JMIR Publications

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  Reviews

  Aug 23, 2019

  Passive Sensing of Health Outcomes Through Smartphones: Systematic Review of Current Solutions and Possible Limitations

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  Authors List:

  • Alina Trifan  
  • Maryse Oliveira  
  • José Luís Oliveira  

  Abstract:

  Background: Technological advancements, together with the decrease in both price and size of a large variety of sensors, has expanded the role and capabilities of regular mobile phones, turning them into powerful yet ubiquitous monitoring systems. At present, smartphones have the potential to continuously collect information about the users, monitor their activities and behaviors in real time, and provide them with feedback and recommendations. Objective: This systematic review aimed to identify recent scientific studies that explored the passive use of smartphones for generating health- and well-being–related outcomes. In addition, it explores users’ engagement and possible challenges in using such self-monitoring systems. Methods: A systematic review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to identify recent publications that explore the use of smartphones as ubiquitous health monitoring systems. We ran reproducible search queries on PubMed, IEEE Xplore, ACM Digital Library, and Scopus online databases and aimed to find answers to the following questions: (1) What is the study focus of the selected papers? (2) What smartphone sensing technologies and data are used to gather health-related input? (3) How are the developed systems validated? and (4) What are the limitations and challenges when using such sensing systems? Results: Our bibliographic research returned 7404 unique publications. Of these, 118 met the predefined inclusion criteria, which considered publication dates from 2014 onward, English language, and relevance for the topic of this review. The selected papers highlight that smartphones are already being used in multiple health-related scenarios. Of those, physical activity (29.6%; 35/118) and mental health (27.9; 33/118) are 2 of the most studied applications. Accelerometers (57.7%; 67/118) and global positioning systems (GPS; 40.6%; 48/118) are 2 of the most used sensors in smartphones for collecting data from which the health status or well-being of its users can be inferred. Conclusions: One relevant outcome of this systematic review is that although smartphones present many advantages for the passive monitoring of users’ health and well-being, there is a lack of correlation between smartphone-generated outcomes and clinical knowledge. Moreover, user engagement and motivation are not always modeled as prerequisites, which directly affects user adherence and full validation of such systems.

  • JMIR Mhealth Uhealth 2019;7(8):e12649

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  Usability and user perceptions of...

  Aug 22, 2019

  Proximity-Based Emergency Response Communities for Patients With Allergies Who Are at Risk of Anaphylaxis: Clustering Analysis and Scenario-Based Survey Study

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  Authors List:

  • Michal Gaziel Yablowitz  
  • Sabine Dölle  
  • David G Schwartz  
  • Margitta Worm  

  Abstract:

  Background: Anaphylaxis is a potentially fatal allergic reaction. However, many patients at risk of anaphylaxis who should permanently carry a life-saving epinephrine auto injector (EAI) do not carry one at the moment of allergen exposure. The proximity-based emergency response communities (ERC) strategy suggests speeding EAI delivery by alerting patient-peers carrying EAI to respond and give their EAI to a nearby patient in need. Objectives: This study had two objectives: (1) to analyze 10,000 anaphylactic events from the European Anaphylaxis Registry (EAR) by elicitor and location in order to determine typical anaphylactic scenarios and (2) to identify patients’ behavioral and spatial factors influencing their response to ERC emergency requests through a scenario-based survey. Methods: Data were collected and analyzed in two phases: (1) clustering 10,000 EAR records by elicitor and incident location and (2) conducting a two-center scenario-based survey of adults and parents of minors with severe allergy who were prescribed EAI, in Israel and Germany. Each group received a four-part survey that examined the effect of two behavioral constructs—shared identity and diffusion of responsibility—and two spatial factors—emergency time and emergency location—in addition to sociodemographic data. We performed descriptive, linear correlation, analysis of variance, and t tests to identify patients’ decision factors in responding to ERC alerts. Results: A total of 53.1% of EAR cases were triggered by food at patients’ home, and 46.9% of them were triggered by venom at parks. Further, 126 Israeli and 121 German participants completed the survey and met the inclusion criteria. Of the Israeli participants, 80% were parents of minor patients with a risk of anaphylaxis due to food allergy; their mean age was 32 years, and 67% were women. In addition, 20% were adult patients with a mean age of 21 years, and 48% were female. Among the German patients, 121 were adults, with an average age of 47 years, and 63% were women. In addition, 21% were allergic to food, 75% were allergic to venom, and 2% had drug allergies. The overall willingness to respond to ERC events was high. Shared identity and the willingness to respond were positively correlated (r=0.51, P<.001) in the parent group. Parents had a stronger sense of shared identity than adult patients (t243= –9.077, P<.001). The bystander effect decreased the willingness of all patients, except the parent group, to respond (F1,269=28.27, P<.001). An interaction between location and time of emergency (F1,473=77.304, P<.001) revealed lower levels of willingness to respond in strange locations during nighttime. Conclusions: An ERC allergy app has the potential to improve outcomes in case of anaphylactic events, but this is dependent on patient-peers’ willingness to respond. Through a two-stage process, our study identified the behavioral and spatial factors that could influence the willingness to respond, providing a basis for future research of proximity-based mental health communities.

  • JMIR Mhealth Uhealth 2019;7(8):e13414

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  mHealth in the Developing...

  Aug 21, 2019

  The Elusive Path Toward Measuring Health Outcomes: Lessons Learned From a Pseudo-Randomized Controlled Trial of a Large-Scale Mobile Health Initiative

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  Authors List:

  • Patricia Mechael  
  • Nadi Nina Kaonga  
  • Subhashini Chandrasekharan  
  • Muthu Perumal Prakash  
  • Joanne Peter  
  • Aakash Ganju  
  • Nirmala Murthy  

  Abstract:

  Mobile health (mHealth) offers new opportunities to improve access to health services and health information. It also presents new challenges in evaluating its impact, particularly in linking the use of a technology intervention that aims to improve health behaviors with the health outcomes that are impacted by changed behaviors. The availability of data from a multitude of sources (paper-based and electronic) provides the conditions to facilitate making stronger connections between self-reported data and clinical outcomes. This commentary shares lessons and important considerations based on the experience of applying new research frameworks and incorporating maternal and child health records data into a pseudo-randomized controlled trial to evaluate the impact of mMitra, a stage-based voice messaging program to improve maternal, newborn, and child health outcomes in urban slums in India.

  • JMIR Mhealth Uhealth 2019;7(8):e14668

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  mHealth for Data Collection and Research

  Aug 19, 2019

  The Validity of Daily Self-Assessed Perceived Stress Measured Using Smartphones in Healthy Individuals: Cohort Study

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  Authors List:

  • Helga Þórarinsdóttir  
  • Maria Faurholt-Jepsen  
  • Henrik Ullum  
  • Mads Frost  
  • Jakob E Bardram  
  • Lars Vedel Kessing  

  Abstract:

  Background: Smartphones may offer a new and easy tool to assess stress, but the validity has never been investigated. Objective: This study aimed to investigate (1) the validity of smartphone-based self-assessed stress compared with Cohen Perceived Stress Scale (PSS) and (2) whether smartphone-based self-assessed stress correlates with neuroticism (Eysenck Personality Questionnaire-Neuroticism, EPQ-N), psychosocial functioning (Functioning Assessment Short Test, FAST), and prior stressful life events (Kendler Questionnaire for Stressful Life Events, SLE). Methods: A cohort of 40 healthy blood donors with no history of personal or first-generation family history of psychiatric illness and who used an Android smartphone were instructed to self-assess their stress level daily (on a scale from 0 to 2; beta values reflect this scale) for 4 months. At baseline, participants were assessed with the FAST rater-blinded and filled out the EPQ, the PSS, and the SLE. The PSS assessment was repeated after 4 months. Results: In linear mixed-effect regression and linear regression models, there were statistically significant positive correlations between self-assessed stress and the PSS (beta=.0167; 95% CI 0.0070-0.0026; P=.001), the EPQ-N (beta=.0174; 95% CI 0.0023-0.0325; P=.02), and the FAST (beta=.0329; 95% CI 0.0036-0.0622; P=.03). No correlation was found between smartphone-based self-assessed stress and the SLE. Conclusions: Daily smartphone-based self-assessed stress seems to be a valid measure of perceived stress. Our study contains a modest sample of 40 healthy participants and adds knowledge to a new but growing field of research. Smartphone-based self-assessed stress is a promising tool for measuring stress in real time in future studies of stress and stress-related behavior.

  • JMIR Mhealth Uhealth 2019;7(8):e13418

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  mHealth in the Developing...

  Aug 19, 2019

  Analysis of Digital Documentation Speed and Sequence Using Digital Paper and Pen Technology During the Refugee Crisis in Europe: Content Analysis

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  Authors List:

  • Kai Kehe  
  • Roland Girgensohn  
  • Walter Swoboda  
  • Dan Bieler  
  • Axel Franke  
  • Matthias Helm  
  • Martin Kulla  
  • Kerstin Luepke  
  • Thomas Morwinsky  
  • Markus Blätzinger  
  • Katalyn Rossmann  

  Abstract:

  • JMIR Mhealth Uhealth 2019;7(8):e13516

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  Reviews

  Aug 19, 2019

  Using Telemedicine to Diagnose Surgical Site Infections in Low- and Middle-Income Countries: Systematic Review

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  Authors List:

  • Charlotte E J Sandberg  
  • Stephen R Knight  
  • Ahmad Uzair Qureshi  
  • Samir Pathak  

  Abstract:

  Background: A high burden of preventable morbidity and mortality due to surgical site infections (SSIs) occurs in low- and middle-income countries (LMICs), and most of these SSIs occur following discharge. There is a high loss to follow-up due to a wide geographical spread of patients, and cost of travel can result in delayed and missed diagnoses. Objective: This review analyzes the literature surrounding the use of telemedicine and assesses the feasibility of using mobile phone technology to both diagnose SSIs remotely in LMICs and to overcome social barriers. Methods: A literature search was performed using Medline, Embase, CINAHL, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar. Included were English language papers reporting the use of telemedicine for detecting SSIs in comparison to the current practice of direct clinical diagnosis. Papers were excluded if infections were not due to surgical wounds, or if SSIs were not validated with in-person diagnosis. The primary outcome of this review was to review the feasibility of telemedicine for remote SSI detection. Results: A total of 404 articles were screened and three studies were identified that reported on 2082 patients across three countries. All studies assessed the accuracy of remote diagnosis of SSIs using predetermined telephone questionnaires. In total, 44 SSIs were accurately detected using telemedicine and an additional 14 were picked up on clinical follow-up. Conclusions: The use of telemedicine has shown to be a feasible method in remote diagnosis of SSIs. Telemedicine is a useful adjunct for clinical practice in LMICs to decrease loss to postsurgical follow-up.

  • JMIR Mhealth Uhealth 2019;7(8):e13309

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  mHealth for Wellness, Behavior Change...

  Aug 16, 2019

  A Mobile Phone App Featuring Cue Exposure Therapy As Aftercare for Alcohol Use Disorders: An Investigator-Blinded Randomized Controlled Trial

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  Authors List:

  • Angelina Isabella Mellentin  
  • Bent Nielsen  
  • Anette Søgaard Nielsen  
  • Fei Yu  
  • Anna Mejldal  
  • Dorthe Grüner Nielsen  
  • Elsebeth Stenager  

  Abstract:

  Background: Cue exposure therapy (CET) is a psychological approach developed to prepare individuals with alcohol use disorder (AUD) for confronting alcohol and associated stimuli in real life. CET has shown promise when treating AUD in group sessions, but it is unknown whether progressing from group sessions to using a mobile phone app is an effective delivery pathway. Methods: A total of 164 individuals with AUD were randomized to one of three groups: CET as group aftercare (CET group), CET as fully automated mobile phone app aftercare (CET app), or aftercare as usual. Study outcomes were assessed face-to-face at preaftercare, postaftercare, and again at 6 months after aftercare treatment. Generalized mixed models were used to compare the trajectories of the groups over time on drinking, cravings, and use of urge-specific coping skills (USCS). Results: In all, 153 of 164 individuals (93%) completed assessments both at posttreatment and 6-month follow-up assessments. No differences in the trajectories of predicted means were found between the experimental groups (CET group and app) compared with aftercare as usual on drinking and craving outcomes over time. Both CET group (predicted mean difference 5.99, SE 2.59, z=2.31, P=.02) and the CET app (predicted mean difference 4.90, SE 2.26, z=2.31, P=.02) showed increased use of USCS compared to aftercare as usual at posttreatment, but this effect was reduced at the 6-month follow-up. No differences were detected between the two experimental CET groups on any outcomes. Conclusions: CET with USCS delivered as aftercare either via group sessions or a mobile phone app did not increase the effectiveness of primary treatment. This suggests that CET with USCS may not be an effective psychological approach for the aftercare of individuals treated for AUD.

  • JMIR Mhealth Uhealth 2019;7(8):e13793

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  mHealth in the Developing...

  Aug 15, 2019

  A Novel Mobile Health Tool for Home-Based Identification of Neonatal Illness in Uganda: Formative Usability Study

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  Authors List:

  • Madison Vanosdoll  
  • Natalie Ng  
  • Anthony Ho  
  • Allison Wallingford  
  • Shicheng Xu  
  • Shababa Binte Matin  
  • Neha Verma  
  • Azadeh Farzin  
  • W. Christopher Golden  
  • Youseph Yazdi  
  • Peter Waiswa  
  • Alain Labrique  
  • Soumyadipta Acharya  

  Abstract:

  Background: While early identification of neonatal illness can impact neonatal mortality rates and reduce the burden of treatment, identifying subtle clinical signs and symptoms of possible severe illness is especially challenging in neonates. The World Health Organization and the United Nations Children’s Fund developed the Integrated Management of Neonatal Childhood Illness guidelines, an evidence-based tool highlighting seven danger signs to assess neonatal health. Currently, many mothers in low-resource settings rely on home visits from community health workers (CHWs) to determine if their baby is sick. However, CHWs visit infrequently, and illness is often detected too late to impact survival. Thus, delays in illness identification pose a significant barrier to providing expedient and effective care. Neonatal Monitoring (NeMo), a novel neonatal assessment tool, seeks to increase the frequency of neonatal screening by task-shifting identification of neonatal danger signs from CHWs to mothers. Objective: This study aimed to explore the usability and acceptability of the NeMo system among target users and volunteer CHWs by assessing ease of use and learnability. Methods: Simulated device use and semistructured interviews were conducted with 32 women in the Iganga-Mayuge districts in eastern Uganda to evaluate the usability of the NeMo system, which involves a smartphone app paired with a low cost, wearable band to aid in identification of neonatal illness. Two versions of the app were evaluated using a mixed methods approach, and version II of the app contained modifications based on observations of the first cohort’s use of the system. During the posed scenario simulations, participants were offered limited guidance from the study team in order to probe the intuitiveness of the NeMo system. The ability to complete a set of tasks with the system was tested and recorded for each participant and closed- and open-ended questions were used to elicit user feedback. Additionally, focus groups with 12 CHWs were conducted to lend additional context and insight to the usability and feasibility assessment. Results: A total of 13/22 subjects (59%) using app version I and 9/10 subjects (90%) using app version II were able to use the phone and app with no difficulty, despite varying levels of smartphone experience. Following modifications to the app’s audio instructions in version II, participants’ ability to accurately answer qualitative questions concerning neonatal danger signs improved by at least 200% for each qualitative danger sign. All participants agreed they would trust and use the NeMo system to assess the health of their babies. Furthermore, CHWs emphasized the importance of community sensitization towards the system to encourage its adoption and regular use, as well as the decision to seek care based on its recommendations. Conclusions: The NeMo system is an intuitive platform for neonatal assessment in a home setting and was found to be acceptable to women in rural Uganda.

  • JMIR Mhealth Uhealth 2019;7(8):e14540

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  mHealth for Wellness, Behavior Change...

  Aug 15, 2019

  Counseling With Guided Use of a Mobile Well-Being App for Students Experiencing Anxiety or Depression: Clinical Outcomes of a Feasibility Trial Embedded in a...

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  Authors List:

  • Emma Broglia  
  • Abigail Millings  
  • Michael Barkham  

  Abstract:

  Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue to offer quality support with fewer resources to a growing student population. The convenience and availability of mobile phone apps offer innovative solutions to address therapeutic challenges and expand the reach of traditional support. Objective: The primary aim of this study was to establish the feasibility of a trial in which guided use of a mobile phone well-being app was introduced into a student counseling service and offered as an adjunct to face-to-face counseling. Methods: The feasibility trial used a two-arm, parallel nonrandomized design comparing counseling alone (treatment as usual, or TAU) versus counseling supplemented with guided use of a mobile phone well-being app (intervention) for 38 university students experiencing moderate anxiety or depression. Students in both conditions received up to 6 sessions of face-to-face counseling within a 3-month period. Students who approached the counseling service and were accepted for counseling were invited to join the trial. Feasibility factors evaluated include recruitment duration, treatment preference, randomization acceptability, and intervention fidelity. Clinical outcomes and clinical change were assessed with routine clinical outcome measures administered every counseling session and follow-up phases at 3 and 6 months after recruitment. Results: Both groups demonstrated reduced clinical severity by the end of counseling. This was particularly noticeable for depression, social anxiety, and hostility, whereby clients moved from elevated clinical to low clinical or from low clinical to nonclinical by the end of the intervention. By the 6-month follow-up, TAU clients’ (n=18) anxiety had increased whereas intervention clients’ (n=20) anxiety continued to decrease, and this group difference was significant (Generalized Anxiety Disorder–7: t22=3.46, P=.002). This group difference was not replicated for levels of depression: students in both groups continued to decrease their levels of depression by a similar amount at the 6-month follow-up (Physical Health Questionnaire–9: t22=1.30, P=.21). Conclusion: Supplementing face-to-face counseling with guided use of a well-being app is a feasible and acceptable treatment option for university students experiencing moderate anxiety or depression. The feasibility trial was successfully embedded into a university counseling service without denying access to treatment and with minimal disruption to the service. This study provides preliminary evidence for using a well-being app to maintain clinical improvements for anxiety following the completion of counseling. The design of the feasibility trial provides the groundwork for the development of future pilot trials and definitive trials embedded in a student counseling service. Trial registration: ISRCTN registry ISRCTN55102899; http://www.isrctn.com/ISRCTN55102899

  • JMIR Mhealth Uhealth 2019;7(8):e14318

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  mHealth for Treatment Adherence

  Aug 13, 2019

  Association Between User Engagement of a Mobile Health App for Gout and Improvements in Self-Care Behaviors: Randomized Controlled Trial

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  Authors List:

  • Anna Serlachius  
  • Kiralee Schache  
  • Anel Kieser  
  • Bruce Arroll  
  • Keith Petrie  
  • Nicola Dalbeth  

  Abstract:

  Background: Mobile health (mHealth) apps represent a promising approach for improving health outcomes in patients with chronic illness, but surprisingly few mHealth interventions have investigated the association between user engagement and health outcomes. We aimed to examine the efficacy of a recommended, commercially available gout self-management app for improving self-care behaviors and to assess self-reported user engagement of the app in a sample of adults with gout. Objective: Our objective was to examine differences in self-reported user engagement between a recommended gout app (treatment group) and a dietary app (active control group) over 2 weeks as well as to examine any differences in self-care behaviors and illness perceptions. Methods: Seventy-two adults with gout were recruited from the community and three primary and secondary clinics. Participants were randomized to use either Gout Central (n=36), a self-management app, or the Dietary Approaches to Stop Hypertension Diet Plan (n=36), an app based on a diet developed for hypertension, for 2 weeks. The user version of the Mobile Application Rating Scale (uMARS, scale: 1 to 5) was used after the 2 weeks to assess self-reported user engagement, which included an open-ended question. Participants also completed a self-report questionnaire on self-care behaviors (scale: 1-5 for medication adherence and diet and 0-7 for exercise) and illness perceptions (scale: 0-10) at baseline and after the 2-week trial. Independent samples t tests and analysis of covariance were used to examine differences between groups at baseline and postintervention. Results: Participants rated the gout app as more engaging (mean difference –0.58, 95% CI –0.96 to –0.21) and more informative (mean difference –0.34, 95% CI –0.67 to –0.01) than the dietary app at the 2-week follow-up. The gout app group also reported a higher awareness of the importance of gout (mean difference –0.64, 95% CI –1.27 to –0.003) and higher knowledge/understanding of gout (mean difference –0.70, 95% CI –1.30 to –0.09) than the diet app group at follow-up. There were no significant differences in self-care behaviors between the two groups postintervention. The gout app group also demonstrated stronger negative beliefs regarding the impact of gout (mean difference –2.43, 95% CI –3.68 to –1.18), stronger beliefs regarding the severity of symptoms (mean difference –1.97, 95% CI –3.12 to –0.82), and a stronger emotional response to gout (mean difference –2.38, 95% CI –3.85 to –0.90) at follow-up. Participant feedback highlighted the importance of tracking health-related information, customizing to the target group/individual, providing more interactive features, and simplifying information. Conclusions: Participants found the commercially available gout app more engaging. However, these findings did not translate into differences in self-care behaviors. The gout app group also demonstrated stronger negative illness perceptions at the follow-up. Overall, these findings suggest that the development of gout apps would benefit from a user-centered approach with a focus on daily, long-term self-care behaviors as well as modifying illness beliefs. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617001052325; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373217.

  • JMIR Mhealth Uhealth 2019;7(8):e15021

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  Quality Evaluation and Descriptive...

  Aug 13, 2019

  Suicide Prevention Mobile Apps: Descriptive Analysis of Apps from the Most Popular Virtual Stores

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  Authors List:

  • Gema Castillo-Sánchez  
  • Ismael Camargo-Henríquez  
  • Juan Luis Muñoz-Sánchez  
  • Manuel Franco-Martín  
  • Isabel de la Torre-Díez  

  Abstract:

  Background: Provision of follow-up and care during treatment of people with suicidal intentions is a challenge for health professionals and experts in information and communications technology (ICT). Therefore, health professionals and ICT experts are making efforts to carry out these activities in collaboration by using mobile apps as a technological resource. Methods: We considered 20 apps previously listed in the article “Mobile Apps for Suicide Prevention: Review of Virtual Stores and Literature” (de la Torre et al, JMIR mHealth uHealth 2017;5[10]:e130). To find the apps in this list, the most popular app stores (Android and iOS) were searched using the keyword “suicide prevention.” The research focused on publicly available app information: language, platform, and user ratings. The results obtained were statistically evaluated using 16 parameters that establish various factors that may affect the choice of the user, and the consequent support that the app can offer to a person at risk for suicide. Results: Of the 20 mobile apps, 4 no longer appeared in the app stores and were therefore excluded. Analysis of the remaining 16 apps sampled showed the following: (1) a high percentage of the apps analyzed in the study (n=13, 82%) are provided in English language; (2) the sampled apps were last updated in 2017, when only 45% of them were updated, but the constant and progressive update of treatments should be reflected in the apps; and (3) the technical quality of these apps cannot be determined on the basis of the distribution of scores, because their popularity indices can be subjective (according to the users). User preference for a particular operating system would require further, more specific research, including study of the differences in the technical and usability aspects between both platforms and the design of medical apps. Conclusions: Although there are positive approaches to the use of apps for suicide prevention and follow-up, the technical and human aspects are yet to be explored and defined. For example, the design and development of apps that support suicide prevention should be strongly supported by health personnel to humanize these apps, so that the effectiveness of the treatments supported by them can be improved.

  • JMIR Mhealth Uhealth 2019;7(8):e13885

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  Articles

  Aug 12, 2019

  An App to Improve Eating Habits of Adolescents and Young Adults (Challenge to Go): Systematic Development of a Theory-Based and Target Group–Adapted Mobile...

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  Authors List:

  • Anna Rohde  
  • Anja Duensing  
  • Christine Dawczynski  
  • Jasmin Godemann  
  • Stefan Lorkowski  
  • Christine Brombach  

  Abstract:

  Background: Due to the widespread use of mobile phones, dietary mobile apps are promising tools for preventing diet-related noncommunicable diseases early in life. However, most of the currently available nutrition apps lack scientific evaluation and user acceptance. Objective: The objective of this study was the systematic design of a theory-driven and target group–adapted dietary mobile app concept to promote healthy eating habits with a focus on drinking habits as well as consumption of fruits and vegetables in adolescents and young adults, especially from disadvantaged backgrounds. Methods: The design process was guided by the behavior change wheel (BCW). The development process comprised 3 stages. In stage 1, the target behavior was specified, and facilitators and barriers were identified. Furthermore, important insights into target group interests, needs, and values in the field of nutrition and apps were revealed. To this end, 2 empirical studies were conducted with the target group. In stage 2, results of stage 1 were translated into behavior change techniques (BCTs) and, finally, into app functionalities and features. Consequently, in stage 3, the concept was evaluated and optimized through expert interviews. Results: Facilitators and barriers for achieving the target behavior were psychological capabilities (eg, self-efficacy), reflective motivation (eg, fitness), automatic motivation, social support, and physical opportunity (eg, time). Target group interests, needs, and values in the field of nutrition were translated into target group preferences for app usage, for example, low usage effort, visual feedback, or recipes. Education, training, incentives, persuasion, and enablement were identified as relevant intervention functions. Together with the target group preferences, these were translated via 14 BCTs, such as rewards, graded tasks, or self-monitoring into the app concept Challenge to go (C2go). The expert evaluation suggested changes of some app features for improving adherence, positive health effects, and technical feasibility. The C2go concept comprises 3 worlds: the (1) drinking, (2) vegetable, and (3) fruit worlds. In each world, the users are faced with challenges including feedback and a quiz. Tips were developed based on the health action process approach and to help users gain challenges and, thereby, achieve the target behavior. Challenges can be played alone or against someone in the community. Due to different activities, points can be collected, and levels can be achieved. Collected points open access to an Infothek (information section), where users can choose content that interests them. An avatar guides user through the app. Conclusions: C2go is aimed at adolescents and young adults and aims to improve their fruit and vegetable consumption as well as drinking habits. It is a theory-driven and target group–adapted dietary mobile intervention concept that uses gamification and was systematically developed using the BCW.

  • JMIR Mhealth Uhealth 2019;7(8):e11575

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