Usability Testing an mHealth Program with Tailored Motivational Messages for Early Adolescents

Obesity among children is a rising concern throughout the world. In the U.S., rates of childhood obesity are the highest among children from diverse and economically disadvantaged households. Obesity in adolescence increases the risk of negative physical and psychological health consequences. Mobile-app-based health interventions have been found to be an effective tool to encourage children to adopt a healthier living style. A novel mobile app prototype was developed for early adolescents to communicate with and engage them interactively about healthy eating and active living. To test the app's usability, students from a U.S. middle school, with a majority of children from low-income families, were recruited to use the app and report their feedback. The usability testing results confirmed that the app was equally well received by participants of different genders, normal weight versus overweight/obesity, and amounts of screen time. Study participants also provided overwhelming positive feedback for the embedded and tailored motivational messages that encourage healthy eating and active living. The conceptualization of the app prototype was guided by the self-determination theory, social cognitive theory, and priming theory, in addition to incorporating evidence-based obesity prevention principles. This prototype, hence, provides a valid platform for building theory-based behavioral interventions.

Co-designing a digital companion with people living with Parkinson's to support self-care in a personalized way: The eCARE-PD Study

eHealth technologies play a role in the development of integrated care models for people living with Parkinson disease by improving communication with their health care teams and support self-care practices in a personalized way. This article presents a co-design approach to designing an eHealth technology, the eCARE-PD platform, that addresses the needs and expectations of people living with Parkinson disease, generates tailored care tips, and recommends actions for managing care priorities at home. We use a co-design approach involving four main iterative phases: (1) preparation, (2) mapping, (3) testing and using, and (4) co-producing solutions and requirements. This approach uses several methods to engage people directly to design this technology. The study allowed us to identify design principles to be integrated in the development of the eCARE-PD platform. These principles incorporate the expectations of future users, which were expressed during the iterative phases of the co-design process: (a) six key design features based on users’ needs and expectations, (b) six main issues users raised during a test at home and key features for improving the design of the eCARE-PD platform, and (c) collective solutions to design an interactive, meaningful, tailored, empathic, and socially acceptable technology. The results of the successive phases of the co-design process allow us to underline the progressive constitution of a technology defined over successive iterations as a digital companion supporting the self-care process at home and having the capacity to generate tailored digital health communication.

Exploring mechanisms of a web-based values-tailored childhood vaccine promotion intervention trial: Effects on parental vaccination values, attitudes, and intentions

A recent childhood vaccine promotion intervention trial showed no effects on vaccination outcomes relative to usual care. The purpose of this paper was to test assumptions and theory-based relationships underlying hypothesised mechanisms for two vaccine promotion educational websites (one tailored to parental values, beliefs, and intentions; one untailored) compared with usual care. This is a secondary analysis of a three-arm randomized controlled trial. Parental vaccine values, hesitancy, attitudes, and intention to vaccinate surveys were administered at baseline (≤2 months) and at 4-6 and 10-12 months of age. Vaccination was assessed using electronic health records. Analyses included random coefficient models and risk differences with exact confidence limits. Parental vaccine values were mostly stable over time. Vaccine attitudes were generally positive, with no differences among study arms. Both tailored and untailored website arms showed similar increases in intention to vaccinate more than usual care. Positive changes in intentions were associated with lower rates of late vaccination. Although attitudes and intentions predicted vaccination behavior and the intervention increased intention to vaccinate all on time, the web-based education and values-tailored messaging approaches were not effective at increasing vaccination rates. Intentions are necessary but insufficient targets for vaccine promotion interventions.

Use of a Smartphone App to Increase Physical Activity Levels in Insufficiently Active Adults: Feasibility Sequential Multiple Assignment Randomized Trial (SMART)

Background

The sequential multiple assignment randomized trial (SMART) design allows for changes in the intervention during the trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has not been utilized in a smartphone/gamified intervention for physical activity.

Objective

We aimed to investigate the feasibility of the SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively.

Methods

We conducted a feasibility 24-week/two-stage SMART in which 18 insufficiently active participants (<10,000 steps/day) were first randomized to group 1 (smartphone app only), group 2 (smartphone app + tailored messages), and a control group (usual routine during the protocol). Participants were motivated to increase their step count by at least 2000 steps/day each week. Based on the 12-week intermediate outcome, responders continued the intervention and nonresponders were rerandomized to subsequent treatment, including a new group 3 (smartphone app + tailored messages + gamification) in which they were instructed to form groups to use several game elements available in the chosen app (Pacer). We considered responders as those with any positive slope in the linear relationship between weeks and steps per day at the end of the first stage of the intervention. We compared the accelerometer-based steps per day before and after the intervention, as well as the slopes of the app-based steps per day between the first and second stages of the intervention.

Results

Twelve participants, including five controls, finished the intervention. We identified two responders in group 1. We did not observe relevant changes in the steps per day either throughout the intervention or compared with the control group. However, the rerandomization of five nonresponders led to a change in the slope of the steps per day (median −198 steps/day [IQR −279 to −103] to 20 steps/day [IQR −204 to 145]; P=.08). Finally, in three participants from group 2, we observed an increase in the number of steps per day up to the sixth week, followed by an inflection to baseline values or even lower (ie, a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into the following: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals.

Conclusions

The SMART design was feasible and changed the behavior of steps per day after rerandomization. Rerandomization should be implemented earlier to take advantage of tailored messages. Additionally, difficulties with technology and realistic and individualized goals should be considered in interventions for physical activity using smartphones.

Trial Registration

Brazilian Registry of Clinical Trials RBR-8xtc9c; http://www.ensaiosclinicos.gov.br/rg/RBR-8xtc9c/.

A Tailored Motivational Messages Library for a Mobile Health Sleep Behavior Change Support System to Promote Continuous Positive Airway Pressure Use Among Patients With Obstructive Sleep Apnea: Development, Content Validation, and Testing

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the most effective treatment for obstructive sleep apnea (OSA). Despite the reported benefits of CPAP therapy in treating OSA, its effectiveness is reduced by less-than-optimal adherence or use. Up to 50% of patients who accept CPAP therapy fail to adhere to it. As a lack of commitment to CPAP therapy is one of the most significant factors that hinder OSA treatment effectiveness, patient motivation and education are critical to help alleviate the problem of poor CPAP adherence or use.

OBJECTIVE

This study aims to support the development of mobile health interventions or information systems solutions to promote CPAP adherence and use among patients with OSA through development, content validation, and testing of tailored motivational messages.

METHODS

In phase 1, an initial library of 60 messages was developed to promote CPAP use among patients with OSA. In phase 2, draft messages were evaluated for content validation testing for relevance and clarity by research and clinical experts. In phase 3, patients with OSA (N=24) were recruited through a Qualtrics panel to rate the perceived persuasiveness of the messages in terms of threat and efficacy perceptions, as per their computed extended parallel process model (EPPM) response states. The average score of the ratings was calculated for each message. The messages were sorted according to their average (from highest to lowest) to select the best 12 messages for each tailored set based on the potential responses from the EPPM.

RESULTS

In phase 1, 60 messages were developed based on the existing literature and a review of existing materials. In phase 2, the enumerated content validity of the messages was established through the use of the content validity index for items. A total of 57 messages were found to have acceptable content relevance and clarity. In phase 3, patients with OSA perceived the final library of 48 messages to be persuasive.

CONCLUSIONS

After the process of content validation and testing, the final library of messages met the criteria for clarity, relevance, and perceived persuasiveness. This study emphasizes the importance of developing and validating the content of motivational messages, grounded in EPPM theory, across the 4 possible response states in terms of high or low efficacy and threat perceptions.

Effectiveness of tailored lifestyle interventions, using web-based and print-mail, for reducing blood pressure among rural women with prehypertension: main results of the Wellness for Women: DASHing towards Health clinical trial

BACKGROUND

Lifestyle modification is recommended for management of prehypertension, yet finding effective interventions to reach rural women is a public health challenge. This community-based clinical trial compared the effectiveness of standard advice to two multi-component theory-based tailored interventions, using web-based or print-mailed delivery, in reducing blood pressure among rural women, ages 40-69, with prehypertension.

METHODS

289 women with prehypertension enrolled in the Wellness for Women: DASHing towards Health trial, a 12-month intervention with 12-month follow-up. Women were randomly assigned to groups using a 1:2:2 ratio, comparing standard advice (30-minute counseling session) to two interventions (two 2-hour counseling sessions, 5 phone goal-setting sessions, strength-training video, and 16 tailored newsletters, web-based or print-mailed). Linear mixed model methods were used to test planned pairwise comparisons of marginal mean change in blood pressure, healthy eating and activity, adjusted for age and baseline level. General estimating equations were used to examine the proportion of women achieving normotensive status and meeting health outcome criteria for eating and activity.

RESULTS

Mean blood pressure reduction ranged from 3.8 (SD = 9.8) mm Hg to 8.1 (SD = 10.4) mm Hg. The 24-month estimated marginal proportions of women achieving normotensive status were 47% for web-based, and 39% for both print-mailed and standard advice groups, with no group differences (p = .11 and p = .09, respectively). Web-based and print-mailed groups improved more than standard advice group for waist circumference (p = .017 and p = .016, respectively); % daily calories from fat (p = .018 and p = .030) and saturated fat (p = .049 and p = .013); daily servings of fruit and vegetables (p = .008 and p < .005); and low fat dairy (p < .001 and p = .002). Greater improvements were observed in web-based versus standard advice groups in systolic blood pressure (p = .048) and estimated VO2max (p = .037). Dropout rates were 6% by 6-months, 11.4% by 24 months, with no differences across groups.

CONCLUSIONS

Rural women with prehypertension receiving distance-delivery theory-based lifestyle modifications can achieve a reduction of blood pressure and attainment of normotensive status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00580528.