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Digital Health Tools: A Critical Assessment of Long-Term Engagement

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Digital Health".

Deadline for manuscript submissions: closed (31 August 2021) | Viewed by 40951

Special Issue Editors

School of Industrial Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
Interests: platform support for personal health data; personalized health behavior change; workflow and compliance management in healthcare
Special Issues, Collections and Topics in MDPI journals
Department of Social Sciences, Wageningen University & Research, 6700EW Wageningen, The Netherlands
Interests: development, evaluation and implementation of healthy lifestyle interventions (physical activity and personalized, context-aware and adaptive interventions (e.g. Just-in-Time Adaptive interventions); gamification; serious games; co-designing for healthy lifestyles; data science for healthy lifestyles

Special Issue Information

Dear Colleagues,

The use of web and mobile technologies for health promotion has attracted great interest from practitioners and academics alike. Indeed, there are application scenarios where mHealth tools demonstrate obvious benefits. Among others, the recent COVID-19 pandemic has led to a surge in the uptake of remote communication between patients/clients and their caregivers in quite acute settings. Still, getting end users to engage with other types of digital health tools remains challenging, especially in relation to long term engagement. 

This Special Issue aims to collect high-quality research on:

  1. Enabling technologies that lower the user burden, such as unobtrusive sensors and algorithms for monitoring (the determinants of) health behavior (e.g., dietary intake, physical activity, cognitive training) over time, in real life; this also includes analyzing environmental factors;
  2. Design process considerations, discussing how to interface with individual target users, group ambassadors, and external forces; similarly, how to organize multidisciplinary research teams (combining disciplines such as design research, data science, human geography, psychology, human computer interaction and industrial design);
  3. Empirical evaluations of the (long-term) effectiveness of digital health tool interventions as a whole and of the intervention components (e.g., gamification elements, behavior change techniques, design features, etc.).

These topics relate to:

  • Novel applications of beacons, GPS loggers, and emotion sensing tools;
  • Applications using big data and artificial intelligence;
  • The engineering of flexible health data and behavior change platforms;
  • Context-aware interventions, such as adaptive Ecological Momentary Assessment (EMA);
  • Just-in-time-adaptive interventions (JITAIs);
  • Critical assessments of behavior change techniques, including but not limited to game-based and marketing-based methods;
  • Personalizing mHealth interventions; 
  • Analysis of drop-out causes;
  • Critical assessments of design processes and techniques like co-design;
  • Health inequalities (e.g., addressing individuals and groups with a low socio-economic status, considering variance in mHealth literacy);
  • Engagement of digital health tools.

Regarding the research design, we welcome primarily: 

  • Innovative feasibility and pilot studies, 
  • Randomized controlled trials,
  • Technical discussions of health data and behavior change platforms,
  • Reports on expert meetings.

Furthermore, we welcome a relative minority of more theoretical results, such as systematic literature reviews and scoping reviews. We highly welcome innovative study designs and approaches such as those relying on micro-randomization via multiphase optimization strategies (MOST) and sequential multiple assignment randomized trials (SMART).  

Dr. Pieter M.E. van Gorp
Dr. Monique Simons
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • mHealth
  • digital therapeutics
  • behavior change

Published Papers (9 papers)

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Research

Jump to: Review

19 pages, 370 KiB  
Article
Ethics of Gamification in Health and Fitness-Tracking
by Chirag Arora and Maryam Razavian
Int. J. Environ. Res. Public Health 2021, 18(21), 11052; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph182111052 - 21 Oct 2021
Cited by 6 | Viewed by 3556
Abstract
The use of game-like elements is become increasingly popular in the context of fitness and health apps. While such “gamified” apps hold great potential in motivating people to improve their health, they also come with a “darker side”. Recent work suggests that these [...] Read more.
The use of game-like elements is become increasingly popular in the context of fitness and health apps. While such “gamified” apps hold great potential in motivating people to improve their health, they also come with a “darker side”. Recent work suggests that these gamified health apps raise a number of ethical challenges that, if left unaddressed, are not only morally problematic but also have adverse effects on user health and engagement with the apps. However, studies highlighting the ethical challenges of gamification have also met with criticism, indicating that they fall short of providing guidance to practitioners. In avoiding this mistake, this paper seeks to advance the goal of facilitating a practice-relevant guide for designers of gamified health apps to address ethical issues raised by use of such apps. More specifically, the paper seeks to achieve two major aims: (a) to propose a revised practice-relevant theoretical framework that outlines the responsibilities of the designers of gamified health apps, and (b) to provide a landscape of the various ethical issues related to gamified health apps based on a systematic literature review of the empirical literature investigating adverse effects of such apps. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
13 pages, 557 KiB  
Article
Assessing the Influence of Physical Activity Upon the Experience Sampling Response Rate on Wrist-Worn Devices
by Alireza Khanshan, Pieter Van Gorp, Raoul Nuijten and Panos Markopoulos
Int. J. Environ. Res. Public Health 2021, 18(20), 10593; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph182010593 - 10 Oct 2021
Cited by 13 | Viewed by 2573
Abstract
The Experience Sampling Method (ESM) is gaining ground for collecting self-reported data from human participants during daily routines. An important methodological challenge is to sustain sufficient response rates, especially when studies last longer than a few days. An obvious strategy is to deliver [...] Read more.
The Experience Sampling Method (ESM) is gaining ground for collecting self-reported data from human participants during daily routines. An important methodological challenge is to sustain sufficient response rates, especially when studies last longer than a few days. An obvious strategy is to deliver the experiential questions on a device that study participants can access easily at different times and contexts (e.g., a smartwatch). However, responses may still be hampered if the prompts are delivered at an inconvenient moment. Advances in context sensing create new opportunities for improving the timing of ESM prompts. Specifically, we explore how physiological sensing on commodity-level smartwatches can be utilized in triggering ESM prompts. We have created Experiencer, a novel ESM smartwatch platform that allows studying different prompting strategies. We ran a controlled experiment (N=71) on Experiencer to study the strengths and weaknesses of two sampling regimes. One group (N=34) received incoming notifications while resting (e.g., sedentary), and another group (N=37) received similar notifications while being active (e.g., running). We hypothesized that response rates would be higher when experiential questions are delivered during lower levels of physical activity. Contrary to our hypothesis, the response rates were found significantly higher in the active group, which demonstrates the relevance of studying dynamic forms of experience sampling that leverage better context-sensitive sampling regimes. Future research will seek to identify more refined strategies for context-sensitive ESM using smartwatches and further develop mechanisms that will enable researchers to easily adapt their prompting strategy to different contextual factors. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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17 pages, 760 KiB  
Communication
Short and Long-Term Innovations on Dietary Behavior Assessment and Coaching: Present Efforts and Vision of the Pride and Prejudice Consortium
by Desiree A. Lucassen, Marlou P. Lasschuijt, Guido Camps, Ellen J. Van Loo, Arnout R. H. Fischer, Roelof A. J. de Vries, Juliet A. M. Haarman, Monique Simons, Emely de Vet, Marina Bos-de Vos, Sibo Pan, Xipei Ren, Kees de Graaf, Yuan Lu, Edith J. M. Feskens and Elske M. Brouwer-Brolsma
Int. J. Environ. Res. Public Health 2021, 18(15), 7877; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18157877 - 25 Jul 2021
Cited by 3 | Viewed by 4623
Abstract
Overweight, obesity and cardiometabolic diseases are major global health concerns. Lifestyle factors, including diet, have been acknowledged to play a key role in the solution of these health risks. However, as shown by numerous studies, and in clinical practice, it is extremely challenging [...] Read more.
Overweight, obesity and cardiometabolic diseases are major global health concerns. Lifestyle factors, including diet, have been acknowledged to play a key role in the solution of these health risks. However, as shown by numerous studies, and in clinical practice, it is extremely challenging to quantify dietary behaviors as well as influencing them via dietary interventions. As shown by the limited success of ‘one-size-fits-all’ nutritional campaigns catered to an entire population or subpopulation, the need for more personalized coaching approaches is evident. New technology-based innovations provide opportunities to further improve the accuracy of dietary assessment and develop approaches to coach individuals towards healthier dietary behaviors. Pride & Prejudice (P&P) is a unique multi-disciplinary consortium consisting of researchers in life, nutrition, ICT, design, behavioral and social sciences from all four Dutch Universities of Technology. P&P focuses on the development and integration of innovative technological techniques such as artificial intelligence (AI), machine learning, conversational agents, behavior change theory and personalized coaching to improve current practices and establish lasting dietary behavior change. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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19 pages, 10107 KiB  
Article
Does Dynamic Tailoring of A Narrative-Driven Exergame Result in Higher User Engagement among Adolescents? Results from A Cluster-Randomized Controlled Trial
by Ayla Schwarz, Greet Cardon, Sebastien Chastin, Jeroen Stragier, Lieven De Marez, Consortium SmartLife and Ann DeSmet
Int. J. Environ. Res. Public Health 2021, 18(14), 7444; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18147444 - 12 Jul 2021
Cited by 5 | Viewed by 2717
Abstract
Physical activity interventions for youth are direly needed given low adherence to physical activity guidelines, but many interventions suffer from low user engagement. Exergames that require bodily movement while played may provide an engaging form of physical activity intervention but are not perceived [...] Read more.
Physical activity interventions for youth are direly needed given low adherence to physical activity guidelines, but many interventions suffer from low user engagement. Exergames that require bodily movement while played may provide an engaging form of physical activity intervention but are not perceived as engaging to all. This study aimed to evaluate whether dynamic tailoring in a narrative-driven mobile exergame for adolescents played in leisure settings, can create higher user engagement compared to a non-tailored exergame. A cluster-randomized controlled trial assessed differences in user engagement between a dynamically tailored (based on an accelerometer sensor integrated in a T-shirt) and non-tailored condition. In total, 94 participants (M age = 14.61 ± 1.93; 35% female) participated and were assigned to one of the two conditions. User engagement was measured via a survey and game metric data. User engagement was low in both conditions. Narrative sensation was higher in the dynamically tailored condition, but the non-tailored condition showed longer play-time. User suggestions to create a more appealing game included simple and more colorful graphics, avoiding technical problems, more variety and shorter missions and multiplayer options. Less cumbersome or more attractive sensing options than the smart T-shirt may offer a more engaging solution, to be tested in future research. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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12 pages, 657 KiB  
Article
Midwives’ Experiences with and Perspectives on Online (Nutritional) Counselling and mHealth Applications for Pregnant Women; an Explorative Qualitative Study
by Renate F. Wit, Desiree A. Lucassen, Yvette H. Beulen, Janine P. M. Faessen, Marina Bos-de Vos, Johanna M. van Dongen, Edith J. M. Feskens, Annemarie Wagemakers and Elske M. Brouwer-Brolsma
Int. J. Environ. Res. Public Health 2021, 18(13), 6733; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18136733 - 23 Jun 2021
Cited by 6 | Viewed by 3171
Abstract
Prenatal nutrition is a key predictor of early-life development. However, despite mass campaigns to stimulate healthy nutrition during pregnancy, the diet of Dutch pregnant women is often suboptimal. Innovative technologies offer an opportunity to develop tailored tools, which resulted in the release of [...] Read more.
Prenatal nutrition is a key predictor of early-life development. However, despite mass campaigns to stimulate healthy nutrition during pregnancy, the diet of Dutch pregnant women is often suboptimal. Innovative technologies offer an opportunity to develop tailored tools, which resulted in the release of various apps on healthy nutrition during pregnancy. As midwives act as primary contact for Dutch pregnant women, the goal was to explore the experiences and perspectives of midwives on (1) nutritional counselling during pregnancy, and (2) nutritional mHealth apps to support midwifery care. Analyses of eleven in-depth interviews indicated that nutritional counselling involved the referral to websites, a brochure, and an app developed by the Dutch Nutrition Centre. Midwives were aware of the existence of other nutritional mHealth apps but felt uncertain about their trustworthiness. Nevertheless, midwives were open towards the implementation of new tools providing that these are trustworthy, accessible, user-friendly, personalised, scientifically sound, and contain easy-digestible information. Midwives stressed the need for guidelines for professionals on the implementation of new tools. Involving midwives early-on in the development of future nutritional mHealth apps may facilitate better alignment with the needs and preferences of end-users and professionals, and thus increase the likelihood of successful implementation in midwifery practice. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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15 pages, 951 KiB  
Article
Women’s Usage Behavior and Perceived Usefulness with Using a Mobile Health Application for Gestational Diabetes Mellitus: Mixed-Methods Study
by Shilpa Surendran, Chang Siang Lim, Gerald Choon Huat Koh, Tong Wei Yew, E Shyong Tai and Pin Sym Foong
Int. J. Environ. Res. Public Health 2021, 18(12), 6670; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18126670 - 21 Jun 2021
Cited by 10 | Viewed by 3620
Abstract
The prevalence of gestational diabetes mellitus (GDM) is increasing, and only a few mobile health (mHealth) applications are specifically designed to manage GDM. In this mixed-methods study, a follow-up study of a randomized controlled trial (RCT) analyzed a largely automated mHealth application-based lifestyle [...] Read more.
The prevalence of gestational diabetes mellitus (GDM) is increasing, and only a few mobile health (mHealth) applications are specifically designed to manage GDM. In this mixed-methods study, a follow-up study of a randomized controlled trial (RCT) analyzed a largely automated mHealth application-based lifestyle coaching program to (a) measure the application’s usage behavior and (b) explore users’ perceptions of its usefulness in GDM management. Quantitative data were collected from the 170 application users who had participated in the intervention arm of the RCT. Semi-structured interviews (n = 14) captured users’ experiences when using the application. Data were collected from June 2019 to January 2020. Quantitative data were analyzed descriptively, and interviews were analyzed thematically. Only 57/170 users (34%) logged at least one meal, and only 35 meals on average were logged for eight weeks because of the incorrectly worded food items and limited food database. On the contrary, an average of 1.85 (SD = 1.60) weight values were logged per week since the weight tracking component was easy to use. Many users (6/14 (43%)) mentioned that the automatic coach messages created an immediate sense of self-awareness in food choices and motivated behavior. The findings suggest that for GDM management, a largely automated mHealth application has the potential to promote self-awareness of healthy lifestyle choices, reducing the need for intensive human resources. Additionally, several gaps in the application’s design were identified which need to be addressed in future works. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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15 pages, 556 KiB  
Article
Reinforcement Learning to Send Reminders at Right Moments in Smartphone Exercise Application: A Feasibility Study
by Shihan Wang, Karlijn Sporrel, Herke van Hoof, Monique Simons, Rémi D. D. de Boer, Dick Ettema, Nicky Nibbeling, Marije Deutekom and Ben Kröse
Int. J. Environ. Res. Public Health 2021, 18(11), 6059; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18116059 - 04 Jun 2021
Cited by 12 | Viewed by 3529
Abstract
Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning [...] Read more.
Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning (RL) technique has been used in a smartphone exercise application to promote physical activity. This RL model determines the ‘right’ time to deliver a restricted number of notifications adaptively, with respect to users’ temporary context information (i.e., time and calendar). A four-week trial study was conducted to examine the feasibility of our model with real target users. JITAI reminders were sent by the RL model in the fourth week of the intervention, while the participants could only access the app’s other functionalities during the first 3 weeks. Eleven target users registered for this study, and the data from 7 participants using the application for 4 weeks and receiving the intervening reminders were analyzed. Not only were the reaction behaviors of users after receiving the reminders analyzed from the application data, but the user experience with the reminders was also explored in a questionnaire and exit interviews. The results show that 83.3% reminders sent at adaptive moments were able to elicit user reaction within 50 min, and 66.7% of physical activities in the intervention week were performed within 5 h of the delivery of a reminder. Our findings indicated the usability of the RL model, while the timing of the moments to deliver reminders can be further improved based on lessons learned. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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17 pages, 999 KiB  
Article
Promoting Occupational Health through Gamification and E-Coaching: A 5-Month User Engagement Study
by Chao Zhang, Pieter van Gorp, Maxine Derksen, Raoul Nuijten, Wijnand A. IJsselsteijn, Alberto Zanutto, Fabio Melillo and Roberto Pratola
Int. J. Environ. Res. Public Health 2021, 18(6), 2823; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18062823 - 10 Mar 2021
Cited by 10 | Viewed by 3055
Abstract
Social gamification systems have shown potential for promoting healthy lifestyles, but applying them to occupational settings faces unique design challenges. While occupational settings offer natural communities for social interaction, fairness issues due to heterogeneous personal goals and privacy concerns increase the difficulty of [...] Read more.
Social gamification systems have shown potential for promoting healthy lifestyles, but applying them to occupational settings faces unique design challenges. While occupational settings offer natural communities for social interaction, fairness issues due to heterogeneous personal goals and privacy concerns increase the difficulty of designing engaging games. We explored a two-level game-design, where the first level related to achieving personal goals and the second level was a privacy-protected social competition to maximize goal compliance among colleagues. The solution was strengthened by employing occupational physicians who personalized users’ goals and coached them remotely. The design was evaluated in a 5-month study with 53 employees from a Dutch university. Results suggested that the application helped half of the participants to improve their lifestyles, and most appreciated the role of the physician in goal-setting. However, long-term user engagement was undermined by the scalability-motivated design choice of one-way communication between employees and their physician. Implications for social gamification design in occupational health are discussed. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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Review

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14 pages, 1212 KiB  
Review
A Review of Digital Cognitive Behavioral Therapy for Insomnia (CBT-I Apps): Are They Designed for Engagement?
by Begum Erten Uyumaz, Loe Feijs and Jun Hu
Int. J. Environ. Res. Public Health 2021, 18(6), 2929; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18062929 - 12 Mar 2021
Cited by 25 | Viewed by 12453
Abstract
There are different ways to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), of which in-person (face to face) is the traditional delivery method. However, the scalability of in-person therapy is low. Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) is an alternative and there [...] Read more.
There are different ways to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), of which in-person (face to face) is the traditional delivery method. However, the scalability of in-person therapy is low. Digital Cognitive Behavioral Therapy for Insomnia (dCBT-I) is an alternative and there are tools on the market that are validated in clinical studies. In this paper, we provide a review of the existing evidence-based CBT-I apps and a summary of the published usability-oriented studies of these apps. The goal is to explore the range of interaction methods commonly applied in dCBT-I platforms, the potential impact for the users, and the design elements applied to achieve engagement. Six commercially available CBT-I apps tested by scientifically valid methods were accessed and reviewed. Commonalities were identified and categorized into interactive elements, CBT-I-related components, managerial features, and supportive motivational features. The dCBT-I apps were effectively assisting the users, and the type of interactions promoted engagement. The apps’ features were based on design principles from interactive product design, experience design, online social media, and serious gaming. This study contributes to the field by providing a critical summary of the existing dCBT-I apps that could guide future developers in the field to achieve a high engagement. Full article
(This article belongs to the Special Issue Digital Health Tools: A Critical Assessment of Long-Term Engagement)
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