Lost in Translation: Transforming Behaviour Change Techniques into Engaging Digital Content and Design for the StopApp

Potential associations between behavior change techniques and engagement with mobile health apps: a systematic review

Introduction

Lack of engagement is a common challenge for digital health interventions. To achieve their potential, it is necessary to understand how best to support users' engagement with interventions and target health behaviors. The aim of this systematic review was to identify the behavioral theories and behavior change techniques being incorporated into mobile health apps and how they are associated with the different components of engagement.

Methods

The review was structured using the PRISMA and PICOS frameworks and searched six databases in July 2022: PubMed, Embase, CINAHL, APA PsycArticles, ScienceDirect, and Web of Science. Risk of bias was evaluated using the Cochrane Collaboration Risk of Bias 2 and the Mixed Methods Appraisal Tools.

Analysis

A descriptive analysis provided an overview of study and app characteristics and evidence for potential associations between Behavior Change Techniques (BCTs) and engagement was examined.

Results

The final analysis included 28 studies. Six BCTs were repeatedly associated with user engagement: goal setting, self-monitoring of behavior, feedback on behavior, prompts/cues, rewards, and social support. There was insufficient data reported to examine associations with specific components of engagement, but the analysis indicated that the different components were being captured by various measures.

Conclusion

This review provides further evidence supporting the use of common BCTs in mobile health apps. To enable developers to leverage BCTs and other app features to optimize engagement in specific contexts and individual characteristics, we need a better understanding of how BCTs are associated with different components of engagement.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022312596.

Smokers' user experience of smoking cessation apps: A systematic review

OBJECTIVES

To explore how smokers view common functions and characteristics of smoking cessation apps.

DESIGN

Systematic review.

SEARCH SOURCES

CINAHL PLUS, MEDLINE, PsycINFO, EMBASE, IEEE Xplore, ACM Digital Library, and Google Scholar.

REVIEW METHODS

Seven digital databases were searched separately using relevant search terms. Search results were uploaded to Covidence. Inclusion and exclusion criteria were identified with the expert team in advance. Titles, abstracts, and full texts were screened by two reviewers independently. Any disagreements were discussed in research meetings. Pertinent data were extracted and analysed using qualitative content analysis. Findings were presented in a narrative approach.

RESULTS

28 studies were included in this review. The overarching themes were app functionality and app characteristics. Under app "functionality", six subthemes emerged: 1) education; 2) tracking; 3) social support; 4) compensation; 5) distraction, and 6) reminding. Under "app characteristics", five subthemes emerged: 1) simplification, 2) personalisation, 3) diverse content forms, 4) interactivity, and 5) privacy and security.

CONCLUSION

Understanding user needs and expectations is crucial for developing a programme theory for smoking cessation app interventions. Relevant needs identified in this review should be linked to broader theories of smoking cessation and app-based intervention.

Design Features Associated With Engagement in Mobile Health Physical Activity Interventions Among Youth: Systematic Review of Qualitative and Quantitative Studies

BACKGROUND

Globally, 81% of youth do not meet the physical activity (PA) guidelines. Youth of families with a low socioeconomic position are less likely to meet the recommended PA guidelines. Mobile health (mHealth) interventions are preferred by youth over traditional in-person approaches and are in line with their media preferences. Despite the promise of mHealth interventions in promoting PA, a common challenge is to engage users in the long term or effectively. Earlier reviews highlighted the association of different design features (eg, notifications and rewards) with engagement among adults. However, little is known about which design features are important for increasing engagement among youth.

OBJECTIVE

To inform the design process of future mHealth tools, it is important to investigate the design features that can yield effective user engagement. This systematic review aimed to identify which design features are associated with engagement in mHealth PA interventions among youth who were aged between 4 and 18 years.

METHODS

A systematic search was conducted in EBSCOhost (MEDLINE, APA PsycINFO, and Psychology & Behavioral Sciences Collection) and Scopus. Qualitative and quantitative studies were included if they documented design features associated with engagement. Design features and related behavior change techniques and engagement measures were extracted. Study quality was assessed according to the Mixed Method Assessment Tool, and one-third of all screening and data extraction were double coded by a second reviewer.

RESULTS

Studies (n=21) showed that various features were associated with engagement, such as a clear interface, rewards, multiplayer game mode, social interaction, variety of challenges with personalized difficulty level, self-monitoring, and variety of customization options among others, including self-set goals, personalized feedback, progress, and a narrative. In contrast, various features need to be carefully considered while designing mHealth PA interventions, such as sounds, competition, instructions, notifications, virtual maps, or self-monitoring, facilitated by manual input. In addition, technical functionality can be considered as a prerequisite for engagement. Research addressing youth from low socioeconomic position families is very limited with regard to engagement in mHealth apps.

CONCLUSIONS

Mismatches between different design features in terms of target group, study design, and content translation from behavior change techniques to design features are highlighted and set up in a design guideline and future research agenda.

TRIAL REGISTRATION

PROSPERO CRD42021254989; https://tinyurl.com/5n6ppz24.

Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity

BACKGROUND

"Healthy Living for People with type 2 Diabetes (HeLP-Diabetes)" was a theory-based digital self-management intervention for people with type 2 diabetes mellitus that encouraged behavior change using behavior change techniques (BCTs) and promoted self-management. HeLP-Diabetes was effective in reducing HbA1c levels in a randomized controlled trial (RCT). National Health Service (NHS) England commissioned a national rollout of HeLP-Diabetes in routine care (now called "Healthy Living"). Healthy Living presents a unique opportunity to examine the fidelity of the national rollout of an intervention originally tested in an RCT.

OBJECTIVE

This research aimed to describe the Healthy Living BCT and self-management content and features of intervention delivery, compare the fidelity of Healthy Living with the original HeLP-Diabetes intervention, and explain the reasons for any fidelity drift during national rollout through qualitative interviews.

METHODS

Content analysis of Healthy Living was conducted using 3 coding frameworks (objective 1): the BCT Taxonomy v1, a new coding framework for assessing self-management tasks, and the Template for Intervention Description and Replication. The extent to which BCTs and self-management tasks were included in Healthy Living was compared with published descriptions of HeLP-Diabetes (objective 2). Semistructured interviews were conducted with 9 stakeholders involved in the development of HeLP-Diabetes or Healthy Living to understand the reasons for any changes during national rollout (objective 3). Qualitative data were thematically analyzed using a modified framework approach.

RESULTS

The content analysis identified 43 BCTs in Healthy Living. Healthy Living included all but one of the self-regulatory BCTs ("commitment") in the original HeLP-Diabetes intervention. Healthy Living was found to address all areas of self-management (medical, emotional, and role) in line with the original HeLP-Diabetes intervention. However, 2 important changes were identified. First, facilitated access by a health care professional was not implemented; interviews revealed this was because general practices had fewer resources in comparison with the RCT. Second, Healthy Living included an additional structured web-based learning curriculum that was developed by the HeLP-Diabetes team but was not included in the original RCT; interviews revealed that this was because of changes in NHS policy that encouraged referral to structured education. Interviewees described how the service provider had to reformat the content of the original HeLP-Diabetes website to make it more usable and accessible to meet the multiple digital standards required for implementation in the NHS.

CONCLUSIONS

The national rollout of Healthy Living had good fidelity to the BCT and self-management content of HeLP-Diabetes. Important changes were attributable to the challenges of scaling up a digital intervention from an RCT to a nationally implemented intervention, mainly because of fewer resources available in practice and the length of time since the RCT. This study highlights the importance of considering implementation throughout all phases of intervention development.

An iterative, interdisciplinary, collaborative framework for developing and evaluating digital behavior change interventions

The rapid expansion of technology promises to transform the behavior science field by revolutionizing the ways in which individuals can monitor and improve their health behaviors. To fully live into this promise, the behavior science field must address distinct challenges, including: building interventions that are not only scientifically sound but also engaging; using evaluation methods to precisely assess intervention components for intervention optimization; and building personalized interventions that acknowledge and adapt to the dynamic ecosystem of individual and contextual variables that impact behavior change. The purpose of this paper is to provide a framework to address these challenges by leveraging behavior science, human-centered design, and data science expertise throughout the cycle of developing and evaluating digital behavior change interventions (DBCIs). To define this framework, we reviewed current models and practices for intervention development and evaluation, as well as technology industry models for product development. The framework promotes an iterative process, aiming to maximize outcomes by incorporating faster and more frequent testing cycles into the lifecycle of a DBCI. Within the framework provided, we describe each phase, from development to evaluation, to discuss the optimal practices, necessary stakeholders, and proposed evaluation methods. The proposed framework may inform practices in both academia and industry, as well as highlight the need to offer collaborative platforms to ensure successful partnerships that can lead to more effective DBCIs that reach broad and diverse populations.

A digital behaviour change intervention to increase booking and attendance at Stop Smoking Services: the MyWay feasibility RCT

Background

Smoking remains a leading cause of illness and preventable death. NHS Stop Smoking Services increase quitting, but, as access is in decline, cost-effective interventions are needed that promote these services. StopApp™ (Coventry University, Coventry, UK) is designed to increase booking and attendance at Stop Smoking Services.

Design

A two-arm feasibility randomised controlled trial of StopApp (intervention) compared with standard promotion and referral to Stop Smoking Services (control) was conducted to assess recruitment, attrition and health equity of the design, alongside health economic and qualitative process evaluations.

Setting

Smokers recruited via general practitioners, community settings and social media.

Participants

Smokers aged ≥ 16 years were recruited in one local authority. Participants had to live or work within the local authority area, and there was a recruitment target of 120 participants.

Interventions

StopApp to increase booking and attendance at Stop Smoking Services.

Main outcome measures

Participants completed baseline measures and follow-up at 2 months post randomisation entirely online. Objective data on the use of Stop Smoking Services were collected from participating Stop Smoking Services, and age groups, sex, ethnicity and socioeconomic status in baseline recruits and follow-up completers/non-completers were assessed for equity.

Results

Eligible participants (n = 123) were recruited over 116 days, with good representation of lower socioeconomic status groups; black, Asian and minority ethnic groups; and all age groups. Demographic profiles of follow-up completers and non-completers were broadly similar. The attrition rate was 51.2%, with loss to follow-up lowest in the social media setting (n = 24/61; 39.3%) and highest in the general practitioner setting (n = 21/26; 80.8%). Most measures had < 5% missing data. Social media represented the most effective and cost-efficient recruitment method. In a future, definitive, multisite trial with recruitment driven by social media, our data suggest that recruiting ≥ 1500 smokers over 12 months is feasible. Service data showed that five bookings for the Stop Smoking Services were scheduled using StopApp, of which two did not attend. Challenges with data access were identified. A further five participants in the intervention arm self-reported booking and accessing Stop Smoking Services outside StopApp compared with two control arm participants. Event rate calculations for the intervention were 8% (Stop Smoking Services data), 17% (including self-reports) and 3.5% from control arm self-reports. A conservative effect size of 6% is estimated for a definitive full trial. A sample size of 840 participants would be required to detect an effect for the primary outcome measure of booking a Stop Smoking Services appointment in a full randomised controlled trial. The process evaluation found that participants were satisfied with the research team contact, study methods and provision of e-vouchers. Staff interviews revealed positive and negative experiences of the trial and suggestions for improvements, including encouraging smokers to take part.

Conclusion

This feasibility randomised controlled trial found that, with recruitment driven wholly or mainly by social media, it is possible to recruit and retain sufficient smokers to assess the effectiveness and cost-effectiveness of StopApp. The study methods and measures were found to be acceptable and equitable, but accessing Stop Smoking Services data about booking, attendance and quit dates was a challenge. A full trial may be feasible if service data are accessible. This will require careful planning with data controllers and a targeted social media campaign for recruitment. Changes to some study measures are needed to avoid missing data, including implementation of a more intensive follow-up data collection process.

Future work

We plan a full, definitive randomised controlled trial if the concerns around data access can be resolved, with adaptations to the recruitment and retention strategy.

Limitations

Our trial had high attrition and problems with collecting Stop Smoking Services data, which resulted in a reliance on self-reporting.

Trial registration

Research Registry: 3995. The trial was registered on 18 April 2018.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

A Digital Health Intervention for Weight Management for Latino Families Living in Rural Communities: Perspectives and Lessons Learned During Development

Rural residents face numerous challenges in accessing quality health care for management of chronic diseases (eg, obesity, diabetes), including scarcity of health care services and insufficient public transport. Digital health interventions, which include modalities such as internet, smartphones, and monitoring sensors, may help increase rural residents’ access to health care. While digital health interventions have become an increasingly popular intervention strategy to address obesity, research examining the use of technological tools for obesity management among rural Latino populations is limited. In this paper, we share our experience developing a culturally tailored, interactive health intervention using digital technologies for a family-oriented, weight management program in a rural, primarily Latino community. We describe the formative research that guided the development of the intervention, discuss the process of developing the intervention technologies including issues of privacy and data security, examine the results of a pilot study, and share lessons learned. Our experience can help others design user-centered digital health interventions to engage underserved populations in the uptake of healthy lifestyle and disease management skills.

Describing the Process and Tools Adopted to Cocreate a Smartphone App for Obesity Prevention in Childhood: Mixed Method Study

Background

Childhood obesity prevention is a public health priority in industrialized countries. The Reggio Emilia Local Health Authority has implemented a program involving primary and secondary prevention as well as the care of obese children. There are many health-promoting mobile apps, but few are targeted to children and very few are sponsored by public health agencies.

Objective

The goal of the research was to describe the process and tools adopted to cocreate a mobile app sponsored by the Reggio Emilia Local Health Authority to be installed in parents’ phones aimed at promoting child health and preventing obesity.

Methods

After stakeholder mapping, a consulting committee including relevant actors, stakeholders, and users was formed. Key persons for childhood obesity prevention were interviewed, focus groups with parents and pediatricians were conducted, and community reporting storytelling was collected. The results of these activities were presented to the consulting committee in order to define the functionalities and contents of the mobile app.

Results

Three key trends emerged from community reporting: being active, playing, and being outdoors; time for oneself, family, and friends; and the pressures of life and work and not having time to be active and socialize. In focus groups, interviews, and labs, mothers showed a positive attitude toward using an app to manage their children's weight, while pediatricians expressed concerns that the app could increase their workload. When these findings were explored by the consulting committee, four key themes were extracted: strong relationships with peers, family members, and the community; access to safe outdoor spaces; children’s need for age-appropriate independence; and professional support should be nonjudgmental and stigma-free. It should be a dialogue that promotes family autonomy. The app functions related to these needs include the following: (1) newsletter with anticipatory guidance, recipes, and vaccination and well-child visit reminders; (2) regional map indicating where physical activity can be done; (3) information on how to manage emergencies (eg, falls, burns, fever); (4) module for reinforcing the counseling intervention conducted by pediatricians for overweight children; and (5) a function to build a balanced daily diet.

Conclusions

The pilot study we conducted showed that cocreation in health promotion is feasible, with the consulting committee being the key co-governance and cocreation tool. The involvement of stakeholders in this committee made it possible to expand the number of persons and institutions actively contributing to the project.

Mobile Applications for the Treatment of Tobacco Use and Dependence

PURPOSE OF REVIEW

Smoking remains a leading preventable cause of premature death in the world; thus, developing effective and scalable smoking cessation interventions is crucial. This review uses the Obesity-Related Behavioral Intervention Trials (ORBIT) model for early phase development of behavioral interventions to conceptually organize the state of research of mobile applications (apps) for smoking cessation, briefly highlight their technical and theory-based components, and describe available data on efficacy and effectiveness.

RECENT FINDINGS

Our review suggests that there is a need for more programmatic efforts in the development of mobile applications for smoking cessation, though it is promising that more studies are reporting early phase research such as user-centered design. We identified and described the app features used to implement smoking cessation interventions, and found that the majority of the apps studied used a limited number of mechanisms of intervention delivery, though more effort is needed to link specific app features with clinical outcomes. Similar to earlier reviews, we found that few apps have yet been tested in large well-controlled clinical trials, although progress is being made in reporting transparency with protocol papers and clinical trial registration.

SUMMARY

ORBIT is an effective model to summarize and guide research on smartphone apps for smoking cessation. Continued improvements in early phase research and app design should accelerate the progress of research in mobile apps for smoking cessation.

Tailored digital behaviour change intervention with e-referral system to increase attendance at NHS stop smoking services (the MyWay project): study protocol for a randomised controlled feasibility trial

INTRODUCTION

In the UK, smokers who use stop smoking services (SSSs) are four times more likely to stop smoking than smokers who do not. Attendance has declined, warranting the development of interventions to address this. StopApp is a novel, brief online behaviour change intervention designed to address common barriers to SSS attendance. It links to widely commissioned service management software that enables instant appointment booking at a user's location and time of choice.

METHODS AND ANALYSIS

A two-arm parallel group, individual participant feasibility randomised controlled trial of StopApp (intervention) compared with the standard promotion of and referral to SSSs (control). The study includes a nested qualitative process evaluation to assess the acceptability of the research processes, with a subsample of participants. Smokers aged over 16 years will be recruited via three routes: General Practice (GP), community settings and online. After consenting and the collection of baseline data, participants will be randomised to control or intervention groups. Participants in the intervention group receive a link to StopApp and those in the control group receive standard web-based information about the SSSs. All participants are told they can book a SSS appointment but are under no obligation to do so. Online follow-up 2 months post randomisation includes data on SSS use and carbon monoxide verified 4-week quit rates. The study aims to recruit 162 smokers.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the West Midlands-Edgbaston NHS Research Ethics Committee. The findings will be reported in conferences and peer-reviewed publications; and will be used to design the parameters necessary for a definitive trial to ascertain the effectiveness of StopApp at increasing booking and attendance at SSSs compared with existing methods for encouraging uptake.