Leanne Morrison

Opportunities and Challenges for Smartphone Applications in Supporting Health Behavior Change: Qualitative Study

Background There is increasing interest from academics and clinicians in harnessing smartphone applications (apps) as a means of delivering behavioral interventions for health. Despite the growing availability of a range of health-related apps on the market, academic research on the development and evaluation of such apps is in the relatively early stages. A few existing studies have explored the views of various populations on using mobile phones for health-related issues and some studies are beginning to report user feedback on specific apps. However, there remains little in depth research on users’ (and potential users’) experiences and views on a wide range of features and technologies that apps are, or will soon be, capable of. In particular, research on young adults is lacking, which is an unfortunate omission considering that this group comprises of a good number of mobile technology adoptors. Objective The current study sought to explore young adults’ perspectives on apps related to health behavior change. It sought their experiences and views of features that might support health behavior change and issues that contribute to interest in and willingness to use such apps. Methods Four focus groups were conducted with 19 students and staff at a University in the United Kingdom. Participants included 13 females and 6 males with a mean age of 23.79 (SD 7.89). The focus group discussions centred on participants’ experiences of using smartphone apps to support a healthy lifestyle, and their interest in and feelings about features and capabilities of such apps. The focus groups were recorded, transcribed, and analyzed using inductive thematic analysis. Results Study findings suggested that young, currently healthy adults have some interest in apps that attempt to support health-related behavior change. Accuracy and legitimacy, security, effort required, and immediate effects on mood emerged as important influences on app usage. The ability to record and track behavior and goals and the ability to acquire advice and information “on the go” were valued. Context-sensing capabilities and social media features tended to be considered unnecessary and off-putting. Conclusions This study provided insight into the opportunities and challenges involved in delivering health-related behavioral interventions through smartphone apps. The findings suggested a number of valued features and characteristics that app developers may wish to consider when creating health behavior apps. Findings also highlighted several major challenges that appeared to need further consideration and research to ensure the development of effective and well-accepted behavior change apps.

The person-based approach to intervention development: application to digital health-related behavior change interventions.

This paper describes an approach that we have evolved for developing successful digital interventions to help people manage their health or illness. We refer to this as the “person-based” approach to highlight the focus on understanding and accommodating the perspectives of the people who will use the intervention. While all intervention designers seek to elicit and incorporate the views of target users in a variety of ways, the person-based approach offers a distinctive and systematic means of addressing the user experience of intended behavior change techniques in particular and can enhance the use of theory-based and evidence-based approaches to intervention development. There are two key elements to the person-based approach. The first is a developmental process involving qualitative research with a wide range of people from the target user populations, carried out at every stage of intervention development, from planning to feasibility testing and implementation. This process goes beyond assessing acceptability, usability, and satisfaction, allowing the intervention designers to build a deep understanding of the psychosocial context of users and their views of the behavioral elements of the intervention. Insights from this process can be used to anticipate and interpret intervention usage and outcomes, and most importantly to modify the intervention to make it more persuasive, feasible, and relevant to users. The second element of the person-based approach is to identify “guiding principles” that can inspire and inform the intervention development by highlighting the distinctive ways that the intervention will address key context-specific behavioral issues. This paper describes how to implement the person-based approach, illustrating the process with examples of the insights gained from our experience of carrying out over a thousand interviews with users, while developing public health and illness management interventions that have proven effective in trials involving tens of thousands of users.

What design features are used in effective e-health interventions? A review using techniques from critical interpretive synthesis

The effectiveness of e-health interventions varies greatly. Despite this, there has been relatively little formal consideration of how differences in the design of an intervention (i.e., how the content is delivered) may explain why some interventions are more effective than others. This review primarily examines the use of the Internet to provide educational and self-management interventions to promote health. The article develops hypotheses about how the design of these interventions may be associated with outcomes. In total, 52 published reports from both a diversity sample and a representative sample were reviewed using techniques from Critical Interpretive Synthesis. Four core interactive design features were identified that may mediate the effects of intervention design on outcomes: Social context and support, contacts with intervention, tailoring, and self-management. A conceptual framework to summarize the design of e-health interventions delivered using the Internet is proposed. The framework provides a guide for systematic research to identify the effects of specific design features on intervention outcomes and to identify the mechanisms underlying any effects. To optimize the design of e-health interventions more work is needed to understand how and why these design features may affect intervention outcomes and to investigate the optimal implementation and dosage of each design feature.

Understanding usage of a hybrid website and smartphone app for weight management: a mixed-methods study.

Background Advancements in mobile phone technology offer huge potential for enhancing the timely delivery of health behavior change interventions. The development of smartphone-based health interventions (apps) is a rapidly growing field of research, yet there have been few longitudinal examinations of how people experience and use these apps within their day-to-day routines, particularly within the context of a hybrid Web- and app-based intervention. Objective This study used an in-depth mixed-methods design to examine individual variation in (1) impact on self-reported goal engagement (ie, motivation, self-efficacy, awareness, effort, achievement) of access to a weight management app (POWeR Tracker) when provided alongside a Web-based weight management intervention (POWeR) and (2) usage and views of POWeR Tracker. Methods Thirteen adults were provided access to POWeR and were monitored over a 4-week period. Access to POWeR Tracker was provided in 2 alternate weeks (ie, weeks 1 and 3 or weeks 2 and 4). Participants’ goal engagement was measured daily via self-report. Mixed effects models were used to examine change in goal engagement between the weeks when POWeR Tracker was and was not available and whether the extent of change in goal engagement varied between individual participants. Usage of POWeR and POWeR Tracker was automatically recorded for each participant. Telephone interviews were conducted and analyzed using inductive thematic analysis to further explore participants’ experiences using POWeR and POWeR Tracker. Results Access to POWeR Tracker was associated with a significant increase in participants’ awareness of their eating (β1=0.31, P=.04) and physical activity goals (β1=0.28, P=.03). The level of increase varied between individual participants. Usage data showed that participants used the POWeR website for similar amounts of time during the weeks when POWeR Tracker was (mean 29 minutes, SD 31 minutes) and was not available (mean 27 minutes, SD 33 minutes). POWeR Tracker was mostly accessed in short bursts (mean 3 minutes, SD 2 minutes) during convenient moments or moments when participants deemed the intervention content most relevant. The qualitative data indicated that nearly all participants agreed that it was more convenient to access information on-the-go via their mobiles compared to a computer. However, participants varied in their views and usage of the Web- versus app-based components and the informational versus tracking tools provided by POWeR Tracker. Conclusions This study provides evidence that smartphones have the potential to improve individuals’ engagement with their health-related goals when used as a supplement to an existing online intervention. The perceived convenience of mobile access to information does not appear to deter use of Web-based interventions or strengthen the impact of app access on goal engagement. A mixed-methods design enabled exploration of individual variation in daily usage of the app-based tools.

What infection control measures will people carry out to reduce transmission of pandemic influenza? A focus group study

BackgroundPandemic influenza poses a future health threat against which infection control behaviours may be an important defence. However, there is little qualitative research examining perceptions of infection control measures in the context of pandemic influenza.MethodsEight focus groups and one interview were conducted with a purposive sample of 31 participants. Participants were invited to discuss their perceptions of infection transmission and likely adherence to infection control measures in both non-pandemic and pandemic contexts. Infection control measures discussed included handwashing, social distancing and cough hygiene (e.g. covering mouth, disposing of tissues immediately etc.).ResultsThematic analysis revealed that although participants were knowledgeable about infection transmission, most expressed unfavourable attitudes toward control behaviours in non-pandemic situations. However, with the provision of adequate education about control measures and appropriate practical support (e.g. memory aids, access to facilities), most individuals report that they are likely to adhere to infection control protocols in the event of a pandemic. Of the behaviours likely to influence infection transmission, handwashing was regarded by our participants as more feasible than cough and sneeze hygiene and more acceptable than social distancing.ConclusionHandwashing could prove a useful target for health promotion, but interventions to promote infection control may need to address a number of factors identified within this study as potential barriers to carrying out infection control behaviours.

Does Brief Telephone Support Improve Engagement With a Web-Based Weight Management Intervention? Randomized Controlled Trial

Background Recent reviews suggest Web-based interventions are promising approaches for weight management but they identify difficulties with suboptimal usage. The literature suggests that offering some degree of human support to website users may boost usage and outcomes. Objective We disseminated the POWeR (“Positive Online Weight Reduction”) Web-based weight management intervention in a community setting. POWeR consisted of weekly online sessions that emphasized self-monitoring, goal-setting, and cognitive/behavioral strategies. Our primary outcome was intervention usage and we investigated whether this was enhanced by the addition of brief telephone coaching. We also explored group differences in short-term self-reported weight loss. Methods Participants were recruited using a range of methods including targeted mailouts, advertisements in the local press, notices on organizational websites, and social media. A total of 786 adults were randomized at an individual level through an online procedure to (1) POWeR only (n=264), (2) POWeR plus coaching (n=247), or (3) a waiting list control group (n=275). Those in the POWeR plus coaching arm were contacted at approximately 7 and 28 days after randomization for short coaching telephone calls aimed at promoting continued usage of the website. Website usage was tracked automatically. Weight was assessed by online self-report. Results Of the 511 participants allocated to the two intervention groups, the median number of POWeR sessions completed was just one (IQR 0-2 for POWeR only, IQR 0-3 for POWeR plus coach). Nonetheless, a substantial minority completed at least the core three sessions of POWeR: 47 participants (17.8%, 47/264) in the POWeR-only arm and 64 participants (25.9%, 64/247) in the POWeR plus coaching arm. Participants in the POWeR plus coaching group persisted with the intervention for longer and were 1.61 times more likely to complete the core three sessions than the POWeR-only group (χ2 1=4.93; OR 1.61, 95% CI 1.06-2.47; n=511). An intention-to-treat analysis showed between-group differences in weight loss (F 2,782=12.421, P<.001). Both intervention groups reported more weight loss than the waiting list control group. Weight loss was slightly, but not significantly, greater in the POWeR plus coaching group. A large proportion of participants assigned to POWeR plus coaching refused phone calls or were not contactable (57.9%, 143/247). Exploratory analyses identified health and sociodemographic differences between those who did and did not engage in coaching when it was made available to them. Users who engaged with coaching used the intervention more and lost more weight than those who did not. Conclusions In common with most Web-based intervention studies, usage of POWeR was suboptimal overall. However, our findings suggest that supplementing Web-based weight management with brief human support could improve usage and outcomes in those who take it up. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 98176068; http://www.controlled-trials.com/ISRCTN98176068 (Archived by WebCite at http://www.webcitation.org/6OKRjM2oy).

Optimizing engagement with Internet‐based health behaviour change interventions: Comparison of self‐assessment with and without tailored feedback using a mixed methods approach

Objectives Internet-based health behaviour interventions have variable effects on health-related outcomes. Effectiveness may be improved by optimizing the design of interventions. This study examined the specific effect on engagement of providing two different design features – tailoring and self-assessment. Design Three versions of an Internet-delivered intervention to support the self-care of mild bowel problems were developed that provided (1) self-assessment without tailored feedback, (2) self-assessment with tailored feedback, and (3) generic information only. Methods A qualitative study explored participants’ engagement with each version of the intervention (N = 24). A larger quantitative study systematically compared participants’ use of the intervention and self-reported engagement using a partial factorial design (n = 178). Results Findings from the qualitative study suggested that self-assessment without tailored feedback appeared to be less acceptable to participants because it was viewed as offering no personal benefit in the absence of personalized advice. In the quantitative study, self-assessment without tailored feedback was associated with greater dropout than when provided in conjunction with tailored feedback. There were significant group differences in participants’ engagement with the intervention and perceptions of the intervention. Self-assessment without tailored feedback was rated as marginally less engaging and was associated with fewer positive perceptions than the generic information condition. Conclusions The acceptability of self-assessment or monitoring components may be optimized by also providing tailored feedback. Without tailored feedback, these components do not appear to be any more engaging than generic information provision.

Phenotypes and Karyotypes of Human Malignant Mesothelioma Cell Lines

Background Malignant mesothelioma is an aggressive tumour of serosal surfaces most commonly pleura. Characterised cell lines represent a valuable tool to study the biology of mesothelioma. The aim of this study was to develop and biologically characterise six malignant mesothelioma cell lines to evaluate their potential as models of human malignant mesothelioma. Methods Five lines were initiated from pleural biopsies, and one from pleural effusion of patients with histologically proven malignant mesothelioma. Mesothelial origin was assessed by standard morphology, Transmission Electron Microscopy (TEM) and immunocytochemistry. Growth characteristics were assayed using population doubling times. Spectral karyotyping was performed to assess chromosomal abnormalities. Authentication of donor specific derivation was undertaken by DNA fingerprinting using a panel of SNPs. Results Most of cell lines exhibited spindle cell shape, with some retaining stellate shapes. At passage 2 to 6 all lines stained positively for calretinin and cytokeratin 19, and demonstrated capacity for anchorage-independent growth. At passage 4 to 16, doubling times ranged from 30–72 hours, and on spectral karyotyping all lines exhibited numerical chromosomal abnormalities ranging from 41 to 113. Monosomy of chromosomes 8, 14, 22 or 17 was observed in three lines. One line displayed four different karyotypes at passage 8, but only one karyotype at passage 42, and another displayed polyploidy at passage 40 which was not present at early passages. At passages 5–17, TEM showed characteristic features of mesothelioma ultrastructure in all lines including microvilli and tight intercellular junctions. Conclusion These six cell lines exhibit varying cell morphology, a range of doubling times, and show diverse passage-dependent structural chromosomal changes observed in malignant tumours. However they retain characteristic immunocytochemical protein expression profiles of mesothelioma during maintenance in artificial culture systems. These characteristics support their potential as in vitro model systems for studying cellular, molecular and genetic aspects of mesothelioma.

Theory-based strategies for enhancing the impact and usage of digital health behaviour change interventions: A review:

There is growing evidence that digital interventions can successfully effect meaningful changes in health-related behaviour. However, optimisation of digital intervention delivery is challenged by low usage, high attrition and small effect sizes. Whilst a number of conceptual frameworks and models exist to guide intervention planning and development, insufficient attention has been paid to how existing psychological theory could inform the optimal implementation and delivery of the design features commonly used in digital health behaviour change interventions. This paper provides a critical review of psychological theories and models in order to consider their implications for the design of digital interventions. The theories reviewed include theories of: persuasion and attitude change; motivation; volition and self-regulation; patient preferences for participation in medical decision making; and social support. A set of theory-based guidelines is provided to inform the development of future interventions.

The effect of timing and frequency of push notifications on usage of a smartphone-based stress management intervention: An exploratory trial

Push notifications offer a promising strategy for enhancing engagement with smartphone-based health interventions. Intelligent sensor-driven machine learning models may improve the timeliness of notifications by adapting delivery to a user’s current context (e.g. location). This exploratory mixed-methods study examined the potential impact of timing and frequency on notification response and usage of Healthy Mind, a smartphone-based stress management intervention. 77 participants were randomised to use one of three versions of Healthy Mind that provided: intelligent notifications; daily notifications within pre-defined time frames; or occasional notifications within pre-defined time frames. Notification response and Healthy Mind usage were automatically recorded. Telephone interviews explored participants’ experiences of using Healthy Mind. Participants in the intelligent and daily conditions viewed (d = .47, .44 respectively) and actioned (d = .50, .43 respectively) more notifications compared to the occasional group. Notification group had no meaningful effects on percentage of notifications viewed or usage of Healthy Mind. No meaningful differences were indicated between the intelligent and non-intelligent groups. Our findings suggest that frequent notifications may encourage greater exposure to intervention content without deterring engagement, but adaptive tailoring of notification timing does not always enhance their use. Hypotheses generated from this study require testing in future work. Trial registration number: ISRCTN67177737