Behavior change techniques in popular alcohol reduction apps: content analysis

Randomized controlled trial of a smartphone app designed to reduce unhealthy alcohol consumption

Background and aims

Unhealthy alcohol use is common and causes tremendous harm. Most people with unhealthy alcohol use will never seek formal alcohol treatment. As an alternative, smartphone apps have been developed as one means to provide help to people concerned about their alcohol use. The aim of this study was to test the efficacy of a smartphone app targeting unhealthy alcohol consumption in a general population sample.

Methods

Participants were recruited from across Canada using online advertisements. Eligible participants who consented to the trial were asked to download a research-specific version of the app and were provided with a code that unlocked it (a different code for each participant to prevent sharing). Those who entered the code were randomized to one of two different versions of the app: 1) the Full app containing all intervention modules; or 2) the Educational only app, containing only the educational content of the app. Participants were followed-up at 6 months. The primary outcome variable was number of standard drinks in a typical week. Secondary outcome variables were frequency of heavy drinking days and experience of alcohol-related problems.

Results

A total of 761 participants were randomized to a condition. The follow-up rate was 81 %. A generalized linear mixed model revealed that participants receiving the full app reduced their typical weekly alcohol consumption to a greater extent than participants receiving the educational only app (incidence rate ratio 0.89; 95 % confidence interval 0.80 to 0.98). No significant differences were observed in the secondary outcome variables (p > .05).

Discussion and conclusion

The results of this trial provide some supportive evidence that smartphone apps can reduce unhealthy alcohol consumption. As this is the second randomized controlled trial demonstrating an impact of this same app (the first one targeted unhealthy alcohol use in university students), increased confidence is placed on the potential effectiveness of the smartphone app employed in the current trial.ClinicalTrials.org number: NCT04745325.

Effectiveness of a smartphone app (Drink Less) versus usual digital care for reducing alcohol consumption among increasing-and-higher-risk adult drinkers in the UK: a two-arm, parallel-group, double-blind, randomised controlled trial

Background

Digital interventions, including apps and websites, can be effective for reducing alcohol consumption. However, many are not evidence- or theory-informed and have not been evaluated. We tested the effectiveness of the Drink Less app for reducing alcohol consumption compared with usual digital care in the UK.

Methods

In this two-arm, parallel group, double-blind, randomised controlled trial, we enrolled increasing-and-higher-risk drinkers (AUDIT ≥ 8) in the UK, who were motivated to reduce their alcohol consumption and willing to use a digital intervention to do so, via online methods. Participants were randomly assigned (1:1), using an online algorithm, to receive a web link to download the Drink Less app (intervention) or to the NHS alcohol advice webpage (usual digital care). Researchers were masked to group allocation. Participants were followed up at one, three and six months. The primary outcome was self-reported weekly alcohol consumption at six months, adjusting for baseline consumption. The full analytic sample was used in most analyses, though missing data was treated in different ways. The primary, pre-registered intention-to-treat analysis assumed baseline-carried-forwards. Secondary pre-registered analyses also focused on the full analytic sample and used alternatives including multiple imputation and last observation carried forwards. This trial is registered with the ISRCTN registry, ISRCTN64052601.

Findings

Between 07/13/2020 and 03/29/2022, 5602 people were randomly assigned to the Drink Less app (n = 2788) or comparator (n = 2814) groups. Six-month follow-up rates were 79% and 80%, respectively. The primary pre-registered conservative intention-to-treat approach assuming non-responders were drinking at baseline levels of consumption, found a non-significant greater reduction of 0.98 units in weekly alcohol consumption in the intervention group at 6-month follow-up (95% CI -2.67 to 0.70). The data were insensitive to detect the hypothesised effect (Bayes factor = 1.17). Data were not missing completely at random, with 6-month follow-up rates differing in terms of education, occupation, and income. We therefore conducted the pre-registered sensitivity analysis using multiple imputation, showing that the Drink Less app resulted in a 2.00-unit greater weekly reduction at 6-month follow-up compared with the NHS alcohol advice webpage (95% CI -3.76 to -0.24). Fewer than 0.1% of participants in both arms who responded to one, three or six-month follow-up reported adverse events linked to participation in the trial.

Interpretation

The Drink Less app may be effective in reducing the alcohol consumption in increasing-and-higher-risk drinkers motivated to reduce their consumption.

Funding

NIHR Public Health Research Programme.

Effect of a smartphone intervention as a secondary prevention for use among university students with unhealthy alcohol use: randomised controlled trial

OBJECTIVE

To estimate the effects of providing access to an alcohol intervention based on a smartphone.

DESIGN

Randomised controlled trial..

SETTING

Four higher education institutions in Switzerland.

PARTICIPANTS

1770 students (≥18 years) who screened positive for unhealthy alcohol use (ie, a score on the alcohol use disorders identification test-consumption (AUDIT-C) of ≥4 for men and ≥3 for women) were randomly assigned by 1:1 allocation ratio in blocks of 10.

INTERVENTION

Providing access to a brief, smartphone based alcohol intervention.

OUTCOME MEASURES

The primary outcome studied was number of standard drinks per week at six months and the secondary outcome was number of heavy drinking days (past 30 days). Additional outcomes were maximum number of drinks consumed on one occasion, alcohol related consequences, and academic performance. Follow-up assessments occurred at months three, six, and 12. Data were analysed by intention to treat and by using generalised linear mixed models with random intercepts for the recruitment site and participants nested within the recruitment site, and with intervention (v control), time (three months v six months; 12 months v six months), and baseline outcome values as fixed effects.

RESULTS

Between 26 April 26 2021 and 30 May 2022, 1770 participants (intervention group (n=884); control group (n=886)) were included. Mean age was 22.4 years (standard deviation 3.07); 958 (54.1%) were women; and 1169 (66.0%) were undergraduate students, 533 (30.1%) were studying for a master's degree, 43 (2.4%) were studying for a doctorate, and 25 (1.4%) were students of other higher education programme. The baseline mean number of standard drinks per week was 8.59 (standard deviation 8.18); the baseline number of heavy drinking days was 3.53 (4.02). Of 1770 participants, follow-up rates were 1706 (96.4%) at three months, 1697 (95.9%) at six months, and 1660 (93.8%) at 12 months. Of 884 students randomly assigned to the intervention group, 738 (83.5%) downloaded the smartphone application. The intervention had a significant overall effect on the number of standard drinks per week (incidence rate ratio 0.90 (95% confidence interval 0.85 to 0.96)), heavy drinking days (0.89 (0.83 to 0.96)), and the maximum number of drinks consumed on one occasion (0.96 (0.93 to 1.00), P=0.029), indicating significantly lower drinking outcomes in the intervention group than in the control group during the follow-up period. The intervention did not affect alcohol related consequences or academic performance.

CONCLUSIONS

Providing access to the smartphone application throughout the 12 month follow-up was effective at limiting the average drinking volume of university students who had self-reported unhealthy alcohol use at baseline.

TRIAL REGISTRATION

ISRCTN 10007691.

Apps targeting anorexia nervosa in young people: a systematic review of active ingredients

Evaluating the presence of behavior change techniques (BCTs) in mHealth apps could be used to better understand what "active ingredients" contribute to outcomes. Despite the early onset of Anorexia Nervosa (AN) and the increasing use of mobile apps to seek mental healthcare among young people, BCTs underpinning mHealth apps targeting AN have never been systematically examined. This review systematically identified and analyzed BCTs underpinning apps targeted at reducing AN in young people in an attempt to understand their active components. Apps were searched and screened in Apple Store and Google Play. Six apps that met the inclusion criteria and were coded by trained researchers against the BCT Taxonomy V1. Overall, 22 of 93 possible BCTs were identified. The most common were "Information about health consequences," "Social support (unspecified)," and "Information about antecedents". Identified BCTs suggested potential overlaps with traditional clinical treatments for AN, such as cognitive behavioral therapy and family-based therapy. Further investigation is required to evaluate the apps' usability and effectiveness.

Design, development and pilot testing of 'Quest', a smartphone-based relapse prevention app for patients with alcohol dependence

OBJECTIVE

To design, develop and pilot the 'Quest' app for smartphone-based relapse prevention for patients diagnosed with alcohol dependence syndrome (ADS).

METHODS

Principles of relapse prevention and motivation enhancement were used to develop the Quest App. Four addiction psychiatrists reviewed the app using the "app evaluation framework". Thirty patients (> 18 yrs age) diagnosed with ADS, who had an Android smartphone, were fluent in writing and reading English and agreed to use the app regularly for the next three months were enrolled in this study. After initial treatment for intoxication/withdrawal and with written consent, patients in the study group (TAUQ) were requested to download the Quest application from a downloadable installation file. The usability and acceptability of Quest App amongst TAUQ patients was evaluated using the usability section of the mHealth App Usability Questionnaire (MAUQ). The short-term effectiveness at the end of three months was compared between TAUQ and comparison group who received Treatment as Usual (TAU).

RESULTS

Both acceptability (65 %) and usability (5.8 out of 7) of the app were high. The patient groups (with or without Quest app) showed a significant reduction in drinking at 30, 60, and 90 days follow-up compared with their baseline number of drinking days. There was no significant difference between the two groups (with or without Quest App) in the median number of lapses and the median number of days of heavy drinking.

CONCLUSIONS

This is the first attempt to develop a smartphone app and test its feasibility in preventing relapse among patients with ADS in the Indian population. Further validation of the app after incorporating feedback and testing on a larger sample size and multiple languages is required.

Development of a Secondary Prevention Smartphone App for Students With Unhealthy Alcohol Use: Results From a Qualitative Assessment

BACKGROUND

Despite considerable efforts devoted to the development of prevention interventions aiming at reducing unhealthy alcohol use in tertiary students, their delivery remains often challenging. Interventions including information technology are promising given their potential to reach large parts of the population.

OBJECTIVE

This study aims to develop a secondary prevention smartphone app with an iterative qualitative design involving the target population.

METHODS

The app development process included testing a first prototype and a second prototype, developed based on the results of 2 consecutive qualitative assessments. Participants (aged ≥18 years, screened positive for unhealthy alcohol use) were students from 4 tertiary education institutions in the French-speaking part of Switzerland. Participants tested prototype 1 or prototype 2 or both and provided feedback in 1-to-1 semistructured interviews after 2-3 weeks of testing.

RESULTS

The mean age of the participants was 23.3 years. A total of 9 students (4/9 female) tested prototype 1 and participated in qualitative interviews. A total of 11 students (6/11 female) tested prototype 2 (6 who tested prototype 1 and 5 new) and participated in semistructured interviews. Content analysis identified 6 main themes: "General Acceptance of the App," "Importance of the Targeted and Relevant App Content," "Importance of Credibility," "Importance of the App Usability," "Importance of a Simple and Attractive Design," "Importance of Notifications to Ensure App Use over Time." Besides a general acceptance of the app, these themes reflected participants' recommendations toward increased usability; to improve the design; to include useful and rewarding contents; to make the app look serious and credible; and to add notifications to ensure its use over time. A total of 11 students tested prototype 2 (6 who tested prototype 1 and 5 new) and participated in semistructured interviews. The 6 same themes emerged from the analysis. Participants from phase 1 generally found the design and content of the app improved.

CONCLUSIONS

Students recommend prevention smartphone apps to be easy to use, useful, rewarding, serious, and credible. These findings may be important to consider when developing prevention smartphone apps to increase the likelihood of app use over time.

TRIAL REGISTRATION

ISRCTN registry 10007691; https://www.isrctn.com/ISRCTN10007691.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-4145-2.

Personalised digital technology for mental health in the armed forces: the potential, the hype and the dangers

The COVID-19 pandemic has resulted in a digital technology revolution which included widespread use in remote healthcare settings, remote working and use of technology to support friends and family to stay in touch. The armed forces have also increased its use of digital technology, but not at the same rate, and it is important that they do not fall behind in the revolution. One area where digital technology could be helpful is the treatment and management of mental health conditions. In a civilian setting, digital technology adoption has been found to be acceptable and feasible yet there is little use in the armed forces. In this personal view, we explore the potential use of personalised digital technology for mental health, the hype surrounding it and the dangers.This paper forms part of the special issue of BMJ Military Health dedicated to personalised digital technology for mental health in the armed forces.

Evaluating a Digital Mental Health Intervention (Wysa) for Workers' Compensation Claimants: Pilot Feasibility Study

OBJECTIVE

This study examines the feasibility and acceptability of an AI-led digital mental health intervention in a Workers' Compensation (WC) program, Wysa for Return to Work.

METHODS

Self-reported demographic data and responses to psychosocial screening questions were analyzed alongside participants' app usage through which four key outcomes were measured: recruitment rate, onboarding rate, retention, and engagement.

RESULTS

The data demonstrated a high need for psychosocial interventions among injured workers, especially women, young adults, and those with high severity injuries. Those with more psychosocial risk factors had a higher rate of onboarding, retention, and engagement, and those with severe injuries had higher retention.

CONCLUSIONS

Our study concluded that Wysa for Return to Work, the AI-led digital mental health intervention that delivers a recovery program using a digital conversational agent, is feasible and acceptable for a return-to-work population.

Efficacy of theory-based interventions aimed at reducing binge drinking in adolescents: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND AND AIMS

Binge drinking is a widespread practice among adolescents worldwide and is associated with various harmful consequences. Theory-based interventions are a promising approach to prevent this drinking behaviour in this population. The aim of the present review was to determine: (1) the characteristics of theory-based interventions targeting binge drinking in adolescents, (2) the impact of such interventions on binge drinking, and (3) the quality of theoretical implementation.

METHODS

For this systematic review, randomised controlled trials were eligible for inclusion if the binge drinking-targeting intervention was based at least on one theoretical framework, and if the population's mean age was between 10 and 18 years. Two authors extracted relevant data. A meta-analysis was conducted to evaluate the effect of interventions on binge drinking. Effect sizes were calculated with the Hedges's g. Binge drinking was measured as a continuous or dichotomous outcome. The quality of theoretical implementation of interventions was measured using an existing "theory coding scheme".

RESULTS

Sixteen studies were identified. Ten were based on a single theory, and six on a combination of theories. The number and type of behaviour change techniques used in each intervention varied greatly. Theory-based interventions led to a small but significant decrease in binge drinking (Hedges's g = 0.10; 95% confidence interval = 0.04, 0.16). The quality of theoretical implementation was globally low, and the reciprocal link between behaviour change techniques and theoretical constructs was unclear for most studies.

CONCLUSIONS

Theory-based interventions have a small but significant beneficial impact on decreasing binge drinking in adolescents. Future research should try to be more effective in matching theoretical determinants of behaviour with the content of the intervention.

A mobile-based pregaming drinking prevention intervention for college students: study protocol for a randomized controlled trial

BACKGROUND

Pregaming is a high-drink context popular among college students that often leads to elevated blood alcohol levels and negative consequences. Over 15 years of research studies have demonstrated that pregaming represents one of the riskiest known behaviors among college students, yet no pregaming-specific interventions have been developed to help prevent this behavior. General brief interventions for students do not reduce pregaming behavior and may not be appropriate, as they do not help students develop skills unique to the pregaming context that could help them drink less. We developed a brief, mobile-based intervention that is proposed to prevent heavy drinking during pregaming for college students, with the ultimate goal that behavioral reductions in this risky practice will ultimately affect global drinking and prevent consequences.

METHODS/DESIGN

The intervention, Pregaming Awareness in College Environments (PACE), was developed by combining two innovations to facilitate behavior change: (1) a mobile-based application that increases accessibility, is easy and engaging to use, and broadens the reach of the intervention content and (2) personalized pregaming-specific intervention content with harm reduction and cognitive behavioral skills proven to be mechanisms preventing and reducing heavy drinking among college students. After a develop and beta-test phase, we propose to test the efficacy of PACE in a preliminary randomized controlled trial with 500 college students who pregame at least once per week. Pregaming, general drinking, and alcohol-related consequences outcomes will be examined in the immediate (2 weeks post-intervention) and short-terms (six and 14-week post-intervention). We will also evaluate moderator effects for age, sex, and heaviness of drinking to allow for more refined information for a planned larger test of the intervention to follow this initial trial of PACE.

DISCUSSION

This pregaming intervention clinical trial, if found to be efficacious, will culminate with an easily-disseminated mobile-based intervention for college student drinkers. It has the potential to reach millions of college students, perhaps as a clinical tool used by college counseling centers as an adjunct to formal care or as a preventive tool for first-year students or other high-risk groups on campus.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04016766.

Adherence and Engagement with a Cognitive Behavioral Therapy Based Conversational Agent (Wysa) in Adults with Chronic Pain: Survival Analysis

BACKGROUND

Digital applications are commonly used to support mental health and well-being. However, successfully retaining and engaging users to complete digital interventions is challenging, and comorbidities such as chronic pain further reduce user engagement. Digital conversational agents may improve user engagement by applying engagement principles that have been implemented within in-person care settings.

OBJECTIVE

To evaluate user retention and engagement with an artificial intelligence (AI)-led digital mental health application (app) that is customized for individuals managing mental health symptoms and coexisting chronic pain (Wysa for Chronic Pain).

METHODS

In this ancillary survival analysis of a clinical trial, participants included 51 adults who presented to a tertiary care center for chronic musculoskeletal pain, who endorsed coexisting symptoms of depression and/or anxiety (PROMIS Depression and/or Anxiety score ≥ 55), and initiated onboarding to an 8-week subscription of Wysa for Chronic Pain. The study outcomes were user retention, defined as revisiting the app each week and the last day of engagement, and user engagement, defined by the number of sessions the user completed.

RESULTS

Users engaged in a cumulative mean of 33.3 sessions during the eight-week study period. The survival analysis depicted a median user retention period (i.e., time to complete disengagement) of 51 days, with the usage of a morning check-in feature statistically significant in its relationship with a longer retention period (p = .001).

CONCLUSIONS

Our findings suggest that the user retention and engagement with a CBT-based conversational agent which is built for users with chronic pain is higher than standard industry metrics. These results have clear implications for addressing issues of suboptimal engagement of digital health interventions and improving access to care for chronic pain. Future work should use these findings to inform the design of evidence-based interventions for individuals with chronic pain and to enhance user retention and engagement of digital health interventions more broadly.

CLINICALTRIAL

NCT04640090, Clinicaltrials.gov.

Facilitators and barriers to social distancing for young people during the COVID-19 pandemic

BACKGROUND

Social (or physical) distancing is an important transmission-prevention behaviour that has been endorsed to minimize COVID-19 transmission. This qualitative study explores the facilitators of and barriers to social distancing for young people during the COVID-19 pandemic, with recognition that young people represent a unique demographic group, with differing psychosocial needs and experiences to other age cohorts.

METHODS

Qualitative data was collected as part of a larger Qualtrics survey between July 28th 2020 and August 24th 2020. Eligible participants were young people living on the Island of Ireland, aged 16-25 years. The survey design was underpinned by the Capability, Opportunity, and Motivation model of behaviour change (COM-B). Semi-inductive thematic analysis was used to analyse comments collected via three free-text survey items. The COM-B model provided a thematic framework to organise subthemes extracted.

RESULTS

A total of N = 477 young people completed the survey, of which N = 347 provided comments for at least one of three free-text survey items. The majority of respondents lived in Northern Ireland (96%), the average age was 21 years, and most respondents were female (73%) and were students (81%). Key barriers identified included lack of environmental support for social distancing (lack of physical Opportunity to social distance), observing other people not social distancing (lack of social Opportunities supporting social distancing), and missing physical interaction from others (relating to the dissuading influence of automatic Motivational factors i.e. the influence of loneliness). Key facilitators included presence of clear and consistent environmental cues and availability of space to support social distancing (increasing physical Opportunity to social distance), increasing awareness and perceived consequences of risk of transmission (enhancing reflective Motivational factors i.e. perceived benefits (versus costs) of social distancing), and increasing opportunities to observe others' adhering to guidelines (increasing social Opportunities supporting social distancing).

CONCLUSIONS

These findings suggest that the actions and endorsement of peers and the physical design of environments have a key role in influencing social distancing behaviour among young people living in NI. The COM-B factors identified in this study can inform the development of tailored interventions using models such as the Behaviour Change Wheel. The findings of this study suggest that intervention functions based on peer modelling and physical environmental restructuring and enablement should be priortitised, however it is imperative that interventions are co-designed with young people to foster collaboration and empowerment.

Smartphone Apps for Vaping Cessation: Quality Assessment and Content Analysis

Background

As the prevalence of electronic cigarette (e-cigarette) use, or vaping, continues to grow, particularly among young people, so does the need for research and interventions to address vaping.

Objective

This study examines the quality of free vaping cessation apps, their contents and features, popularity among users, and adherence to evidence-based principles.

Methods

A systematic search of existing apps for vaping cessation was conducted in December 2020. Eligible apps were free, in English, and included features specifically targeting vaping cessation. Each app included in the analysis was used daily for at least seven consecutive days, assessed using the Mobile App Rating Scale, and rated by at least two authors (AK, EL, or SS) based on adherence to evidence-based practices. Intraclass correlation coefficient (ICC) estimates were computed to assess interrater reliability (excellent agreement; ICC 0.92; 95% CI 0.78-0.98).

Results

A total of 8 apps were included in the quality assessment and content analysis: 3 were developed specifically for vaping cessation and 5 focused on smoking cessation while also claiming to address vaping cessation. The mean of app quality total scores was 3.66 out of 5. Existing vaping cessation apps employ similar approaches to smoking cessation apps. However, they are very low in number and have limited features developed specifically for vaping cessation.

Conclusions

Given the lack of vaping cessation interventions at a time when they are urgently needed, smartphone apps are potentially valuable tools. Therefore, it is recommended that these apps apply evidence-based practices and undergo rigorous evaluations that can assess their quality, contents and features, and popularity among users. Through this process, we can improve our understanding of how apps can be effective in helping users quit vaping.

"Drinkers Like Me": A Thematic Analysis of Comments Responding to an Online Article About Moderating Alcohol Consumption

Background

There has been media coverage surrounding the dangers of heavy drinking and benefits of moderation, with TV and radio presenter, Adrian Chiles, documenting his experience of moderating alcohol consumption in an online article for the Guardian. By analysing the comments in response to Chiles' article, this study aimed to explore (i) posters' (someone who has posted a comment in response to the article) attitudes or beliefs toward moderating alcohol and (ii) posters' experiences of moderating or abstaining from alcohol.

Method

A secondary qualitative analysis of online comments in response to an article about moderating alcohol consumption. Main outcome measures: Comments (n = 784) in response to a United Kingdom online news article about moderating alcohol consumption were extracted and inductive thematic analysis was used.

Results

For aim one, two themes were developed; "general attitudes toward drinking" and "general attitudes toward reducing consumption". These themes reflect negative perceptions of alcohol and issues around changing attitudes. For aim two, three themes were developed: "moderation vs. abstention", "reflection on past drinking behaviours", and "current drinking behaviours". These themes represent posters' experiences and implications changing their drinking habits.

Conclusion

Our analysis provides a novel insight into perceptions and experiences of moderating or abstaining from alcohol. Alcohol is embedded within United Kingdom culture, creating difficulties for those who choose to moderate or abstain from alcohol. Our analysis highlights the need for public health to focus on shifting the current drinking culture, through clearer drinking guidelines and a wider availability of alcohol-free alternatives.

The development of a dynamically tailored mobile alcohol intervention entitled ‘What Do You Drink’ to reduce excessive drinking among Dutch lower educated (MBO) students aged 16 to 24 years: An Intervention Mapping approach (Preprint)

Background

The high prevalence and adverse consequences of excessive drinking among lower-educated adolescents and young adults are public concerns in the Netherlands. Evidence-based alcohol prevention programs targeting adolescents and young adults with a low educational background are sparse.

Objective

This study aimed to describe the planned process for the theory- and evidence-based development, implementation, and evaluation of a dynamically tailored mobile alcohol intervention, entitled What Do You Drink (WDYD), aimed at lower-educated students from secondary vocational education and training (Middelbaar Beroepsonderwijs in Dutch).

Methods

We used intervention mapping as the framework for the systematic development of WDYD. It consists of the following six steps: assessing needs (step 1), formulating intervention objectives (step 2), translating theoretical methods into practical applications (step 3), integrating these into a coherent program (step 4), anticipating future implementation and adoption (step 5), and developing an evaluation plan (step 6).

Results

Reducing excessive drinking among Dutch lower-educated students aged 16 to 24 years was defined as the desired behavioral outcome and subdivided into the following five program objectives: make the decision to reduce drinking, set realistic drinking goals, use effective strategies to achieve drinking goals, monitor own drinking behavior, and evaluate own drinking behavior and adjust goals. Risk awareness, motivation, social norms, and self-efficacy were identified as the most important and changeable individual determinants related to excessive drinking and, therefore, were incorporated into WDYD. Dynamic tailoring was selected as the basic intervention method for changing these determinants. A user-centered design strategy was used to enhance the fit of the intervention to the needs of students. The intervention was developed in 4 iterations, and the prototypes were subsequently tested with the students and refined. This resulted in a completely automated, standalone native app in which students received dynamically tailored feedback regarding their alcohol use and goal achievement via multiple sessions within 17 weeks based on diary data assessing their alcohol consumption, motivation, confidence, and mood. A randomized controlled trial with ecological momentary assessments will be used to examine the effects, use, and acceptability of the intervention.

Conclusions

The use of intervention mapping led to the development of an innovative, evidence-based intervention to reduce excessive alcohol consumption among lower-educated Dutch adolescents and young adults. Developing an intervention based on theory and empirical evidence enables researchers and program planners to identify and retain effective intervention elements and to translate the intervention to new populations and settings. This is important, as black boxes, or poorly described interventions, have long been a criticism of the eHealth field, and effective intervention elements across mobile health alcohol interventions are still largely unknown.

Trial Registration

Netherlands Trial Registry NTR6619; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6619

A Preliminary Evaluation of Mobile Phone Apps to Curb Alcohol Consumption

Mobile apps have become increasingly prevalent in modern society, and persuasive technology has a broader market than ever. Mobile-based alcohol cessation apps can promote positive behaviour change in users and improve the overall health of our society. This research aimed to understand the various features users respond to and make design recommendations for alcohol cessation apps. This paper reports on three sources of feedback (user ratings, user reviews, MARS App Quality score) provided on 20 alcohol cessation apps in the Google Play Store. Our findings suggest that self-control type apps received much greater positive user reviews than motivational apps. In addition, this trend was not observed through numeric user ratings. We also speculate on design recommendations for apps that are meant to inhibit alcohol intake.

Perceptions of Factors Influencing Engagement With Health and Well-being Apps in the United Kingdom: Qualitative Interview Study

BACKGROUND

Digital health devices, such as health and well-being smartphone apps, could offer an accessible and cost-effective way to deliver health and well-being interventions. A key component of the effectiveness of health and well-being apps is user engagement. However, engagement with health and well-being apps is typically poor. Previous studies have identified a list of factors that could influence engagement; however, most of these studies were conducted on a particular population or for an app targeting a particular behavior. An understanding of the factors that influence engagement with a wide range of health and well-being apps can inform the design and the development of more engaging apps in general.

OBJECTIVE

The aim of this study is to explore user experiences of and reasons for engaging and not engaging with a wide range of health and well-being apps.

METHODS

A sample of adults in the United Kingdom (N=17) interested in using a health or well-being app participated in a semistructured interview to explore experiences of engaging and not engaging with these apps. Participants were recruited via social media platforms. Data were analyzed with the framework approach, informed by the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework, which are 2 widely used frameworks that incorporate a comprehensive set of behavioral influences.

RESULTS

Factors that influence the capability of participants included available user guidance, statistical and health information, reduced cognitive load, well-designed reminders, self-monitoring features, features that help establish a routine, features that offer a safety net, and stepping-stone app characteristics. Tailoring, peer support, and embedded professional support were identified as important factors that enhance user opportunities for engagement with health and well-being apps. Feedback, rewards, encouragement, goal setting, action planning, self-confidence, and commitment were judged to be the motivation factors that affect engagement with health and well-being apps.

CONCLUSIONS

Multiple factors were identified across all components of the COM-B model that may be valuable for the development of more engaging health and well-being apps. Engagement appears to be influenced primarily by features that provide user guidance, promote minimal cognitive load, support self-monitoring (capability), provide embedded social support (opportunity), and provide goal setting with action planning (motivation). This research provides recommendations for policy makers, industry, health care providers, and app developers for increasing effective engagement.

Regulation and accreditation of addictive behaviour applications-navigating the landscape

BACKGROUND

mHealth applications (apps) for addictive behaviours offer widespread provision of digital support, with particular benefits for stigmatized groups and those with poor access to treatment services. Regulation and accreditation may encourage the uptake and use of evidence-based addictive behaviour apps, yet this is a complex and confusing landscape. We navigate international regulatory and accreditation guidance, explore some of the implementation challenges and provide implications for app developers, health-care professionals and app users.

ANALYSIS

We explore the classification of health and wellbeing, blended support and clinical therapy apps as medical devices by country to help readers navigate the complexity of the guidance. We describe an addictive behaviour app classified as a medical device and explore the innovative approaches to regulation that are currently emerging. We discuss the use of curated on-line app libraries that adhere to thresholds for characteristics such as quality, user satisfaction or effectiveness, which we hope will become the starting-point in the search for suitable apps, rather than commercial app stores. We also explore the ethical concerns associated with apps and how curated libraries address these.

CONCLUSIONS

International regulation of applications as medical devices varies across countries and would benefit from standardization in a simple, usable and transparent format. Efforts to provide accreditation of non-medical device applications are also variable, and public bodies provide mixed messages concerning endorsement. Health-care professionals and users are encouraged to use accredited applications for addictive behaviours where they exist, or explore other forms of digital intervention with a stronger evidence base.

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in SMART Recovery Mutual Support Groups: Stage 1 Mixed Methods Pilot Study

Background

Mutual support groups are an important source of long-term help for people impacted by addictive behaviors. Routine outcome monitoring (ROM) and feedback are yet to be implemented in these settings. SMART Recovery mutual support groups focus on self-empowerment and use evidence-based techniques (eg, motivational and behavioral strategies). Trained facilitators lead all SMART Recovery groups, providing an opportunity to implement ROM.

Objective

The aim of this stage 1 pilot study is to explore the feasibility, acceptability, and preliminary outcomes of a novel, purpose-built mobile health ROM and feedback app (SMART Track) in mutual support groups coordinated by SMART Recovery Australia (SRAU) over 8 weeks.

Methods

SMART Track was developed during phase 1 of this study using participatory design methods and an iterative development process. During phase 2, 72 SRAU group participants were recruited to a nonrandomized, prospective, single-arm trial of the SMART Track app. Four modes of data collection were used: ROM data directly entered by participants into the app; app data analytics captured by Amplitude Analytics (number of visits, number of unique users, visit duration, time of visit, and user retention); baseline, 2-, and 8-week follow-up assessments conducted through telephone; and qualitative telephone interviews with a convenience sample of study participants (20/72, 28%) and facilitators (n=8).

Results

Of the 72 study participants, 68 (94%) created a SMART Track account, 64 (88%) used SMART Track at least once, and 42 (58%) used the app for more than 5 weeks. During week 1, 83% (60/72) of participants entered ROM data for one or more outcomes, decreasing to 31% (22/72) by the end of 8 weeks. The two main screens designed to provide personal feedback data (Urges screen and Overall Progress screen) were the most frequently visited sections of the app. Qualitative feedback from participants and facilitators supported the acceptability of SMART Track and the need for improved integration into the SRAU groups. Participants reported significant reductions between the baseline and 8- week scores on the Severity of Dependence Scale (mean difference 1.93, SD 3.02; 95% CI 1.12-2.73) and the Kessler Psychological Distress Scale-10 (mean difference 3.96, SD 8.31; 95% CI 1.75-6.17), but no change on the Substance Use Recovery Evaluator (mean difference 0.11, SD 7.97; 95% CI –2.02 to 2.24) was reported.

Conclusions

Findings support the feasibility, acceptability, and utility of SMART Track. Given that sustained engagement with mobile health apps is notoriously difficult to achieve, our findings are promising. SMART Track offers a potential solution for ROM and personal feedback, particularly for people with substance use disorders who attend mutual support groups.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336

International Registered Report Identifier (IRRID)

RR2-10.2196/15113

Orthodontic apps: an assessment of quality (using the Mobile App Rating Scale (MARS)) and behaviour change techniques (BCTs)

BACKGROUND

Apps have been shown to be an effective tool in changing patients' behaviours in orthodontics and can be used to improve their compliance with treatment. The Behaviour Change Techniques (BCTs) and quality (using MARS) within these apps have previously not been published.

OBJECTIVES

1. To evaluate the quality of these apps aiming to change behaviour. 2. To assess BCTs used in patient focused orthodontic apps.

METHODS

The UK Google Play and Apple App Stores were searched to identify all orthodontic apps and 305 apps were identified. All 305 apps were assessed for the presence of BCTs using an accepted taxonomy of BCTs (Behaviour Change Wheel (BCW)), widely utilised in healthcare. Of those containing BCTs, the quality was assessed using the Mobile App Rating Scale (MARS), a validated and multi-dimensional tool which rates apps according to 19 objective criteria. Data collection was carried out by two calibrated, independent assessors and repeated after 6 weeks for 25% of the apps by both assessors.

RESULTS

BCTs were found in 31 apps, although only 18 of them were analysed for quality and 13 apps were excluded. Six different BCTs were identified: these were most commonly 'prompts/cues', and 'information about health consequences'. All apps were shown to be of moderate quality (range 3.1-3.7/5). Inter-rater and intra-rater reliability for BCT and quality assessment were excellent.

CONCLUSIONS

The current availability of orthodontic apps of sufficient quality to recommend to patients is very limited. There is therefore a need for high-quality orthodontic apps with appropriate BCTs to be created, which may be utilised to improve patients' compliance with treatment.

An Evaluation Service for Digital Public Health Interventions: User-Centered Design Approach

Background

Digital health interventions (DHIs) have the potential to improve public health by combining effective interventions and population reach. However, what biomedical researchers and digital developers consider an effective intervention differs, thereby creating an ongoing challenge to integrating their respective approaches when evaluating DHIs.

Objective

This study aims to report on the Public Health England (PHE) initiative set out to operationalize an evaluation framework that combines biomedical and digital approaches and demonstrates the impact, cost-effectiveness, and benefit of DHIs on public health.

Methods

We comprised a multidisciplinary project team including service designers, academics, and public health professionals and used user-centered design methods, such as qualitative research, engagement with end users and stakeholders, and iterative learning. The iterative approach enabled the team to sequentially define the problem, understand user needs, identify opportunity areas, develop concepts, test prototypes, and plan service implementation. Stakeholders, senior leaders from PHE, and a working group critiqued the outputs.

Results

We identified 26 themes and 82 user needs from semistructured interviews (N=15), expressed as 46 Jobs To Be Done, which were then validated across the journey of evaluation design for a DHI. We identified seven essential concepts for evaluating DHIs: evaluation thinking, evaluation canvas, contract assistant, testing toolkit, development history, data hub, and publish health outcomes. Of these, three concepts were prioritized for further testing and development, and subsequently refined into the proposed PHE Evaluation Service for public health DHIs. Testing with PHE’s Couch-to-5K app digital team confirmed the viability, desirability, and feasibility of both the evaluation approach and the Evaluation Service.

Conclusions

An iterative, user-centered design approach enabled PHE to combine the strengths of academic and biomedical disciplines with the expertise of nonacademic and digital developers for evaluating DHIs. Design-led methodologies can add value to public health settings. The subsequent service, now known as Evaluating Digital Health Products, is currently in use by health bodies in the United Kingdom and is available to others for tackling the problem of evaluating DHIs pragmatically and responsively.

Physical distancing messages targeting youth on the social media accounts of Canadian public health entities and the use of behavioral change techniques

Introduction

Physical distancing (PD) is an important public health strategy to reduce the transmission of COVID-19 and has been promoted by public health authorities through social media. Although youth have a tendency to engage in high-risk behaviors that could facilitate COVID-19 transmission, there is limited research on the characteristics of PD messaging targeting this population on social media platforms with which youth frequently engage. This study examined social media posts created by Canadian public health entities (PHEs) with PD messaging aimed at youth and young adults aged 16–29 years and reported behavioral change techniques (BCTs) used in these posts.

Methods

A content analysis of all social media posts of Canadian PHEs from Facebook, Twitter, Instagram and YouTube were conducted from April 1st to May 31st, 2020. Posts were classified as either implicitly or explicitly targeting youth and young adults. BCTs in social media posts were identified and classified based on Behavior Change Technique Taxonomy version 1 (BCTTv1). Frequency counts and proportions were used to describe the data.

Results

In total, 319 youth-targeted PD posts were identified. Over 43% of the posts originated from Ontario Regional public health units, and 36.4 and 32.6% of them were extracted from Twitter and Facebook, respectively. Only 5.3% of the total posts explicitly targeted youth. Explicit posts were most frequent from federal PHEs and posted on YouTube. Implicit posts elicited more interactions than explicit posts regardless of jurisdiction level or social media format. Three-quarters of the posts contained at least one BCT, with a greater portion of BCTs found within implicit posts (75%) than explicit posts (52.9%). The most common BCTs from explicit posts were instructions on how to perform a behavior (25.0%) and restructuring the social environment (18.8%).

Conclusions

There is a need for more PD messaging that explicitly targets youth. BCTs should be used when designing posts to deliver public health messages and social media platforms should be selected depending on the target population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11659-y.

Harmful smartphone applications promoting alcohol and illicit substance use: a review and content analysis in the United States

Few studies have conducted analysis of commercially available smartphone applications designed to promote alcohol and illicit substance use. The aim of this review is to determine harmful themes of content in applications promoting alcohol and illicit substance use found using recovery app search terms. A systematic search, via Apple iTunes and Google Play stores, was conducted of applications targeting abstinence or reduced substance use in online app stores (n = 1,074 apps) in March 2018. We conducted a secondary analysis of apps encouraging alcohol and illicit substance use in July 2018. Our initial search yielded 904 apps pertaining to alcohol and illicit substance use. Four reviewers conducted a content analysis of 102 apps meeting inclusion criteria and assessed app design, delivery features, text, and multimedia content pertaining to substance use. The initial coding scheme was refined using a data-driven, iterative method grouping in thematic categories. The number of apps coded to a specific substance include: alcohol (n = 74), methamphetamine (n =13), cocaine (n = 15), heroin (n = 12), and marijuana (n = 15), with nine apps overlapping more than one substance. Key themes identified among apps included: (i) tangibility (alcohol home delivery services); (ii) social networks (builtin social media platforms promoting substance use); (iii) software design (gamification or simulation of substance use); and (iv) aesthetics (sexual or violent imagery). Despite claims of restricting apps promoting substance use, further efforts are needed by online app stores to reduce the availability of harmful content.

Brief interventions to prevent excessive alcohol use in adolescents at low-risk presenting to Emergency Departments: Three-arm, randomised trial of effectiveness and cost-effectiveness

BACKGROUND

Alcohol consumption and related harm increase rapidly from the age of 12 years. We evaluated whether alcohol screening and brief intervention is effective and cost-effective in delaying hazardous or harmful drinking amongst low-risk or abstaining adolescents attending Emergency Departments (EDs).

METHODS

This ten-centre, three-arm, parallel-group, single-blind, pragmatic, individually randomised trial screened ED attenders aged between 14 and 17 years for alcohol consumption. We sampled at random one third of those scoring at most 2 on AUDIT-C who had access to the internet and, if aged under 16, were Gillick competent or had informed consent from parent or guardian. We randomised them between: screening only (control intervention); one session of face-to-face Personalised Feedback and Brief Advice (PFBA); and PFBA plus an electronic brief intervention (eBI) on smartphone or web. We conducted follow-up after six and 12 months. The principal outcomes were alcohol consumed over the 3 months before 12-month follow up, measured by AUDIT-C; and quality-adjusted life-years.

FINDINGS

Between October 2014 and May 2015, we approached 5,016 eligible patients of whom 3,326 consented to be screened and participate in the trial; 2,571 of these were low-risk drinkers or abstainers, consuming an average 0.14 units per week. We randomised: 304 to screening only; 285 to PFBA; and 294 to PFBA and eBI. We found no significant difference between groups, notably in weekly alcohol consumption: those receiving screening only drank 0.10 units (95% confidence interval 0.05 to 0.18); PFBA 0.12 (0.06 to 0.21); PFBA and eBI 0.10 (0.05 to 0.19).

INTERPRETATION

While drinking levels remained low in this population, this trial found no evidence that PFBA with or without eBI was more effective than screening alone in reducing or delaying alcohol consumption.

Refining the content and design of an alcohol reduction app, Drink Less, to improve its usability and effectiveness: a mixed methods approach

Background: Digital interventions have the potential to reduce alcohol consumption, although evidence on the effectiveness of apps is lacking. Drink Less is a popular, evidence-informed app with good usability, putting it in a strong position to be improved upon prior to conducting a confirmatory evaluation. This paper describes the process of refining Drink Less to improve its usability and likely effectiveness. Methods: The refinement consisted of three phases and involved qualitative and quantitative (mixed) methods: i) identifying changes to app content, based on findings from an initial evaluation of Drink Less, an updated review of digital alcohol interventions and a content analysis of user feedback; ii) designing new app modules with public input and a consultation with app developers and researchers; and iii) improving the app's usability through user testing. Results: As a result of the updated review of digital alcohol interventions and user feedback analysis in Phase 1, three new modules: 'Behaviour Substitution', 'Information about Antecedents' and 'Insights', were added to the app. One existing module - 'Identity Change' - was removed based on the initial evaluation of Drink Less. Phases 2 and 3 resulted in changes to existing features, such as improving the navigational structure and onboarding process, and clarifying how to edit drinks and goals. Conclusions: A mixed methods approach was used to refine the content and design of Drink Less, providing insights into how to improve its usability and likely effectiveness. Drink Less is now ready for a confirmatory evaluation.

Refining the content and design of an alcohol reduction app, Drink Less, to improve its usability and effectiveness: a mixed methods approach

Background: Digital interventions have the potential to reduce alcohol consumption, although evidence on the effectiveness of apps is lacking. Drink Less is a popular, evidence-informed app with good usability, putting it in a strong position to be improved upon prior to conducting a confirmatory evaluation. This paper describes the process of refining Drink Less to improve its usability and likely effectiveness. Methods: The refinement consisted of three phases and involved qualitative and quantitative (mixed) methods: i) identifying changes to app content, based on findings from an initial evaluation of Drink Less, an updated review of digital alcohol interventions and a content analysis of user feedback; ii) designing new app modules with public input and a consultation with app developers and researchers; and iii) improving the app's usability through user testing. Results: As a result of the updated review of digital alcohol interventions and user feedback analysis in Phase 1, three new modules: 'Behaviour Substitution', 'Information about Antecedents' and 'Insights', were added to the app. One existing module - 'Identity Change' - was removed based on the initial evaluation of Drink Less. Phases 2 and 3 resulted in changes to existing features, such as improving the navigational structure and onboarding process, and clarifying how to edit drinks and goals. Conclusions: A mixed methods approach was used to refine the content and design of Drink Less, providing insights into how to improve its usability and likely effectiveness. Drink Less is now ready for a confirmatory evaluation.

Influences on the Uptake of Health and Well-being Apps and Curated App Portals: Think-Aloud and Interview Study

BACKGROUND

Health and well-being smartphone apps can provide a cost-effective solution to addressing unhealthy behaviors. The selection of these apps tends to occur in commercial app stores, where thousands of health apps are available. Their uptake is often influenced by popularity indicators. However, these indicators are not necessarily associated with app effectiveness or evidence-based content. Alternative routes to app selection are increasingly available, such as via curated app portals, but little is known about people's experiences of them.

OBJECTIVE

The aim of this study is to explore how people select health apps on the internet and their views on curated app portals.

METHODS

A total of 18 UK-based adults were recruited through social media and asked during an in-person meeting to verbalize their thoughts while searching for a health or well-being app on the internet on a platform of their choice. The search was then repeated on 2 curated health app portals: the National Health Service Apps Library and the Public Health England One You App portal. This was followed by semistructured interviews. Data were analyzed using framework analysis, informed by the Capability, Opportunity, Motivation-Behavior model and the Theoretical Domains Framework.

RESULTS

Searching for health and well-being apps on the internet was described as a minefield. App uptake appeared to be influenced by participants' capabilities such as app literacy skills and health and app awareness, and opportunities including the availability of apps, app esthetics, the price of an app, and social influences. Motivation factors that seemed to affect the uptake were perceived competence, time efficiency, perceived utility and accuracy of an app, transparency about data protection, commitment and social identity, and a wide range of emotions. Social influences and the perceived utility of an app were highlighted as particularly important. Participants were not previously aware of curated portals but found the concept appealing. Curated health app portals appeared to engender trust and alleviate data protection concerns. Although apps listed on these were perceived as more trustworthy, their presentation was considered disappointing. This disappointment seemed to stem from the functionality of the portals, lack of user guidance, and lack of tailored content to an individual's needs.

CONCLUSIONS

The uptake of health and well-being apps appears to be primarily affected by social influences and the perceived utility of an app. App uptake via curated health app portals perceived as credible may mitigate concerns related to data protection and accuracy, but their implementation must better meet user needs and expectations.

Usability and Acceptability of a Mobile App for the Self-Management of Alcohol Misuse Among Veterans (Step Away): Pilot Cohort Study

BACKGROUND

Alcohol misuse is common among Operation Enduring Freedom and Operation Iraqi Freedom veterans, yet barriers limit treatment participation. Mobile apps hold promise as means to deliver alcohol interventions to veterans who prefer to remain anonymous, have little time for conventional treatments, or live too far away to attend treatment in person.

OBJECTIVE

This pilot study evaluated the usability and acceptability of Step Away, a mobile app designed to reduce alcohol-related risks, and explored pre-post changes on alcohol use, psychological distress, and quality of life.

METHODS

This single-arm pilot study recruited Operation Enduring Freedom and Operation Iraqi Freedom veterans aged 18 to 55 years who exceeded National Institute on Alcohol Abuse and Alcoholism drinking guidelines and owned an iPhone. Enrolled veterans (N=55) completed baseline and 1-, 3-, and 6-month assessments. The System Usability Scale (scaled 1-100, ≥70 indicating acceptable usability) assessed the effectiveness, efficiency, and satisfaction dimensions of usability, while a single item (scaled 1-9) measured the attractiveness of 10 screenshots. Learnability was assessed by app use during week 1. App engagement (proportion of participants using Step Away, episodes of use, and minutes per episode per week) over 6 months measured acceptability. Secondary outcomes included pre-post change on heavy drinking days (men: ≥5 drinks per day; women: ≥4 drinks per day) and Short Inventory of Problems-Revised, Kessler-10, and brief World Health Organization Quality of Life Questionnaire scores.

RESULTS

Among the 55 veterans enrolled in the study, the mean age was 37.4 (SD 7.6), 16% (9/55) were women, 82% (45/55) were White, and 82% (45/55) had an alcohol use disorder. Step Away was used by 96% (53/55) of participants in week 1, 55% (30/55) in week 4, and 36% (20/55) in week 24. Step Away use averaged 55.1 minutes (SD 57.6) in week 1 and <15 minutes per week in weeks 2 through 24. Mean System Usability Scale scores were 69.3 (SD 19.7) and 71.9 (SD 15.8) at 1 and 3 months, respectively. Median attractiveness scores ranged from 5 to 8, with lower ratings for text-laden screens. Heavy drinking days decreased from 29.4% (95% CI 23.4%-35.4%) at baseline to 16.2% (95% CI 9.9%-22.4%) at 6 months (P<.001). Likewise, over 6 months, Short Inventory of Problems-Revised scores decreased from 6.3 (95% CI 5.1-7.5) to 3.6 (95% CI 2.4-4.9) (P<.001) and Kessler-10 scores decreased from 18.8 (95% CI 17.4-20.1) to 17.3 (95% CI 15.8-18.7) (P=.046). Changes were not detected on quality of life scores.

CONCLUSIONS

Operation Enduring Freedom and Operation Iraqi Freedom veterans found the usability of Step Away to be acceptable and engaged in the app over the 6-month study. Reductions were seen in heavy drinking days, alcohol-related problems, and Kessler-10 scores. A larger randomized trial is warranted to confirm our findings.

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

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

Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review

BACKGROUND

Web-based interventions are thought to overcome barriers to treatment, such as accessibility and geographical location, which can undermine the effectiveness of traditional face-to-face interventions. Owing to these features, researchers are increasingly testing the efficacy of web-based interventions as ways to reduce alcohol misuse, binge eating, and gambling. However, many web-based interventions have poorly defined mechanisms of action; therefore, it is often uncertain how they propose to bring about behavior change.

OBJECTIVE

This systematic review aims to identify effective behavior change techniques (BCTs) present in web-based interventions aimed at reducing alcohol consumption, binge eating, or gambling.

METHODS

This systematic review covered research conducted in the last 20 years. Inclusion criteria for interventions were web-based administration; targeting alcohol use, binge eating, and/or gambling; and reporting on baseline and postintervention measures of behavior. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. We coded intervention effectiveness, study quality, and BCTs present in the interventions.

RESULTS

Following removal of 4152 ineligible articles, 45 were included in the review: 32 (71%) targeted alcohol misuse, 6 (13%) targeted binge eating, and 7 (16%) targeted gambling. In total, 5 frequency counts were performed to identify the most commonly used BCTs: all studies, effective interventions, high-quality studies at 2 thresholds, and both high quality and effective studies. The results obtained from this were integrated to identify 7 BCTs. These 7 BCTs were problem solving, feedback on behavior, self-monitoring of behavior, self-monitoring of outcomes, instruction on how to perform a behavior, information about social and health consequences, and social comparison. A total of 4 BCTs were found in all frequency counts: feedback on behavior, self-monitoring of behavior, instruction on how to perform a behavior, and social comparison. Self-monitoring of outcomes of behavior was found in 3 of the 5 frequency counts, problem solving was found in 2 frequency counts, and information about social and health consequences was found in 1 frequency count.

CONCLUSIONS

This systematic review identified 7 of the most frequently used BCTs used in web-based interventions focused on alcohol misuse, binge eating, and gambling. These results can inform the development of evidence-based eHealth interventions that have the potential to lead to effective, positive behavior changes in all 3 areas.

Identifying Self-Management Support Needs for Pregnant Women With Opioid Misuse in Online Health Communities: Mixed Methods Analysis of Web Posts

Background

The current opioid crisis in the United States impacts broad population groups, including pregnant women. Opioid use during pregnancy can affect the health and wellness of both mothers and their infants. Understanding women’s efforts to self-manage opioid use or misuse in pregnancy is needed to identify intervention points for improving maternal outcomes.

Objective

This study aims to identify the characteristics of women in an online health community (OHC) with opioid use or misuse during pregnancy and the self-management support needs of these mothers.

Methods

A total of 200 web posts by pregnant women with opioid use participating in an OHC were double coded. Concepts and their thematic connections were identified through an inductive process until theoretical saturation was reached. Statistical tests were performed to identify patterns.

Results

The majority of pregnant women (150/200, 75.0%) in the OHC exhibited signs of misuse, and 62.5% (125/200) of the participants were either contemplating or pursuing dosage reduction. Self-managed withdrawal was more common (P<.001) than professional treatment among the population. A total of 5 themes of self-management support needs were identified as women sought information about the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. In addition, 58.5% (117/200) of the pregnant women expressed negative emotions, of whom only 10.2% (12/117) sought to address their emotional needs with the help of the OHC.

Conclusions

OHCs provide vital self-management support for pregnant women with opioid use or misuse. Women pursuing self-managed dosage reduction are prone to misinformation and repeated relapses, which can result in extreme measures to avoid testing positive for drug use at labor. The study findings provide evidence for public policy considerations, including universal screening of substance use for pregnant women, emphasis on treatment rather than legal punishment, and further expansion of the Drug Addiction Treatment Act waiver training program. The improvement of web-based platforms that can organize geo-relevant information, dispense clinically validated withdrawal schedules, and offer structured peer support is envisioned for harm reduction among pregnant women who opt for self-management of opioid misuse.

Evaluating the effectiveness of the smartphone app, Drink Less, compared with the NHS alcohol advice webpage, for the reduction of alcohol consumption among hazardous and harmful adult drinkers in the UK at 6-month follow-up: protocol for a randomised controlled trial

BACKGROUND AND AIMS

Digital interventions are effective for reducing alcohol consumption but evidence is limited regarding smartphone apps. Drink Less is a theory- and evidence-informed app to help people reduce their alcohol consumption that has been refined in terms of its content and design for usability across the sociodemographic spectrum. We aim to evaluate the effectiveness and cost-effectiveness of recommending Drink Less at reducing alcohol consumption compared with usual digital care.

DESIGN

Two-arm individually randomised controlled trial.

SETTING

Online trial in the United Kingdom (UK).

PARTICIPANTS

Hazardous or harmful drinkers (Alcohol Use Disorders Identification Test [AUDIT] score ≥8) aged 18+ who want to drink less alcohol (n = 5562). Participants will be recruited from July 2020 to May 2022 using multiple strategies with a focus on remote digital methods.

INTERVENTION AND COMPARATOR

Participants will be randomised to receive either an email recommending that they use Drink Less (intervention) or view the National Health Service (NHS) webpage on alcohol advice (comparator).

MEASUREMENTS

The primary outcome is change in self-reported weekly alcohol consumption, assessed using the extended AUDIT-Consumption, between baseline and 6-month follow-up. Secondary outcomes include change in self-reported weekly alcohol consumption assessed at 1- and 3-month follow-ups, and the proportion of hazardous drinkers; alcohol-related problems and injury; health-related quality of life; and use of health services assessed at 6-month follow-up. Effectiveness will be examined with adjusted regression models, adjusting for baseline alcohol consumption and using an intention-to-treat approach. A mixed-methods process evaluation will assess engagement, acceptability and mechanism of action. Economic evaluations will be conducted using both a short- and longer-term time horizon.

COMMENTS

This study will establish the effectiveness and cost-effectiveness of the Drink Less app at reducing alcohol consumption among hazardous and harmful adult drinkers and will be the first randomised controlled trial of an alcohol reduction app for the general population in the United Kingdom. This study will inform the decision on whether it is worth investing resources in large-scale implementation.

The use of mobile phones for the prevention and control of arboviral diseases: a scoping review

BACKGROUND

The rapid expansion of dengue, Zika and chikungunya with large scale outbreaks are an increasing public health concern in many countries. Additionally, the recent coronavirus pandemic urged the need to get connected for fast information transfer and exchange. As response, health programmes have -among other interventions- incorporated digital tools such as mobile phones for supporting the control and prevention of infectious diseases. However, little is known about the benefits of mobile phone technology in terms of input, process and outcome dimensions. The purpose of this scoping review is to analyse the evidence of the use of mobile phones as an intervention tool regarding the performance, acceptance, usability, feasibility, cost and effectiveness in dengue, Zika and chikungunya control programmes.

METHODS

We conducted a scoping review of studies and reports by systematically searching: i) electronic databases (PubMed, PLOS ONE, PLOS Neglected Tropical Disease, LILACS, WHOLIS, ScienceDirect and Google scholar), ii) grey literature, using Google web and iii) documents in the list of references of the selected papers. Selected studies were categorized using a pre-determined data extraction form. Finally, a narrative summary of the evidence related to general characteristics of available mobile health tools and outcomes was produced.

RESULTS

The systematic literature search identified 1289 records, 32 of which met the inclusion criteria and 4 records from the reference lists. A total of 36 studies were included coming from twenty different countries. Five mobile phone services were identified in this review: mobile applications (n = 18), short message services (n=7), camera phone (n = 6), mobile phone tracking data (n = 4), and simple mobile communication (n = 1). Mobile phones were used for surveillance, prevention, diagnosis, and communication demonstrating good performance, acceptance and usability by users, as well as feasibility of mobile phone under real life conditions and effectiveness in terms of contributing to a reduction of vectors/ disease and improving users-oriented behaviour changes. It can be concluded that there are benefits for using mobile phones in the fight against arboviral diseases as well as other epidemic diseases. Further studies particularly on acceptance, cost and effectiveness at scale are recommended.

Inventory and Analysis of Controlled Trials of Mobile Phone Applications Targeting Substance Use Disorders: A Systematic Review

Background: Less than 20% of people with addictions have access to adequate treatment. Mobile health could improve access to care. No systematic review evaluates effectiveness of mobile health applications for addiction. Objectives: First aim was to describe controlled trials evaluating the effectiveness of smartphone applications targeting substance use disorders and addictive behaviors. Secondly, we aimed to understand how the application produced changes in behavior and craving management. Method: A systematic review based on PRISMA recommendations was conducted on MEDLINE, CENTRAL, and PsycINFO. Studies had to be controlled trials concerning addictive disorders (substance/behavior), mobile application-based interventions, assessing effectiveness or impact of those applications upon use, published after 2008. Relevant information was systematically screened for synthesis. Quality and risk of bias were evaluated with JADAD score. Results: Search strategy retrieved 22 articles (2014-2019) corresponding to 22 applications targeting tobacco, alcohol, other substances and binge eating disorder. Control groups had access to usual treatments or a placebo-application or no treatment. Eight applications showed reduced use. Most of the applications informed about risks of use and suggestions for monitoring use. Twelve applications managed craving. Discussion: Heterogeneity limited study comparisons. Duration of studies was too short to predict sustainable results. A reduction of craving seemed related to a reduction in use. Conclusion: There is a lack of robust and comparable studies on mHealth applications for addiction treatment. Such applications could become significant contributors in clinical practice in the future so longer-termed double-blind studies are needed. Targeting craving to prevent relapse should be systematic.

Efficacy of a complex smartphone application for reducing hazardous alcohol consumption: Study protocol for a randomized controlled trial with analysis of in-app user behavior in relation to outcome

OBJECTIVE

The efficacy of alcohol reduction applications is variable, and the underlying factors are largely unknown. The aim of this study is threefold: evaluate the relationship between user engagement and intervention efficacy, investigate the efficacy of the different functions applied, and investigate the efficacy of the intervention application compared to control groups.

METHODS

A randomized controlled trial will be conducted to determine the efficacy of a newly developed smartphone application compared to the controls in reducing alcohol consumption at a 30, 60, 90, 120, 150, and 180 days follow-up. Hazardous drinkers, aged 18 years or older, will be recruited through web articles and will be randomized (blinded to their allocation), to receive one of the two versions of the application (educational or control application) for 30 days, or will be allocated to a wait-list control group. Function usage times will be recorded on a single-user level to determine the association between application usage and efficacy.

RESULTS

Data collection will be completed by July 2020, and follow-up will be completed by January 2021.

CONCLUSIONS

The evaluation of intervention efficacy as a function of user behavior will hopefully contribute to the science of developing more efficient alcohol intervention applications in the future.

Mobile Apps to Reduce Tobacco, Alcohol, and Illicit Drug Use: Systematic Review of the First Decade

Background

Mobile apps for problematic substance use have the potential to bypass common barriers to treatment seeking. Ten years following the release of the first app targeting problematic tobacco, alcohol, and illicit drug use, their effectiveness, use, and acceptability remains unclear.

Objective

This study aims to conduct a systematic literature review of trials evaluating mobile app interventions for problematic tobacco, alcohol, and illicit drug use.

Methods

The review was conducted according to recommended guidelines. Relevant databases were searched, and articles were included if the mobile app study was a controlled intervention trial and reported alcohol, tobacco, or illicit drug consumption as outcomes.

Results

A total of 20 studies met eligibility criteria across a range of substances: alcohol (n=11), tobacco (n=6), alcohol and tobacco (n=1), illicit drugs (n=1), and illicit drugs and alcohol (n=1). Samples included the general community, university students, and clinical patients. The analyzed intervention sample sizes ranged from 22 to 14,228, and content was considerably diverse, from simple stand-alone apps delivering self-monitoring or psychoeducation to multicomponent apps with interactive features and audio content, or used as adjuncts alongside face-to-face treatment. Intervention duration ranged from 1 to 35 weeks, with notifications ranging from none to multiple times per day. A total of 6 of the 20 app interventions reported significant reductions in substance use at post or follow-up compared with a comparison condition, with small to moderate effect sizes. Furthermore, two other app interventions reported significant reductions during the intervention but not at post treatment, and a third reported a significant interaction of two app intervention components.

Conclusions

Although most app interventions were associated with reductions in problematic substance use, less than one-third were significantly better than the comparison conditions at post treatment. A total of 5 out of the 6 apps that reported intervention effects targeted alcohol (of those, one targeted alcohol and illicit drugs and another alcohol and tobacco) and 1 targeted tobacco. Moreover, 3 out of 6 apps included feedback (eg, personalized) and 2 had high risk of bias, 1 some risk, and 3 low risk. All 6 apps included interventions of 6 weeks or longer. Common study limitations were small sample sizes; risk of bias; lack of relevant details; and, in some cases, poorly balanced comparison conditions. Appropriately powered trials are required to understand which app interventions are most effective, length of engagement required, and subgroups most likely to benefit. In sum, evidence to date for the effectiveness of apps targeting problematic substance use is not compelling, although the heterogeneous comparison conditions and trial designs across studies limit the ability to compare efficacy between apps. We discuss potential approaches that can help ascertain whether the promise of mobile app interventions for problematic substance use can be fulfilled.

Identifying Effective Behavior Change Techniques for Alcohol and Illicit Substance Use During Pregnancy: A Systematic Review

Background

During pregnancy, consuming alcohol and using illicit drugs can have serious health implications for both mother and child. Behavioral change interventions, especially those underpinned by theoretical constructs, can be effective in reducing harmful substance use among pregnant women.

Purpose

To understand what type of behavior change mechanisms could be useful in reducing alcohol consumption or achieving abstinence from illicit drug use during pregnancy, this review aimed to identify behavior change techniques (BCTs), the smallest, active components of interventions that may be effective. It also aimed to establish the extent that psychosocial-based theories were used to inform intervention design.

Methods

To identify eligible randomized controlled trials (RCTs), five databases were searched electronically from the end search dates of the most recent Cochrane systematic reviews on behavioral interventions for each behavior, until March 2018. Within the RCTs, intervention descriptions were analyzed for BCT content and extent of theory use in the intervention design process and outcome measurements, in each trial, was established. “Effectiveness percentages,” the number of times a BCT had been a component of an effective intervention divided by the total number of interventions it had been used in, were calculated for BCTs used in two or more trials.

Results

Including all RCTs from the Cochrane reviews, and those published subsequently, nine alcohol and six illicit drug trials were identified. Interventions tested in four alcohol RCTs and no illicit drugs RCTs showed positive results. Subsequent data were extracted for alcohol consumption trials only. Thirteen BCTs showed “potential effectiveness” for alcohol consumption. Six of nine included alcohol trials reported using theory but not extensively.

Conclusions

Action planning, behavioral contract, prompts/cues, self-talk, offer/direct toward written material, problem solving, feedback on behavior, social support (unspecified), information about health consequences, behavior substitution, assess current readiness and ability to reduce excess alcohol consumption, goal setting (behavior), and tailor interactions appropriately are BCTs that could be useful in helping reduce alcohol consumption among pregnant women.

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

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

[Digital interventions in prevention and health promotion: What kind of evidence do we have and what is needed?]

Digital technologies increasingly affect our daily lives and interact with our living environment. A high potential for prevention and health promotion is referred to digital interventions. So far, however, there is a lack of well-founded evidence on the effectiveness of such measures. This paper will address the challenges of evidence-based digital interventions in prevention and health promotion. The results are summarised in the form of a narrative review.So far, evidence-based medicine methods have not been sufficiently used in the evaluation of benefits and harms in the field of prevention and health promotion. The reasons for this are found in the complexity of the corresponding measures. This complexity is further increased by digital interventions. Nevertheless, it is urgently recommended to place a stronger focus on evidence-based interventions in order to enable meaningful and comprehensible evaluation procedures with regard to the effectiveness of digital interventions in prevention and health promotion.Digitalisation leads to new demands on prevention and health promotion. A critical perspective on the actual impact of digital interventions and their social implications is needed. The development of a solid knowledge base is necessary in order to promote acceptance of the technologies and to achieve sustainable implementation.

Smartphone apps for managing alcohol consumption: a literature review

Background

Smartphone applications (apps) designed to assist users to reduce hazardous and harmful alcohol consumption show potential as an inexpensive alternative to traditional brief intervention in primary care. The aim of this paper is to provide an overview of the literature on alcohol reduction apps and the availability of evidenced-based apps on top commercial app stores.

Methods

We reviewed literature through to December 2019 using the databases PubMed, MEDLINE, PsycINFO and Google Scholar and keyword search terms smartphone/mobile/phone AND application/app AND alcohol. Articles were included if the primary intervention was a smartphone app and the study measured participant changes in frequency or volume of alcohol consumption.

Results

21 relevant articles were identified that evaluated 19 unique smartphone apps. Of the 19 unique apps, seven were designed for use among youth and 12 in adult populations. The available evidence for the efficacy of alcohol reduction apps among youth is inconclusive, with results from these evaluations not showing a clear benefit in reducing alcohol consumption compared to control groups. The results of apps designed for adult populations appears more promising, but results are still mixed. Of the 19 alcohol reduction apps that have been evaluated only eight of these are currently publicly available in commercial app stores. Of these eight apps, only four were demonstrated in the literature to assist with reducing alcohol consumption.

Conclusion

The evidence for alcohol reduction apps is promising but inconclusive. Few apps that have been evaluated in the scientific literature are currently available for download in commercial app stores.

Apps to prescribe therapeutic exercise among rehabilitating adults: a systematic review

INTRODUCTION

There is a growing interest across scientific literature on smartphone applications (apps) aiming to modify various health behaviors. Interventions that include behavior change techniques (BCTs) have been advocated to increase their efficacy. The extent to which those techniques are present among apps is unclear. The aim of this review is to analyze the existing apps for prescribing therapeutic exercise (TE) in rehabilitating adults.

EVIDENCE ACQUISITION

The study sample was identified through systematic searches in iTunes (Apple) and Google Play (Android). Applications (apps) were assessed according to the taxonomy of BCTs for the presence/absence of these techniques. Mean and ranges were calculated for the number of observed BCTs. Number of techniques observed in free apps in both stores was calculated, but formal statistical were not conducted due to the exploratory nature of this study.

EVIDENCE SYNTHESIS

Eighteen apps were identified (11 for iPhone, two for Android, and five for both). The average number of BCT included in the eligible apps was 11 (range 4 to 16), with predominance of four techniques: "request the establishment of behavior" (100% of the apps), "providing instructions" (100%), "requesting an implementation" (100%), and "determine graded tasks" (100%). Techniques such as "taking a behavioral contract," "stress management," "prevention of relapse," and "promote the identification of barriers" were not used in the apps reviewed.

CONCLUSIONS

Our work demonstrates that apps prescribing TE among rehabilitating adults applied an average of 11 BCTs. Presence of BCTs varied by app type. No difference in the number of BCTs identified between iOS and Android apps was found.

Engagement in a Novel Internet Intervention for Alcohol Reduction: A Qualitative Study of User Motivations and Experiences

Internet interventions are effective in reducing alcohol consumption, but little is known regarding their acceptability. We aimed to inform recruitment and retention strategies by exploring users' motivations and experiences in using a novel, Internet intervention, the Hello Sunday Morning (HSM) program. We conducted one-to-one, telephone-enabled qualitative interviews with 24 adult users of HSM (50 percent female; M_age = 42.42 years), purposively selected to ensure diversity in demographics and drinking levels. Data were analyzed using thematic analysis. Two themes, each with two subthemes were identified: (1a) pathway to HSM: HSM attracted participants seeking help for alcohol-related problems, and those not yet seeking help; (1b) format and framing: the positive, nonthreatening framing and anonymous, convenient format enabled participants to join out of interest, curiosity, or desire for a challenge; (2a) support and normalization: participants gained social support from other users, and their problems with alcohol and desire to seek help were normalized; (2b) goal setting and self-monitoring: setting goals and monitoring progress provided participants with motivation and self-accountability. We conclude that evidence-based behavior change techniques, including social support, normative strategies, goal setting, and self-monitoring, were appealing to users. These aspects could be incorporated into other programs to recruit participants who might otherwise avoid or delay seeking help.

Smartphone-based secondary prevention intervention for university students with unhealthy alcohol use identified by screening: study protocol of a parallel group randomized controlled trial

BACKGROUND

Unhealthy alcohol use is a leading cause of morbidity and mortality among young people, including university students. Delivering secondary prevention interventions against unhealthy alcohol use is challenging. Information technology has the potential to reach large parts of the general population. The present study is proposed to test a proactive secondary prevention smartphone-based intervention against unhealthy alcohol use.

METHODS

This is a parallel-group, randomized controlled trial (1:1 allocation ratio) among 1696 university students with unhealthy alcohol use, identified by screening and followed up at 3, 6, and 12 months. Participants will be randomized to receive access to a smartphone-based intervention or to a no intervention control condition. The primary outcome will be self-reported volume of alcohol drunk over the past 30 days, reported as the mean number of standard drinks per week over the past 30 days, measured at 6 months. Secondary outcomes will be number of heavy drinking days over the past 30 days, at 6 months. Additional outcomes will be maximum number of drinks on any day over the past 30 days, alcohol-related consequences (measured using the Short Inventory of Problems (SIP-2R), and academic performance.

DISCUSSION

The aim of this trial is to close the evidence gap on the efficacy of smartphone-based secondary prevention interventions. If proven effective, smartphone-based interventions have the potential to reach a large portion of the population, completing what is available on the Internet.

TRIAL REGISTRATION

ISRCTN, 10007691. Registered on 2 December 2019. Recruitment will start in April 2020.

A Context-Specific Digital Alcohol Brief Intervention in Symptomatic Breast Clinics (Abreast of Health): Development and Usability Study

Background

Potentially modifiable risk factors account for approximately 23% of breast cancer cases. In the United Kingdom, alcohol consumption alone is held responsible for 8% to 10% of cases diagnosed every year. Symptomatic breast clinics focus on early detection and treatment, but they also offer scope for delivery of low-cost lifestyle interventions to encourage a cancer prevention culture within the cancer care system. Careful development work is required to effectively translate such interventions to novel settings.

Objective

The aim of this study was to develop a theory of change and delivery mechanism for a context-specific alcohol and lifestyle brief intervention aimed at women attending screening and symptomatic breast clinics.

Methods

A formative study combined evidence reviews, analysis of mixed method data, and user experience research to develop an intervention model, following the 6 Steps in Quality Intervention Development (6SQuID) framework.

Results

A Web app focused on improving awareness, encouraging self-monitoring, and reframing alcohol reduction as a positive choice to improve health was found to be acceptable to women. Accessing this in the clinic waiting area on a tablet computer was shown to be feasible. An important facilitator for change may be the heightened readiness to learn associated with a salient health visit (a teachable moment). Women may have increased motivation to change if they can develop a belief in their capability to monitor and, if necessary, reduce their alcohol consumption.

Conclusions

Using the 6SQuID framework supported the prototyping and maximized acceptability and feasibility of an alcohol brief intervention for women attending symptomatic breast clinics, regardless of their level of alcohol consumption.

Smartphones in mental health: a critical review of background issues, current status and future concerns

There has been increasing interest in the use of smartphone applications (apps) and other consumer technology in mental health care for a number of years. However, the vision of data from apps seamlessly returned to, and integrated in, the electronic medical record (EMR) to assist both psychiatrists and patients has not been widely achieved, due in part to complex issues involved in the use of smartphone and other consumer technology in psychiatry. These issues include consumer technology usage, clinical utility, commercialization, and evolving consumer technology. Technological, legal and commercial issues, as well as medical issues, will determine the role of consumer technology in psychiatry. Recommendations for a more productive direction for the use of consumer technology in psychiatry are provided.