Apps to improve diet, physical activity and sedentary behaviour in children and adolescents: a review of quality, features and behaviour change techniques.
ABSTRACT: The number of commercial apps to improve health behaviours in children is growing rapidly. While this provides opportunities for promoting health, the content and quality of apps targeting children and adolescents is largely unexplored. This review systematically evaluated the content and quality of apps to improve diet, physical activity and sedentary behaviour in children and adolescents, and examined relationships of app quality ratings with number of app features and behaviour change techniques (BCTs) used.Systematic literature searches were conducted in iTunes and Google Play stores between May-November 2016. Apps were included if they targeted children or adolescents, focused on improving diet, physical activity and/or sedentary behaviour, had a user rating of at least 4+ based on at least 20 ratings, and were available in English. App inclusion, downloading and user-testing for quality assessment and content analysis were conducted independently by two reviewers. Spearman correlations were used to examine relationships between app quality, and number of technical app features and BCTs included.Twenty-five apps were included targeting diet (n = 12), physical activity (n = 18) and sedentary behaviour (n = 7). On a 5-point Mobile App Rating Scale (MARS), overall app quality was moderate (total MARS score: 3.6). Functionality was the highest scoring domain (mean: 4.1, SD: 0.6), followed by aesthetics (mean: 3.8, SD: 0.8), and lower scoring for engagement (mean: 3.6, SD: 0.7) and information quality (mean: 2.8, SD: 0.8). On average, 6 BCTs were identified per app (range: 1-14); the most frequently used BCTs were providing 'instructions' (n = 19), 'general encouragement' (n = 18), 'contingent rewards' (n = 17), and 'feedback on performance' (n = 13). App quality ratings correlated positively with numbers of technical app features (rho = 0.42, p < 0.05) and BCTs included (rho = 0.54, p < 0.01).Popular commercial apps to improve diet, physical activity and sedentary behaviour in children and adolescents had moderate quality overall, scored higher in terms of functionality. Most apps incorporated some BCTs and higher quality apps included more app features and BCTs. Future app development should identify factors that promote users' app engagement, be tailored to specific population groups, and be informed by health behaviour theories.
Project description:OBJECTIVE:The objective of this study was to systematically evaluate commercially available medication adherence apps for the inclusion of behavior change techniques (BCTs) and to conduct a usability analysis on a subset of apps with adolescents and young adults living with a chronic illness. METHODS:Medication adherence apps were identified via a search of iTunes app store in August 2016. Seventy-five apps meeting initial inclusion criteria were independently coded by two researchers for the presence/absence of 26 BCTs. Twenty adolescents and young adults (ages: 13-20 years) with inflammatory bowel disease conducted usability testing on a subset of apps (n?=?4). RESULTS:Across 75 apps coded for presence/absence of 26 BCTs, only 7 unique BCTs were identified. The number of BCTs per app ranged from 2 to 6, with an average of 3.3 BCTs. In usability testing, quality ratings varied across apps. Medisafe received the highest average scores on engagement, functionality, aesthetics, and information subscales. Medisafe and MyTherapy ranked first and second, respectively, on overall quality and perceived impact ratings. CONCLUSION:Content evaluation revealed only a limited number of BCTs that have been translated to medication adherence apps. Among apps with comparable content, clear user preferences emerged based on perceived quality and usability. Greater collaboration is needed between psychologists and health technologists to incorporate more evidence-based BCTs in apps. Findings also indicate a need for app developers to consider and incorporate the preferences of younger end users to improve app quality and engagement for pediatric populations.
Project description:Objective:Mobile applications (apps) are increasingly being utilized in health behavior change interventions. To determine the presence of underlying behavior change mechanisms, apps for physical activity have been coded for behavior change techniques (BCTs). However, apps for sedentary behavior have yet to be assessed for BCTs. Thus, the purpose of the present study was to review apps designed to decrease sedentary time and determine the presence of BCTs. Methods:Systematic searches of the iTunes App and Google Play stores were completed using keyword searches. Two reviewers independently coded free (n = 36) and paid (n = 14) app descriptions using a taxonomy of 93 BCTs (December 2016-January 2017). A subsample (n = 4) of free apps were trialed for one week by the reviewers and coded for the presence of BCTs (February 2017). Results:In the free and paid app descriptions, only 10 of 93 BCTs were present with a mean of 2.42 BCTs (range 0-6) per app. The BCTs coded most frequently were "prompts/cues" (n = 43), "information about health consequences" (n = 31), and "self-monitoring of behavior" (n = 17). For the four free apps that were trialed, three additional BCTs were coded that were not coded in the descriptions: "graded tasks," "focus on past successes," and "behavior substitution." Conclusions:These sedentary behavior apps have fewer BCTs compared with physical activity apps and traditional (i.e., non-app) physical activity and healthy eating interventions. The present study sheds light on the behavior change potential of sedentary behavior apps and provides practical insight about coding for BCTs in apps.
Project description:BACKGROUND: There has been a recent proliferation in the development of smartphone applications (apps) aimed at modifying various health behaviours. While interventions that incorporate behaviour change techniques (BCTs) have been associated with greater effectiveness, it is not clear to what extent smartphone apps incorporate such techniques. The purpose of this study was to investigate the presence of BCTs in physical activity and dietary apps and determine how reliably the taxonomy checklist can be used to identify BCTs in smartphone apps. METHODS: The top-20 paid and top-20 free physical activity and/or dietary behaviour apps from the New Zealand Apple App Store Health & Fitness category were downloaded to an iPhone. Four independent raters user-tested and coded each app for the presence/absence of BCTs using the taxonomy of behaviour change techniques (26 BCTs in total). The number of BCTs included in the 40 apps was calculated. Krippendorff's alpha was used to evaluate interrater reliability for each of the 26 BCTs. RESULTS: Apps included an average of 8.1 (range 2-18) techniques, the number being slightly higher for paid (M?=?9.7, range 2-18) than free apps (M?=?6.6, range 3-14). The most frequently included BCTs were "provide instruction" (83% of the apps), "set graded tasks" (70%), and "prompt self-monitoring" (60%). Techniques such as "teach to use prompts/cues", "agree on behavioural contract", "relapse prevention" and "time management" were not present in the apps reviewed. Interrater reliability coefficients ranged from 0.1 to 0.9 (Mean 0.6, SD?=?0.2). CONCLUSIONS: Presence of BCTs varied by app type and price; however, BCTs associated with increased intervention effectiveness were in general more common in paid apps. The taxonomy checklist can be used by independent raters to reliably identify BCTs in physical activity and dietary behaviour smartphone apps.
Project description:OBJECTIVES:To explore the relationship between popularity of mobile application (apps) for physical activity (PA) and their likely efficacy. The primary objective was to assess the association between app popularity (indicated by user ratings) and likely efficacy (indicated by the number of Behaviour Change Techniques (BCT) present). The secondary objective was to assess the relationship between user ratings and those BCTs that have been shown to be effective in increasing PA. DESIGN:Observational study. METHODS:400 top-ranked free and paid apps from iTunes and Google Play stores were screened, and were included if the primary behaviour targeted was PA and they had stand-alone functionality. The outcome variable of user rating was dichotomised into high (4, 5 stars) or low (1, 2, 3 stars) rating. SETTING:iTunes and Google Play app stores. PARTICIPANTS:No individual participants but the study used user-led rating system in the app store. PRIMARY AND SECONDARY OUTCOME MEASURES:BCTs and user rating. RESULTS:Of 400 apps, 156 were eligible and 65 were randomly selected, downloaded and assessed by two reviewers. There was no relationship overall between star ratings and the number of BCTs present, nor between star ratings and the presence of BCTs known to be effective in increasing PA. App store was strongly associated with star ratings, with lower likelihood of finding 4 or 5 stars in iTunes compared with Google Play (OR 0.74, 95%?CI 0.73 to 0.76, p<0.001). CONCLUSIONS:The findings of this study suggest that popularity does not necessarily imply the likelihood of effectiveness. Hence, public health impact is unlikely to be achieved by allowing market forces to 'prescribe' what is used by the public.
Project description:The importance of diet during pregnancy is critically important for the short- and long-term health of both mother and child. The number of apps targeting pregnant women is rapidly increasing, yet the nutritional content of these tools remains largely unexplored. This review aimed to evaluate the coverage and content of nutrition information in smartphone apps available to U.K. pregnant women. Keyword searches were conducted in iTunes and Google Play stores in November 2018. Candidate apps were included if they targeted pregnant women, provided pregnancy-specific nutritional information, had a user rating of at least 4+ based on at least 20 ratings, and were available in English. Nutritional content was assessed for accuracy against U.K. recommendations. Behaviour change techniques (BCTs) were also evaluated. Twenty-nine apps were included, seven of which originated in the United Kingdom. There was a large variability in the quality of smartphone app nutritional information. The accuracy of nutrition information varied, and several apps conveyed inappropriate information for pregnancy. On average, 10 BCTs were identified per app (range 2-15). Overall, smartphone apps do not consistently provide accurate and useful nutritional information to pregnant women. This study highlights the need for the integration of evidence-based nutritional information during app development and for increased regulatory oversight. App developers should also make it clear that nutritional content is intended for a specific geographical region or population or modify for the intended audience. These are important considerations for the design of future apps, which are increasingly used to complement existing maternity services.
Project description:BACKGROUND:Modern families are facing conflicting demands on their time and resources, which may be at the detriment of child and family diet quality. Innovative nutrition interventions providing parents with behavioral support for the provision of healthy food could alleviate this issue. Mobile apps have the potential to deliver such interventions by providing practical behavioral support remotely, interactively, and in context. OBJECTIVE:This review aimed to identify and assess popular, commercially available food- and nutrition-related mobile apps that offer support for the provision of healthy family food by (1) describing app scope and characteristics, (2) assessing app quality, and (3) conducting a behavioral analysis of app content and features. METHODS:Searches in the Google Play Store and Apple App Store between August 2017 and November 2017 identified apps addressing the food provision process. Apps were included if they were applicable to parents or families, written in English, and with a user rating of ≥4 stars. Weight loss and diet monitoring apps and subscription apps with no free versions were excluded. App quality was assessed using the Mobile App Rating Scale (4 domains: engagement, functionality, aesthetics, and information). App content and features were extracted and behavior change techniques (BCTs) identified. RESULTS:Of the 2881 apps screened, 1.77% (51/2881) were included for assessment, comprising 23 recipe and recipe manager apps, 12 meal planning apps, 10 shopping list apps, 4 family organizers, and 2 food choice apps. Half (n=26) of the apps functioned primarily through user data input. Food choice and family organizer apps scored highest for app quality (mean 3.5 [SD 0.6] out of 5), whereas most apps scored well for functionality and poorly for engagement. Common app features with the potential to support healthy food provision included meal planners (n=26), shopping lists (n=44), and the ability to share app content (n=48). Behavioral support features mapped to relatively few BCTs (mean 3.9 [SD 1.9] per app), with Adding objects to the environment present in all apps, and 65% (33/51) including Instruction on how to perform the behavior. CONCLUSIONS:Recipe and recipe manager apps, meal planning apps, and family organizers with integrated meal planning and shopping lists scored well for functionality and incorporated behavioral support features that could be used to address barriers to healthy food provision, although features were focused on planning behaviors. Future apps should combine a range of features such as meal planners, shopping lists, simple recipes, reminders and prompts, and food ordering to reduce the burden of the food provision pathway and incorporate a range of BCTs to maximize behavior change potential. Researchers and developers should consider features and content that improve the engagement quality of such apps.
Project description:BACKGROUND:The quality of life of people living with chronic conditions is highly dependent on self-management behaviors. Mobile health (mHealth) apps could facilitate self-management and thus help improve population health. To achieve their potential, apps need to target specific behaviors with appropriate techniques that support change and do so in a way that allows users to understand and act upon the content with which they interact. OBJECTIVE:Our objective was to identify apps targeted toward the self-management of chronic conditions and that are available in France. We aimed to examine what target behaviors and behavior change techniques (BCTs) they include, their level of understandability and actionability, and the associations between these characteristics. METHODS:We extracted data from the Google Play store on apps labelled as Top in the Medicine category. We also extracted data on apps that were found through 12 popular terms (ie, keywords) for the four most common chronic condition groups-cardiovascular diseases, cancers, respiratory diseases, and diabetes-along with apps identified through a literature search. We selected and downloaded native Android apps available in French for the self-management of any chronic condition in one of the four groups and extracted background characteristics (eg, stars and number of ratings), coded the presence of target behaviors and BCTs using the BCT taxonomy, and coded the understandability and actionability of apps using the Patient Education Material Assessment Tool for audiovisual materials (PEMAT-A/V). We performed descriptive statistics and bivariate statistical tests. RESULTS:A total of 44 distinct native apps were available for download in France and in French: 39 (89%) were found via the Google Play store and 5 (11%) were found via literature search. A total of 19 (43%) apps were for diabetes, 10 for cardiovascular diseases (23%), 8 for more than one condition in the four groups (18%), 6 for respiratory diseases (14%), and 1 for cancer (2%). The median number of target behaviors per app was 2 (range 0-7) and of BCTs per app was 3 (range 0-12). The most common BCT was self-monitoring of outcome(s) of behavior (31 apps), while the most common target behavior was tracking symptoms (30 apps). The median level of understandability was 42% and of actionability was 0%. Apps with more target behaviors and more BCTs were also more understandable (ρ=.31, P=.04 and ρ=.35, P=.02, respectively), but were not significantly more actionable (ρ=.24, P=.12 and ρ=.29, P=.054, respectively). CONCLUSIONS:These apps target few behaviors and include few BCTs, limiting their potential for behavior change. While content is moderately understandable, clear instructions on when and how to act are uncommon. Developers need to work closely with health professionals, users, and behavior change experts to improve content and format so apps can better support patients in coping with chronic conditions. Developers may use these criteria for assessing content and format to guide app development and evaluation of app performance. TRIAL REGISTRATION:PROSPERO CRD42018094012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94012.
Project description:BACKGROUND:Food allergies and intolerances are increasing worldwide, and mobile phone apps could be a promising tool for self-management of these issues. OBJECTIVE:This study aimed to systemically search and assess food allergy or intolerance apps in app stores using the multidimensional Mobile App Rating Scale (MARS) to rate the objective and subjective quality and to identify critical points for future improvements. METHODS:This systematic search identified apps through the keywords "food allergy," "food intolerance," and "allergens" in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ?3 (of 5 stars) to limit the selection to the most highly rated apps; ?1000 reviews as an indicator of reliability; and the most recent update performed up to 2017. Then, the apps were divided according to their purpose (searching for allergen-free "food products," "restaurants," or recipes in "meal planners") and evaluated on a scale of 1 to 5 points using the MARS in terms of (1) app classification category with a descriptive aim; (2) app subjective and objective quality categories comprised of engagement, functionality, esthetics, and information sections (Medline was searched for eligible apps to check whether they had been tested in trials); and (3) an optional app-specific section. Furthermore, the output and input features were evaluated. Differences between MARS sections and between app purposes and correlations among MARS sections, star ratings, and numbers of reviews were evaluated. RESULTS:Of the 1376 apps identified, 14 were included: 12 related to food allergies and intolerances that detect 2-16 food allergens and 2 related only to gluten intolerance. The mean (SD) MARS scores (maximum 5 points) were 3.8 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5 (SD 0.6) for subjective quality; and 3.6 (SD 0.7) for the app-specific section. Therefore, a rating ?3 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1, SD 0.6), esthetics (mean 4, SD 0.5), and information (mean 3.8, SD 0.4). However, when the apps were compared by purpose, critical points were identified: meal planner apps showed significantly higher engagement (mean 4.1, SD 0.4) than food product (mean 3.0, SD 0.6; P=.05) and restaurant (mean 3.2, SD 0.3; P=.02) apps. CONCLUSIONS:In this systematic search of food allergy or intolerance apps, acceptable MARS quality was identified, although the engagement section for food product and restaurant purpose apps should be improved and the included apps should be tested in trials. The critical points identified in this systematic search can help improve the innovativeness and applicability of future food allergy and intolerance apps.
Project description:Smartphone applications (apps) offer a potentially cost-effective and a wide-reach aid to smoking cessation. In 2012, a content analysis of smoking cessation apps suggested that most apps did not adopt behaviour change techniques (BCTs), which according to previous research had suggested would promote higher success rates in quitting smoking. This study examined whether or not, this situation had changed by 2014 for free smoking cessation apps available in the Apple App Store. It also compared the use of engagement and ease-of-use features between the two time points.137 free apps available in the Apple App Sore in 2014 were coded using an established framework for the presence or absence of evidence-based BCTs, and engagement and ease-of-use features. The results from the 2014 data were compared with a similar exercise conducted on 83 free apps available in 2012.BCTs supporting identity change, rewarding abstinence and advising on changing routines were less prevalent in 2014 as compared with 2012 (14.6% vs. 42.2%, 18.2% vs. 48.2%, and 17.5% vs. 24.1%, respectively). Advice on coping with cravings and advice on the use of stop-smoking medication were more prevalent in 2014 as compared with 2012 (27.7% vs. 20.5% and 14.6% vs 3.6%, respectively). The use of recognised engagement features was less common in 2014 than in 2012 (45.3% vs. 69.6%) while ease-of-use features remained very high (94.5% vs. 82.6%).There was little evidence of improvement in the use of evidence-based BCTs in free smoking cessation iPhone-based apps between 2012 and 2014.