Danielle E. Jake-Schoffman

Methods for Evaluating the Content, Usability, and Efficacy of Commercial Mobile Health Apps

Commercial mobile apps for health behavior change are flourishing in the marketplace, but little evidence exists to support their use. This paper summarizes methods for evaluating the content, usability, and efficacy of commercially available health apps. Content analyses can be used to compare app features with clinical guidelines, evidence-based protocols, and behavior change techniques. Usability testing can establish how well an app functions and serves its intended purpose for a target population. Observational studies can explore the association between use and clinical and behavioral outcomes. Finally, efficacy testing can establish whether a commercial app impacts an outcome of interest via a variety of study designs, including randomized trials, multiphase optimization studies, and N-of-1 studies. Evidence in all these forms would increase adoption of commercial apps in clinical practice, inform the development of the next generation of apps, and ultimately increase the impact of commercial apps.

Faith, Activity, and Nutrition Randomized Dissemination and Implementation Study: Countywide Adoption, Reach, and Effectiveness

INTRODUCTION Faith-based organizations can contribute to improving population health, but few dissemination and implementation studies exist. This paper reports countywide adoption, reach, and effectiveness from the Faith, Activity, and Nutrition dissemination and implementation study. DESIGN This was a group-randomized trial. Data were collected in 2016. Statistical analyses were conducted in 2017. SETTING/PARTICIPANTS Churches in a rural, medically underserved county in South Carolina were invited to enroll, and attendees of enrolled churches were invited to complete questionnaires (n=1,308 participated). INTERVENTION Churches (n=59) were randomized to an intervention or control (delayed intervention) condition. Church committees attended training focused on creating opportunities, setting guidelines/policies, sharing messages, and engaging pastors for physical activity (PA) and healthy eating (HE). Churches also received 12 months of telephone-based technical assistance. Community health advisors provided the training and technical assistance. MAIN OUTCOMES MEASURES The Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework guided measurement of adoption and reach. To assess effectiveness, church attendees completed post-test only questionnaires of perceptions of church environment, PA and fruit and vegetable (FV) self-efficacy, FV intake, and PA. Regression models controlled for church clustering and predominant race of congregation, as well as member age, gender, education, and self-reported cancer diagnosis. RESULTS Church adoption was 42% (55/132). Estimated reach was 3,527, representing 42% of regular church attendees and 15% of county residents. Intervention church attendees reported greater church-level PA opportunities, PA and HE messages, and PA and HE pastor support (p<0.0001), but not FV opportunities (p=0.07). PA self-efficacy (p=0.07) and FV self-efficacy (p=0.21) were not significantly higher in attendees of intervention versus control churches. The proportion of inactive attendees was lower in intervention versus control churches (p=0.02). The proportion meeting FV (p=0.27) and PA guidelines (p=0.32) did not differ by group. CONCLUSIONS This innovative dissemination and implementation study had high adoption and reach with favorable environmental impacts, positioning it for broader dissemination. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02868866.

A developmental cascade perspective of paediatric obesity: a conceptual model and scoping review

ABSTRACT Considering the immense challenge of preventing obesity, the time has come to reconceptualise the way we study the obesity development in childhood. The developmental cascade model offers a longitudinal framework to elucidate the way cumulative consequences and spreading effects of risk and protective factors, across and within biopsychosocial spheres and phases of development, can propel individuals towards obesity. In this article, we use a theory-driven model-building approach and a scoping review that included 310 published studies to propose a developmental cascade model of paediatric obesity. The proposed model provides a basis for testing hypothesised cascades with multiple intervening variables and complex longitudinal processes. Moreover, the model informs future research by resolving seemingly contradictory findings on pathways to obesity previously thought to be distinct (low self-esteem, consuming sugary foods, and poor sleep cause obesity) that are actually processes working together over time (low self-esteem causes consumption of sugary foods which disrupts sleep quality and contributes to obesity). The findings of such inquiries can aid in identifying the timing and specific targets of preventive interventions across and within developmental phases. The implications of such a cascade model of paediatric obesity for health psychology and developmental and prevention sciences are discussed.

Social Media and Obesity in Adults: a Review of Recent Research and Future Directions

Purpose of ReviewSocial media is widely used and has potential to connect adults with obesity with information and social support for weight loss and to deliver lifestyle interventions. The purpose of this review is to summarize recent observational and intervention research on social media and obesity.Recent FindingsOnline patient communities for weight loss abound but may include misinformation. Systematic reviews and meta-analyses suggest that social media-delivered lifestyle interventions modestly impact weight, yet how social media was used and participant engagement varies widely.SummaryThe rapidly changing social media landscape poses challenges for patients, clinicians, and researchers. Research is needed on how patients can establish supportive communities for weight loss and the role of clinicians in these communities. Emerging research on meaningful engagement in, and the efficacy and cost-effectiveness of, social media-delivered lifestyle interventions should provide insights into how to leverage social media to address the obesity epidemic.

Motivating future directions of behavioral medicine

These abstracts received editorial review, upon which the SIGs developed a manuscript to describe their vision for the future of their field. Manuscripts were subjected to editorial and peer review and resulted in the representation of 15/24 (62.5%) SIGs in this special issue. While the SIGs represent diverse areas of study, several common themes emerged as critical areas for future research across the articles. Behavioral medicine methodology: design, implementation, and dissemination Methodological issues represent a vital area of research in behavioral medicine where substantial progress can be made. The ongoing importance of rigorous methodology characterized by clearly operationalized concepts and measurement approaches must still be underscored to improve the validity and reliability of results across research areas (Geller et al., 2016; Park et al., 2016). Mechanisms of change should be explored to fully understand the process by which a lifestyle or behavior—such as religion and/or spirituality—impacts health outcomes (Park et al., 2016). Behavior change ontologies—a clearly defined, shared vocabulary of terms and the specific relationships between those terms—have the potential to transform behavioral science field to an integrative field where data are compared and contrasted (Larsen et al., 2016). Ontologies could lead to new approaches to hypothesis generation and knowledge discovery in our field. Indeed, while the randomized clinical trial (RCT) has long been considered the pinnacle in understanding the effectiveness of treatment, there is an increasing shift away from these designs in favor of more innovative flexible approaches that focus on ‘‘real-world’’ implementation and patient-centered outcomes. Vogel et al. (2016) argue the RCT with patient-level randomization cannot appropriately assess the effectiveness of integrated behavioral health, and underscore the value in quasi-experimental, qualitative, and mixed methods designs to addressing gaps in our knowledge base. Buscemi et al. (2016) argue for a multiphase optimization strategy (MOST) approach to optimize multicomponent behavioral and bio-behavioral interventions. Inspired by engineering, MOST offers a framework that includes three phases to inform clinical trial design: preparation, optimization, and evaluation (Collins et al., 2005). While preparation and evaluation are common components of trial design, the focus on optimization or ‘‘the process of finding the best possible solution, subject to the given constraints’’ sets MOST apart from traditional RCT designs. Most designs may be particularly applicable in the eHealth or technology based interventions (Moller et al. 2016). Alcaraz et al. (2016) introduce the ConNECT Framework to link behavioral medicine and health equity in order to achieve equitable health and outcomes in the 21st century. ConNECT’s five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training are promising in promoting health equity across behavioral medicine areas. The importance of dissemination to achieve maximal health impact was shared across several articles (e.g., Geller et al., 2016). While there is a large evidence base demonstrating that lifestyle interventions can aid in prevention of chronic disease, not enough people are benefiting from these programs (Stetson et al., 2016). What we need are low-cost, high-impact approaches to disseminating this knowledge on a larger scale. And, to achieve the goal of low-cost interventions, we need to better understand how cost is related to dissemination and intervention sustainability in different healthcare systems (Vogel et al., 2016). Buscemi et al. (2006) highlight the Reach, Effectiveness-Adoption, Implementation, Maintenance (REAIM) framework as a useful model to guide such dissemination. RE-AIM is designed to improve the quality, rapidity, and impact of translational research by guiding researchers in Reaching their intended population, focusing on Efficacy or effectiveness, increasing intervention Adoption, and ensuring Implementation consistency and intervention Maintenance over time (Glasgow et al., 1999). Lewis et al. (2016) further underscore the value of the REAIM framework, and provide several examples of how REAIM has been used within physical activity dissemination studies. The burden of chronic disease is large, and many individuals are working to manage consequences of multiple chronic health conditions simultaneously, necessitating the need for broadly applicable lifestyle solutions. Geller et al. (2016) describe the emerging directions of the field of multiple health behavior change, including a need for a better understanding of the ways that cross-motivations could be employed to bolster the impact of multiple health behavior change interventions as well as a need to shift the focus of the field to sustainable interventions that can impact long-term change and maintenance of those changes. Vogel et al. (2016) describe the potential for religiousness and spirituality to aid in the prevention and treatment of various diseases, specifically describing their effects in addressing cardiovascular disease, cancer, and substance abuse. With a movement toward patient-centered care, informed and shared decision making is a critical part 2 J Behav Med (2017) 40:1–5

SoMe and Self Harm: The Use of Social Media in Depressed and Suicidal Youth

Increased access and use of social media on smartphones and tablets have changed interpersonal communication styles. Because of the ease of social media access and the ability to reach a large number of individuals, social media is an ever more important modality that connects individuals. Importantly, adolescents have adopted social media platforms to discuss issues related to mental health. There is little existing data regarding how adolescents who are depressed or suicidal use social media prior to treatment in the emergency department (ED) for medical care of their psychiatric illness. In this paper, we present formative evidence of social media behaviors in 29 adolescents seeking emergency care for depression or suicidal ideation. Participants were surveyed regarding social media use and motivations to post content regarding depression, death or dying. Among the participants who allowed the research team to view their social media accounts, 40% (n=6) posted content related to depression, death or dying, while 20% (n=3) wrote that they felt depressed and 13.3% (n=2) posted that they wanted to die. Qualitative discussions with participants provided description of reasons for posting content on social media about depression, death and dying, or reasons that individuals refrained from posting online. Despite methodological and technical challenges in research, social media may prove be valuable in detection and intervention of adolescents who are depressed and contemplating suicide.

Objective measurement of physical activity outcomes in lifestyle interventions among adults: A systematic review

Valid, reliable, and direct measures of physical activity (PA) are critical to assessing the impact of lifestyle PA interventions. However, little is known about the extent to which objective measures have been used to assess the outcomes of lifestyle PA interventions. This systematic review had two aims: 1) evaluate the extent to which PA is measured objectively in lifestyle PA interventions targeting adults and 2) explore and summarize what objective measures have been used and what PA dimensions and metrics have been reported. Pubmed, Cochrane Central Register, and PsychInfo were searched for lifestyle PA interventions conducted between 2006 and 2016. Of the 342 articles that met the inclusion criteria, 239 studies measured PA via subjective measures and 103 studies measured PA via objective measures. The proportion of studies using objective measures increased from 4.4% to 70.6% from 2006 to 2016. All studies measuring PA objectively utilized wearable devices; half (50.5%) used pedometers only and 40.8% used accelerometers only. A majority of the 103 studies reported steps (73.8%) as their PA metric. Incorporating objective measures of PA should continue to be a priority in PA research. More work is needed to address the challenges of comprehensive and consistent collecting, reporting, and analyzing of PA metrics.

Investigating Socioeconomic Disparities in the Potential Healthy Eating and Physical Activity Environments of Churches

Faith-based settings have the potential to improve health in underresourced communities, but little research has quantified and compared health-promoting elements in church environments. This study examines the number of potential indoor and outdoor physical activity opportunities, healthy eating opportunities, healthy living media, and total environmental resources present in churches ( n  = 54) in a rural, southeastern US county and the relationship between these resources and neighborhood income. In our sample, most churches offered potential indoor and outdoor opportunities for physical activity and healthy eating opportunities, with more variability in the number of healthy living media items on display compared to other environmental components. Common potential opportunities present in churches for physical activity included a fellowship hall and green/open space, while potential opportunities for healthy eating frequently included a refrigerator and sink. Compared to those in medium- and high-income neighborhoods, churches in low-income neighborhoods scored higher on measures of potential outdoor physical activity opportunities and lower on measures of total potential environment resources, healthy eating opportunities, healthy living media, and indoor physical activity opportunities, though only indoor physical activity opportunities reached statistical significance. Potential opportunities for using existing resources in and around churches for health promotion should be investigated further, particularly in rural areas.

Using the Habit App for Weight Loss Problem Solving: Development and Feasibility Study

Background Reviews of weight loss mobile apps have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-monitoring is often low, especially among patients with motivational challenges. One behavioral strategy that is leveraged in virtually every visit of behavioral weight loss interventions and is specifically used to deal with adherence and motivational issues is problem solving. Problem solving has been successfully implemented in depression mobile apps, but not yet in weight loss apps. Objective This study describes the development and feasibility testing of the Habit app, which was designed to automate problem-solving therapy for weight loss. Methods Two iterative single-arm pilot studies were conducted to evaluate the feasibility and acceptability of the Habit app. In each pilot study, adults who were overweight or obese were enrolled in an 8-week intervention that included the Habit app plus support via a private Facebook group. Feasibility outcomes included retention, app usage, usability, and acceptability. Changes in problem-solving skills and weight over 8 weeks are described, as well as app usage and weight change at 16 weeks. Results Results from both pilots show acceptable use of the Habit app over 8 weeks with on average two to three uses per week, the recommended rate of use. Acceptability ratings were mixed such that 54% (13/24) and 73% (11/15) of participants found the diet solutions helpful and 71% (17/24) and 80% (12/15) found setting reminders for habits helpful in pilots 1 and 2, respectively. In both pilots, participants lost significant weight (P=.005 and P=.03, respectively). In neither pilot was an effect on problem-solving skills observed (P=.62 and P=.27, respectively). Conclusions Problem-solving therapy for weight loss is feasible to implement in a mobile app environment; however, automated delivery may not impact problem-solving skills as has been observed previously via human delivery. Trial Registration ClinicalTrials.gov NCT02192905; https://clinicaltrials.gov/ct2/show/NCT02192905 (Archived by WebCite at http://www.webcitation.org/6zPQmvOF2)

Using Commercial Physical Activity Trackers for Health Promotion Research: Four Case Studies

Background. Wearable physical activity (PA) trackers are becoming increasingly popular for intervention and assessment in health promotion research and practice. The purpose of this article is to present lessons learned from four studies that used commercial PA tracking devices for PA intervention or assessment, present issues encountered with their use, and provide guidelines for determining which tools to use. Method. Four case studies are presented that used PA tracking devices (iBitz, Zamzee, FitBit Flex and Zip, Omron Digital Pedometer, Sensewear Armband, and MisFit Flash) in the field—two used the tools for intervention and two used the tools as assessment methods. Results. The four studies presented had varying levels of success with using PA devices and experienced several issues that impacted their studies, such as companies that went out of business, missing data, and lost devices. Percentage ranges for devices that were lost were 0% to 29% and was 0% to 87% for those devices that malfunctioned or lost data. Conclusions. There is a need for low-cost, easy-to-use, accurate PA tracking devices to use as both intervention and assessment tools in health promotion research related to PA.