Eye tracking equipment measured attention (dwell time) to precise website features. Linear regression analyses compared attention to HPHC descriptions and the correct recognition of 15 HPHC chemicals. A randomly selected sub-sample (N = 30) of participants qualitatively rated website usability.

Results

Despite spending less dwell time on the HPHC text and entire website, adult smokers who viewed the generic + static website had greater improvement in HPHC recognition compared to the tailored + interactive website (4.6 vs 3.6; p = .02); this finding contrasts with current literature on tailoring and interactivity. Both websites were rated highly on ease-of-use and readability.

Conclusions

Basic formats and narrative HPHC Web-based content attracted less visual attention, yet increased recognition of these chemicals in cigarettes, compared to brand-tailored, interactive web-based content.

Persuasive design features within a consumer-focused eHealth intervention integrated with the electronic health record: A mixed methods study of effectiveness and acceptability

INTRODUCTION

eHealth strategies targeting health-related behaviour often incorporate persuasive software design. To further engage patients with their overall health management, consumer-facing web portals may be integrated with data from one or more care providers. This study aimed to explore effectiveness for healthier behaviour of persuasive design characteristics within a web application integrated with the primary health care electronic record; also patient and general practitioner (GP) preferences for future integrated records.

METHODS

Mixed methods study within the Consumer Navigation of Electronic Cardiovascular Tools randomised controlled trial. Participants were patients with moderate-high risk of cardiovascular disease, and their GPs. Survey and web analytic data were analysed with descriptive statistics. Interview and focus group transcripts were recorded, transcribed, coded and analysed for themes.

RESULTS

Surveys (n = 397) received from patients indicated improved medication adherence (31.8%); improved mental health and well-being (40%); higher physical activity (47%); and healthier eating (61%). Users of the interactive features reported benefiting from personalised cardiovascular disease risk score (73%); goal tracking (69%); risk factor self-monitoring (52%) and receipt of motivational health tips (54%). Focus group and interview participants (n = 55) described customisations that would increase portal appeal and relevance, including more provider interaction. Of the GP survey respondents (n = 38), 74% reported increased patient attendance and engagement with their care. For future integrated portals, 94% of GPs were in favour and key themes among interviewees (n = 17) related to design optimisation, impact on workflow and data security.

CONCLUSION

Intervention features reflecting the persuasive design categories of Primary Task support, Dialogue support and System Credibility support facilitated healthier lifestyle behaviour. Patients valued customisable functions and greater patient-provider interactivity. GPs identified system challenges but saw advantages for patients and the health care relationship. Future studies could further elucidate the persuasive design principles that are at play and which may promote adoption of EHR-integrated consumer portals.

Design and Delivery Features That May Improve the Use of Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Anxiety: A Realist Literature Synthesis With a Persuasive Systems Design Perspective

Background

Internet-based cognitive behavioral therapy (iCBT) is a persuasive system as its design combines therapeutic content, technological features, and interactions between the user and the program to reduce anxiety for children and adolescents. How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use (eg, module completion) are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects.

Objective

The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes.

Methods

A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories—Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs.

Results

A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features (Tailoring, Personalization [Primary task supports]; Rewards, Reminders, Social role [Dialogue supports]; and Trustworthiness, Expertise, Authority [System credibility supports]) associated with moderate-to-high program use. Important features of delivery Context were adjunct support (a face-to-face, Web- or email-based communications component) and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use.

Conclusions

The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users.

Nonpublication Rates and Characteristics of Registered Randomized Clinical Trials in Digital Health: Cross-Sectional Analysis

Background

Clinical trials are key to advancing evidence-based medical research. The medical research literature has identified the impact of publication bias in clinical trials. Selective publication for positive outcomes or nonpublication of negative results could misdirect subsequent research and result in literature reviews leaning toward positive outcomes. Digital health trials face specific challenges, including a high attrition rate, usability issues, and insufficient formative research. These challenges may contribute to nonpublication of the trial results. To our knowledge, no study has thus far reported the nonpublication rates of digital health trials.

Objective

The primary research objective was to evaluate the nonpublication rate of digital health randomized clinical trials registered in ClinicalTrials.gov. Our secondary research objective was to determine whether industry funding contributes to nonpublication of digital health trials.

Methods

To identify digital health trials, a list of 47 search terms was developed through an iterative process and applied to the “Title,” “Interventions,” and “Outcome Measures” fields of registered trials with completion dates between April 1, 2010, and April 1, 2013. The search was based on the full dataset exported from the ClinlicalTrials.gov database, with 265,657 trials entries downloaded on February 10, 2018, to allow publication of studies within 5 years of trial completion. We identified publications related to the results of the trials through a comprehensive approach that included an automated and manual publication-identification process.

Results

In total, 6717 articles matched the a priori search terms, of which 803 trials matched our latest completion date criteria. After screening, 556 trials were included in this study. We found that 150 (27%) of all included trials remained unpublished 5 years after their completion date. In bivariate analyses, we observed statistically significant differences in trial characteristics between published and unpublished trials in terms of the intervention target condition, country, trial size, trial phases, recruitment, and prospective trial registration. In multivariate analyses, differences in trial characteristics between published and unpublished trials remained statistically significant for the intervention target condition, country, trial size, trial phases, and recruitment; the odds of publication for non-US–based trials were significant, and these trials were 3.3 (95% CI 1.845-5.964) times more likely to be published than US–based trials. We observed a trend of 1.5 times higher nonpublication rates for industry-funded trials. However, the trend was not statistically significant.

Conclusions

In the domain of digital health, 27% of registered clinical trials results are unpublished, which is lower than nonpublication rates in other fields. There are substantial differences in nonpublication rates between trials funded by industry and nonindustry sponsors. Further research is required to define the determinants and reasons for nonpublication and, more importantly, to articulate the impact and risk of publication bias in the field of digital health trials.

A randomized clinical trial of the effectiveness of a Web-based health behaviour change support system and group lifestyle counselling on body weight loss in overweight and obese subjects: 2-year outcomes

BACKGROUND

Weight loss can prevent and treat obesity-related diseases. However, lost weight is usually regained, returning to the initial or even higher levels in the long term. New counselling methods for maintaining lifestyle changes are urgently needed.

OBJECTIVES

An information and communication technology-based health behaviour change support system (HBCSS) that utilizes persuasive design and methods of cognitive behavioural therapy (CBT) was developed with the aim of helping individuals to maintain body weight. The purpose of this study was to assess whether CBT-based group counselling combined with HBCSS or HBCSS alone helps to maintain improved lifestyle changes needed for weight loss compared to self-help guidance or usual care.

METHODS

A randomized lifestyle intervention for overweight or obese persons (BMI 27-35 kg m^-2 and age 20-60 years), recruited from the population registry in the city of Oulu, Finland, was conducted. This study comprised six randomly assigned study arms: CBT-based group counselling (eight sessions led by a nutritionist), self-help guidance-based group counselling (SHG; two sessions led by a nurse) and control, each with or without HCBSS, for 52 weeks. Subjects visited the study centre for anthropometric measurements, blood sample collection and to complete questionnaires at baseline, 12 and 24 months. The main outcome was weight change from baseline to 12 months and from baseline to 24 months.

RESULTS

Of the 1065 volunteers screened for the study, 532 subjects (51% men) met the inclusion criteria and were enrolled. The retention rate was 80% at 12 months and 70% at 24 months. CBT-based counselling with HBCSS produced the largest weight reduction without any significant weight gain during follow-up. The mean weight change in this arm was 4.1% [95% confidence interval (CI), -5.4 to -2.8, P < 0.001) at 12 months and 3.4% (95% CI, -4.8 to -2.0, P < 0.001) at 24 months. HBCSS even without any group counselling reduced the mean weight by 1.6% (95% CI, -2.9 to -0.3, P = 0.015) at 24 months.

CONCLUSION

The combination of CBT-based group counselling and HBCSS-based weight management is feasible for overweight or obese individuals. Moreover, HBCSS alone could be disseminated to the population at large as an effective means of treating obesity.

Users' Intrinsic Goals Linked to Alcohol Dependence Risk Level and Engagement With a Health Promotion Website (Hello Sunday Morning): Observational Study

BACKGROUND

Hello Sunday Morning (HSM) is a self-guided health promotion website with the aim to improve drinking culture. Members are encouraged to sign up for a 3-month period of alcohol abstention and record and track their progress and goals.

OBJECTIVE

This study used self-determination theory (SDT) to examine the nature of goals subscribed by HSM users to test the extent to which intrinsic goal pursuit was linked to lower alcohol dependency risk and higher engagement with the HSM website.

METHODS

HSM users (N=2216; 59.75%, 1324/2216, females; aged 18-79 years) completed the World Health Organization's Alcohol Use Disorders Identification Test (WHO-AUDIT, which measures alcohol dependence risk level) at sign-up and at 4 and 6 months after sign-up. In addition, the website had a goals-subscription feature that allowed participants to share their goals. Two independent raters classified the goals according to a coding system we devised based on SDT, which proposes that intrinsic goals (eg, growth, relationships, community, and health) better promote positive outcomes than extrinsic goals (eg, wealth, fame, and image).

RESULTS

Although there was substantial (1016/2216, 45.84%) attrition of HSM users from sign-up to 6 months, the attrition rate could not be attributed to alcohol dependency risk because people in different WHO-AUDIT risk zones were equally likely to be missing at 4 and 6 months after sign-up. The SDT-driven coding of goals yielded the following categories: wealth and image (extrinsic goals); relationships, personal growth, community engagement, and physical health (intrinsic goals); and alcohol use-related goals (which were hard to classify as either extrinsic or intrinsic). Alcohol dependence risk level correlated positively with goals related to money (r=.16), personal growth (r=.17), relationships (r=.10), and alcohol use (r=.25). Website engagement correlated negatively with alcohol dependence risk level (r=.10) and positively with relationship (r=.10) and community goals (r=.12).

CONCLUSIONS

HSM users with higher alcohol dependence risk tended to engage with the website less, but to the extent that they did, they tended to subscribe to goals related to alcohol use and improving their personal growth, relationships, and finances. In line with SDT, engagement with goals-particularly the intrinsic goals of connecting with close-others and the broader community-related to increased website engagement. Web-based tools intended to promote healthy behaviors in users may be effective in engaging their users if the users' experience on the website supports the pursuit of intrinsic goals.

Embedding persuasive design for self-health management systems in Dutch healthcare informatics education: Application of a theory-based method

The development of eHealth is dramatically changing the way healthcare is provided and organized. eHealth applications are used not only by healthcare professionals but also by patients specifically to self-manage their health condition. The development of eHealth applications requires a new methodological approach, departing from the more conventional methods dedicated to designing health information systems. There is a gap between theories to design persuasive eHealth applications and practices. In the Netherlands, eHealth innovation emerges from three areas. In research, the development of eHealth application often remains in a pilot phase. Healthcare organizations are also keen to innovate but do not always have the know-how. We further witness technology push from business and industry, undermining the co-creation process of the innovation. We consequently advocate an integrated, systematic and practical but scientifically based methodology to design effective persuasive eHealth applications. This approach is being successfully embedded in our educational health informatics program.

Blended Smoking Cessation Treatment: Exploring Measurement, Levels, and Predictors of Adherence

Background

Blended face-to-face and Web-based treatment is a promising way to deliver cognitive behavioral therapy. Since adherence has been shown to be a measure for treatment’s acceptability and a determinant for treatment’s effectiveness, in this study, we explored adherence to a new blended smoking cessation treatment (BSCT).

Objective

The objective of our study was to (1) develop an adequate method to measure adherence to BSCT; (2) define an adequate degree of adherence to be used as a threshold for being adherent; (3) estimate adherence to BSCT; and (4) explore the possible predictors of adherence to BSCT.

Methods

The data of patients (N=75) were analyzed to trace adherence to BSCT delivered at an outpatient smoking cessation clinic. In total, 18 patient activities (eg, using a Web-based smoking diary tool or responding to counselors’ messages) were selected to measure adherence; the degree of adherence per patient was compared with quitting success. The minimum degree of adherence of patients who reported abstinence was examined to define a threshold for the detection of adherent patients. The number of adherent patients was calculated for each of the 18 selected activities; the degree of adherence over the course of the treatment was displayed; and the number of patients who were adherent was analyzed. The relationship between adherence and 33 person-, smoking-, and health-related characteristics was examined.

Results

The method for measuring adherence was found to be adequate as adherence to BSCT correlated with self-reported abstinence (P=.03). Patients reporting abstinence adhered to at least 61% of BSCT. Adherence declined over the course of the treatment; the percentage of adherent patients per treatment activity ranged from 82% at the start of the treatment to 11%-19% at the final-third of BSCT; applying a 61% threshold, 18% of the patients were classified as adherent. Marital status and social modeling were the best independent predictors of adherence. Patients having a partner had 11-times higher odds of being adherent (OR [odds ratio]=11.3; CI: 1.33-98.99; P=.03). For social modeling, graded from 0 (=partner and friends are not smoking) to 8 (=both partner and nearly all friends are smoking), each unit increase was associated with 28% lower odds of being adherent (OR=0.72; CI: 0.55-0.94; P=.02).

Conclusions

The current study is the first to explore adherence to a blended face-to-face and Web-based treatment (BSCT) based on a substantial group of patients. It revealed a rather low adherence rate to BSCT. The method for measuring adherence to BSCT could be considered adequate because the expected dose-response relationship between adherence and quitting could be verified. Furthermore, this study revealed that marital status and social modeling were independent predictors of adherence.

Trial Registration

Netherlands Trial Registry NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113 (Archived by WebCite at http://www.webcitation.org/71BAPwER8).

Persuasive technology to support active and healthy ageing: An exploration of past, present, and future

The age of the population worldwide is rapidly increasing, bringing social and economic challenges. Persuasive technology can alleviate the burden on traditional healthcare services when used to support healthy behaviors, for instance in the prevention and treatment of chronic diseases. Additionally, healthy behaviors are key factors for active and healthy ageing by delaying or even reversing functional decline. In this manuscript, we present a multi-perspective analysis of technologies that can be used in the support of active and healthy ageing in the daily life. First, we take the perspective of physical and mental health, by focusing on the promotion of physical activity and emotional wellbeing. From a temporal perspective, we look at how technology evolved from past, present and future. The overview of the literature is structured in four main sections: (1) measurement of current behavior (monitoring), (2) analysis of the data gathered to derive meaningful information (analyzing & reasoning), (3) support the individual in the adoption or maintenance of a behavior (coaching), and (4) tools or interfaces that provide the information to the individual to stimulate the desired behavior (applications). Finally, we provide recommendations for the design, development and implementation of future technological innovations to support Active and Healthy Ageing in daily life.

Socially-driven persuasive health intervention design: Competition, social comparison, and cooperation

Persuasive technologies are tools for motivating behaviour change using persuasive strategies. socially-driven persuasive technologies employ three common socially-oriented persuasive strategies in many health domains: competition, social comparison, and cooperation. Research has shown the possibilities for socially-driven persuasive interventions to backfire by demotivating behaviour, but we lack knowledge about how the interventions could motivate or demotivate behaviours. To close this gap, we studied 1898 participants, specifically Socially-oriented strategies and their comparative effectiveness in socially-driven persuasive health interventions that motivate healthy behaviour change. The results of a thematic analysis of 278 pages of qualitative data reveal important strengths and weaknesses of the individual socially-oriented strategies that could facilitate or hinder their effectiveness at motivating behaviour change. These include their tendency to simplify behaviours and make them fun, challenge people and make them accountable, give a sense of accomplishment and their tendency to jeopardize user's privacy and relationships, creates unnecessary tension, and reduce self-confidence and self-esteem, and provoke a health disorder and body shaming, respectively. We contribute to the health informatics community by developing 15 design guidelines for operationalizing the strategies in persuasive health intervention to amplify their strengths and overcome their weaknesses.

A Pilot Randomized Controlled Trial of an Internet-Based Alcohol Intervention in a Workplace Setting

PURPOSE

The aim of this study was to compare the effectiveness of a brief and an intensive self-help alcohol intervention and to assess the feasibility of recruiting to such interventions in a workplace setting.

METHOD

Employees who screened positive for hazardous drinking (n = 85) received online personalized normative feedback and were randomly assigned to one out of two conditions: either they received an e-booklet about the effects of alcohol or they received a self-help intervention comprising 62 web-based, fully automated, and interactive sessions, plus reminder e-mails, and mobile phone text messages (Short Message Service).

RESULTS

Two months after baseline, the responders in the intensive condition drank an average of five to six drinks less per week compared to the responders in the brief condition (B = 5.68, 95% CI = 0.48-10.87, P = .03). There was no significant difference between conditions, using baseline observation carried forward imputation (B = 2.96, 95% CI = -0.50-6.42, P = .09). Six months after baseline, no significant difference was found, neither based on complete cases nor intent-to-treat (B = 1.07, 95% CI = -1.29-3.44, P = .37). Challenges with recruitment are thoroughly reported.

CONCLUSION

The study supports the feasibility and the safety of use for both brief and intensive Internet-based self-help in an occupational setting. The study may inform future trials, but due to recruitment problems and low statistical power, the findings are inconclusive in terms of the intensive program being more effective than brief intervention alone.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01931618.

Peer-Based Social Media Features in Behavior Change Interventions: Systematic Review

Background

Incorporating social media features into digital behavior change interventions (DBCIs) has the potential to contribute positively to their success. However, the lack of clear design principles to describe and guide the use of these features in behavioral interventions limits cross-study comparisons of their uses and effects.

Objective

The aim of this study was to provide a systematic review of DBCIs targeting modifiable behavioral risk factors that have included social media features as part of their intervention infrastructure. A taxonomy of social media features is presented to inform the development, description, and evaluation of behavioral interventions.

Methods

Search terms were used in 8 databases to identify DBCIs that incorporated social media features and targeted tobacco smoking, diet and nutrition, physical activities, or alcohol consumption. The screening and review process was performed by 2 independent researchers.

Results

A total of 5264 articles were screened, and 143 articles describing a total of 134 studies were retained for full review. The majority of studies (70%) reported positive outcomes, followed by 28% finding no effects with regard to their respective objectives and hypothesis, and 2% of the studies found that their interventions had negative outcomes. Few studies reported on the association between the inclusion of social media features and intervention effect. A taxonomy of social media features used in behavioral interventions has been presented with 36 social media features organized under 7 high-level categories. The taxonomy has been used to guide the analysis of this review.

Conclusions

Although social media features are commonly included in DBCIs, there is an acute lack of information with respect to their effect on outcomes and a lack of clear guidance to inform the selection process based on the features’ suitability for the different behaviors. The proposed taxonomy along with the set of recommendations included in this review will support future research aimed at isolating and reporting the effects of social media features on DBCIs, cross-study comparisons, and evaluations.

Self-Guided Web-Based Interventions: Scoping Review on User Needs and the Potential of Embodied Conversational Agents to Address Them

Background

Web-based mental health interventions have evolved from innovative prototypes to evidence-based and clinically applied solutions for mental diseases such as depression and anxiety. Open-access, self-guided types of these solutions hold the promise of reaching and treating a large population at a reasonable cost. However, a considerable factor that currently hinders the effectiveness of these self-guided Web-based interventions is the high level of nonadherence. The absence of a human caregiver apparently has a negative effect on user adherence. It is unknown to what extent this human support can be handed over to the technology of the intervention to mitigate this negative effect.

Objective

The first objective of this paper was to explore what is known in literature about what support a user needs to stay motivated and engaged in an electronic health (eHealth) intervention that requires repeated use. The second objective was to explore the current potential of embodied conversational agents (ECAs) to provide this support.

Methods

This study reviews and interprets the available literature on (1) support within eHealth interventions that require repeated use and (2) the potential of ECAs by means of a scoping review. The rationale for choosing a scoping review is that the subject is broad, diverse, and largely unexplored. Themes for (1) and (2) were proposed based on grounded theory and mapped on each other to find relationships.

Results

The results of the first part of this study suggest the presence of user needs that largely remain implicit and unaddressed. These support needs can be categorized as task-related support and emotion-related support. The results of the second part of this study suggest that ECAs are capable of engaging and motivating users of information technology applications in the domains of learning and behavioral change. Longitudinal studies must be conducted to determine under what circumstances ECAs can create and maintain a productive user relationship. Mapping the user needs on the ECAs’ capabilities suggests that different kinds of ECAs may provide different solutions for improving the adherence levels.

Conclusions

Autonomous ECAs that do not respond to a user’s expressed emotion in real time but take on empathic roles may be sufficient to motivate users to some extent. It is unclear whether those types of ECAs are competent enough and create sufficient believability among users to address the user’s deeper needs for support and empathy. Responsive ECAs may offer a better solution. However, at present, most of these ECAs have difficulties to assess a user’s emotional state in real time during an open dialogue. By conducting future research with relationship theory–based ECAs, the added value of ECAs toward user needs can be better understood.

Key Components in eHealth Interventions Combining Self-Tracking and Persuasive eCoaching to Promote a Healthier Lifestyle: A Scoping Review

BACKGROUND

The combination of self-tracking and persuasive eCoaching in automated interventions is a new and promising approach for healthy lifestyle management.

OBJECTIVE

The aim of this study was to identify key components of self-tracking and persuasive eCoaching in automated healthy lifestyle interventions that contribute to their effectiveness on health outcomes, usability, and adherence. A secondary aim was to identify the way in which these key components should be designed to contribute to improved health outcomes, usability, and adherence.

METHODS

The scoping review methodology proposed by Arskey and O'Malley was applied. Scopus, EMBASE, PsycINFO, and PubMed were searched for publications dated from January 1, 2013 to January 31, 2016 that included (1) self-tracking, (2) persuasive eCoaching, and (3) healthy lifestyle intervention.

RESULTS

The search resulted in 32 publications, 17 of which provided results regarding the effect on health outcomes, 27 of which provided results regarding usability, and 13 of which provided results regarding adherence. Among the 32 publications, 27 described an intervention. The most commonly applied persuasive eCoaching components in the described interventions were personalization (n=24), suggestion (n=19), goal-setting (n=17), simulation (n=17), and reminders (n=15). As for self-tracking components, most interventions utilized an accelerometer to measure steps (n=11). Furthermore, the medium through which the user could access the intervention was usually a mobile phone (n=10). The following key components and their specific design seem to influence both health outcomes and usability in a positive way: reduction by setting short-term goals to eventually reach long-term goals, personalization of goals, praise messages, reminders to input self-tracking data into the technology, use of validity-tested devices, integration of self-tracking and persuasive eCoaching, and provision of face-to-face instructions during implementation. In addition, health outcomes or usability were not negatively affected when more effort was requested from participants to input data into the technology. The data extracted from the included publications provided limited ability to identify key components for adherence. However, one key component was identified for both usability and adherence, namely the provision of personalized content.

CONCLUSIONS

This scoping review provides a first overview of the key components in automated healthy lifestyle interventions combining self-tracking and persuasive eCoaching that can be utilized during the development of such interventions. Future studies should focus on the identification of key components for effects on adherence, as adherence is a prerequisite for an intervention to be effective.

The Feasibility and Acceptability of a Web-Based Alcohol Management Intervention in Community Sports Clubs: A Cross-Sectional Study

Background

The implementation of comprehensive alcohol management strategies can reduce excessive alcohol use and reduce the risk of alcohol-related harm at sporting venues. Supporting sports venues to implement alcohol management strategies via the Web may represent an effective and efficient means of reducing harm caused by alcohol in this setting. However, the feasibility and acceptability of such an approach is unknown.

Objective

This study aimed to identify (1) the current access to and use of the Web and electronic devices by sports clubs; (2) the perceived usefulness, ease of use, and intention to use a Web-based program to support implementation of alcohol management policies in sports clubs; (3) the factors associated with intention to use such a Web-based support program; and (4) the specific features of such a program that sports clubs would find useful.

Methods

A cross-sectional survey was conducted with club administrators of community football clubs in the state of New South Wales, Australia. Perceived usefulness, ease of use and intention to use a hypothetical Web-based alcohol management support program was assessed using the validated Technology Acceptance Model (TAM) instrument. Associations between intention to use a Web-based program and club characteristics as well as perceived ease of use and usefulness was tested using Fisher’s exact test and represented using relative risk (RR) for high intention to use the program.

Results

Of the 73 football clubs that were approached to participate in the study, 63 consented to participate and 46 were eligible and completed the survey. All participants reported having access to the Web and 98% reported current use of electronic devices (eg, computers, iPads/tablets, smartphones, laptops, televisions, and smartboards). Mean scores (out of a possible 7) for the TAM constructs were high for intention to use (mean 6.25, SD 0.87), perceived ease of use (mean 6.00, SD 0.99), and perceived usefulness (mean 6.17, SD 0.85). Intention to use the Web-based alcohol management program was significantly associated with perceived ease of use (P=.02, RR 1.4, CI 1.0-2.9), perceived usefulness (P=.03, RR 1.5, CI 1.0-6.8) and club size (P=.02, RR 0.8, CI 0.5-0.9). The most useful features of such a program included the perceived ability to complete program requirements within users’ own time, complete program accreditation assessment and monitoring online, develop tailored action plans, and receive email reminders and prompts to complete action.

Conclusions

A Web-based alcohol management approach to support sports clubs in the implementation of recommended alcohol management policies appears both feasible and acceptable. Future research should aim to determine if such intended use leads to actual use and club implementation of alcohol management policies.

Comparing motivational, self-regulatory and habitual processes in a computer-tailored physical activity intervention in hospital employees - protocol for the PATHS randomised controlled trial

BACKGROUND

Most people do not engage in sufficient physical activity to confer health benefits and to reduce risk of chronic disease. Healthcare professionals frequently provide guidance on physical activity, but often do not meet guideline levels of physical activity themselves. The main objective of this study is to develop and test the efficacy of a tailored intervention to increase healthcare professionals' physical activity participation and quality of life, and to reduce work-related stress and absenteeism. This is the first study to compare the additive effects of three forms of a tailored intervention using different techniques from behavioural theory, which differ according to their focus on motivational, self-regulatory and/or habitual processes.

METHODS/DESIGN

Healthcare professionals (N = 192) will be recruited from four hospitals in Perth, Western Australia, via email lists, leaflets, and posters to participate in the four group randomised controlled trial. Participants will be randomised to one of four conditions: (1) education only (non-tailored information only), (2) education plus intervention components to enhance motivation, (3) education plus components to enhance motivation and self-regulation, and (4) education plus components to enhance motivation, self-regulation and habit formation. All intervention groups will receive a computer-tailored intervention administered via a web-based platform and will receive supporting text-messages containing tailored information, prompts and feedback relevant to each condition. All outcomes will be assessed at baseline, and at 3-month follow-up. The primary outcome assessed in this study is physical activity measured using activity monitors. Secondary outcomes include: quality of life, stress, anxiety, sleep, and absenteeism. Website engagement, retention, preferences and intervention fidelity will also be evaluated as well as potential mediators and moderators of intervention effect.

DISCUSSION

This is the first study to examine a tailored, technology-supported intervention aiming to increase physical activity in healthcare professionals. The study will evaluate whether including additional theory-based behaviour change techniques aimed at promoting motivation, self-regulation and habit will lead to increased physical activity participation relative to information alone. The online platform developed in this study has potential to deliver efficient, scalable and personally-relevant intervention that can be translated to other occupational settings.

TRIAL REGISTRATION

Australian New-Zealand Clinical Trial Registry: ACTRN12616000462482, submitted 29/03/2016, prospectively registered 8/04/2016.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

User-experiences with a web-based self-help intervention for partners of cancer patients based on acceptance and commitment therapy and self-compassion: a qualitative study

BACKGROUND

Partners of cancer patients are the cornerstone of supportive cancer care. They assume different roles and responsibilities that optimally support the patient. Such support is highly demanding, and many partners report (mental) health problems. However, many of them do not use professional supportive care themselves. Offering a Web-based self-help intervention based on Acceptance and Commitment Therapy (ACT) and self-compassion could be an important resource to support this group. This qualitative study aimed to examine user-experiences with a Web-based self-help intervention based on ACT and self-compassion among partners of cancer patients.

METHODS

Individual in-depth interviews, about partners' appreciation of the intervention and lessons learned, were conducted with 14 partners of cancer patients who used the Web-based self-help intervention. Interviews were audio-recorded, transcribed verbatim and analyzed by three independent coders both deductively and inductively.

RESULTS

In general, partners appreciated the intervention, however, they also expressed ambivalent feelings towards peer support, the content of the feedback of their counselor, and the 'tunneled' structure of the intervention. The majority of the partners reported being more self-compassionate accepting that they experienced negative thoughts and feelings, they reported that they learned to increase the distance between their thoughts and themselves, they indicated being more aware of their personal values, and they thought that they were better able to commit to those values. They also reported other (non-specific) helpful processes such as insight and acknowledgement, positivity, the possibility to tell their story, time for themselves, and feeling closer and more connected with their partner (the patient).

CONCLUSIONS

Partners of cancer patients indicated to appreciate the Web-based self-help intervention based on ACT and self-compassion. They felt that the intervention helped them to cope with negative emotions, thoughts, and one's suffering; to practice self-kindness; and to clarify values based on difficult recent experiences. In addition, they felt that the intervention supported them to obtain insight and acknowledgement, positivity, to tell their story, make time for themselves, and feeling closer and more connected with the patient. We think that a Web-based psychological intervention based on ACT and self-compassion may be a valuable contribution in supporting partners of cancer patients.

A Review of Persuasive Principles in Mobile Apps for Chronic Arthritis Patients: Opportunities for Improvement

BACKGROUND

Chronic arthritis (CA), an umbrella term for inflammatory rheumatic and other musculoskeletal diseases, is highly prevalent. Effective disease-modifying antirheumatic drugs for CA are available, with the exception of osteoarthritis, but require a long-term commitment of patients to comply with the medication regimen and management program as well as a tight follow-up by the treating physician and health professionals. Additionally, patients are advised to participate in physical exercise programs. Adherence to exercises and physical activity programs is often very low. Patients would benefit from support to increase medication compliance as well as compliance to the physical exercise programs. To address these shortcomings, health apps for CA patients have been created. These mobile apps assist patients in self-management of overall health measures, health prevention, and disease management. By including persuasive principles designed to reinforce, change, or shape attitudes or behaviors, health apps can transform into support tools that motivate and stimulate users to achieve or keep up with target behavior, also called persuasive systems. However, the extent to which health apps for CA patients consciously and successfully employ such persuasive principles remains unknown.

OBJECTIVE

The objective of this study was to evaluate the number and type of persuasive principles present in current health apps for CA patients.

METHODS

A review of apps for arthritis patients was conducted across the three major app stores (Google Play, Apple App Store, and Windows Phone Store). Collected apps were coded according to 37 persuasive principles, based on an altered version of the Persuasive System Design taxonomy of Oinas-Kukkonen and Harjuma and the taxonomy of Behavior Change Techniques of Michie and Abraham. In addition, user ratings, number of installs, and price of the apps were also coded.

RESULTS

We coded 28 apps. On average, 5.8 out of 37 persuasive principles were used in each app. The most used category of persuasive principles was System Credibility with an average of 2.6 principles. Task Support was the second most used, with an average of 2.3 persuasive principles. Next was Dialogue Support with an average of 0.5 principles. Social Support was last with an average of 0.01 persuasive principles only.

CONCLUSIONS

Current health apps for CA patients would benefit from adding Social Support techniques (eg, social media, user fora) and extending Dialogue Support techniques (eg, rewards, praise). The addition of automated tracking of health-related parameters (eg, physical activity, step count) could further reduce the effort for CA patients to manage their disease and thus increase Task Support. Finally, apps for health could benefit from a more evidence-based approach, both in developing the app as well as ensuring that content can be verified as scientifically proven, which will result in enhanced System Credibility.

The relationship between persuasive technology principles, adherence and effect of web-Based interventions for mental health: A meta-analysis

BACKGROUND

Research has shown that web-based interventions concerning mental health can be effective, although there is a broad range in effect sizes. Why some interventions are more effective than others is not clear. Persuasive technology is one of the aspects which has a positive influence on changing attitude and/or behavior, and can contribute to better outcomes. According to the Persuasive Systems Design Model there are various principles that can be deployed. It is unknown whether the number and combinations of principles used in a web-based intervention affect the effectiveness. Another issue in web-based interventions is adherence. Little is known about the relationship of adherence on the effectiveness of web-based interventions.

OBJECTIVE

This study examines whether there is a relationship between the number and combinations of persuasive technology principles used in web-based interventions and the effectiveness. Also the influence of adherence on effectiveness of web-based interventions is investigated.

METHODS

This study elaborates on the systematic review by [37] and therefore the articles were derived from that study. Only web-based interventions were included that were intended to be used on more than one occasion and studies were excluded when no information on adherence was provided. 48 interventions targeted at mental health were selected for the current study. A within-group (WG) and between-group (BG) meta-analysis were performed and subsequently subgroup analyses regarding the relationship between the number and combinations of persuasive technology principles and effectiveness. The influence of adherence on the effectiveness was examined through a meta-regression analysis.

RESULTS

For the WG meta-analysis 40 treatment groups were included. The BG meta-analysis included 19 studies. The mean pooled effect size in the WG meta-analysis was large and significant (Hedges' g=0.94), while for the BG meta-analysis this was moderate to large and significant (Hedges' g=0.78) in favor of the web-based interventions. With regard to the number of persuasive technology principles, the differences between the effect sizes in the subgroups were significant in the WG subgroup analyses for the total number of principles and for the number of principles in the three categories Primary Task Support, Dialogue Support, and Social Support. In the BG subgroup analyses only the difference in Primary Task Support was significant. An increase in the total number of principles and Dialogue Support principles yielded larger effect sizes in the WG subgroup analysis, indicating that more principles lead to better outcomes. The number of principles in the Primary Task Support (WG and BG) and Social Support (WG) did not show an upward trend but had varying effect sizes. We identified a number of combinations of principles that were more effective, but only in the WG analyses. The association between adherence and effectiveness was not significant.

CONCLUSIONS

There is a relationship between the number of persuasive technology principles and the effectiveness of web-based interventions concerning mental health, however this does not always mean that implementing more principles leads to better outcomes. Regarding the combinations of principles, specific principles seemed to work well together (e.g. tunneling and tailoring; reminders and similarity; social learning and comparison), but adding another principle can diminish the effectiveness (e.g. tunneling, tailoring and reduction). In this study, an increase in adherence was not associated with larger effect sizes. The findings of this study can help developers to decide which persuasive principles to include to make web-based interventions more persuasive.

Understanding persuasion contexts in health gamification: A systematic analysis of gamified health behavior change support systems literature

BACKGROUND

Gamification is increasingly used as a design strategy when developing behavior change support systems in the healthcare domain. It is commonly agreed that understanding the contextual factors is critical for successful gamification, but systematic analyses of the persuasive contexts have been lacking so far within gamified health intervention studies.

OBJECTIVES AND METHODS

Through a persuasion context analysis of the gamified health behavior change support systems (hBCSSs) literature, we inspect how the contextual factors have been addressed in the prior gamified health BCSS studies. The implications of this study are to provide the practitioners and researchers examples of how to conduct a systematic analysis to help guide the design and research on gamified health BCSSs. The ideas derived from the analysis of the included studies will help identify potential pitfalls and shortcomings in both the research and implementations of gamified health behavior change support systems.

RESULTS

We systematically analyzed the persuasion contexts of 15 gamified health intervention studies. According to our results, gamified hBCSSs are implemented under different facets of lifestyle change and treatments compliance, and use a multitude of technologies and methods. We present a set of ideas and concepts to help improve endeavors in studying gamified health intervention through comprehensive understanding of the persuasive contextual factors.

CONCLUSIONS

Future research on gamified hBCSSs should systematically compare the different combinations of contextual factors, related theories, chosen gamification strategies, and the study of outcomes to help understand how to achieve the most efficient use of gamification on the different aspects of healthcare. Analyzing the persuasion context is essential to achieve this. With the attained knowledge, those planning health interventions can choose the 'tried-and-tested' approaches for each particular situation, rather than develop solutions in an ad-hoc manner.