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Prevention and management of work-related stress and related mental problems is a great challenge. Mobile applications are a promising way to integrate prevention strategies into the everyday lives of citizens.
The objectives of this study was to study the usage, acceptance, and usefulness of a mobile mental wellness training application among working-age individuals, and to derive preliminary design implications for mobile apps for stress management.
Oiva, a mobile app based on acceptance and commitment therapy (ACT), was designed to support active learning of skills related to mental wellness through brief ACT-based exercises in the daily life. A one-month field study with 15 working-age participants was organized to study the usage, acceptance, and usefulness of Oiva. The usage of Oiva was studied based on the usage log files of the application. Changes in wellness were measured by three validated questionnaires on stress, satisfaction with life (SWLS), and psychological flexibility (AAQ-II) at the beginning and at end of the study and by user experience questionnaires after one week’s and one month’s use. In-depth user experience interviews were conducted after one month’s use to study the acceptance and user experiences of Oiva.
Oiva was used actively throughout the study. The average number of usage sessions was 16.8 (SD 2.4) and the total usage time per participant was 3 hours 12 minutes (SD 99 minutes). Significant pre-post improvements were obtained in stress ratings (mean 3.1 SD 0.2 vs mean 2.5 SD 0.1,
A feasibility study of Oiva mobile mental wellness training app showed good acceptability, usefulness, and engagement among the working-age participants, and provided increased understanding on the essential features of mobile apps for stress management. Five design implications were derived based on the qualitative findings: (1) provide exercises for everyday life, (2) find proper place and time for challenging content, (3) focus on self-improvement and learning instead of external rewards, (4) guide gently but do not restrict choice, and (5) provide an easy and flexible tool for self-reflection.
Work-related mental health problems are the most common cause of disability in the countries of the Organization for Economic Cooperation and Development [
Preventative interventions targeted at individuals at risk may be used to contain the costs and suffering related to stress and mental disorders [
Technology-assisted prevention programs enable easier, earlier, and more flexible access to care at a lower cost, and many of them have been shown to reach equal effectiveness to face-to-face therapies in the treatment of psychological problems [
Most computerized therapies build on psychological therapy methods, usually cognitive-behavioral therapies (CBT) [
Psychological flexibility can be increased through the six core processes of ACT [
Psychological flexibility is associated with better mental health and behavioral changes [
Mobile interventions have been used effectively to promote physical health, but despite increasing activity in the area, mobile mental wellness apps are still in their infancy [
CBT-based interventions commonly use monitoring of symptoms and mood states as a strategy to develop self-awareness and coping abilities [
Several mobile interventions, such as Mood Map and PRISM, have combined monitoring of mental states with brief exercises [
In therapeutic context, PRISM is a mobile intervention that was evaluated in a two-week study among 10 outpatients with bipolar disorder [
Some interventions have combined mobile and Web apps that serve different functions. Mobilyze! is a mobile phone and Web-based intervention for depression [
One of the few larger studies is the trial of myCompass, a mobile phone and Web-based program for stress, depression, and anxiety [
Randomized controlled studies of mobile mental wellness apps, especially in preventative context, appear to be scarce. One of the few examples is the evaluation of MEMO, a 9-week mobile intervention for preventing teenage depression consisting of mobile messages and a mobile website [
To our knowledge, the only ACT-based mobile intervention reported thus far was by Ly et al [
Conclusive evidence of effectiveness of existing mobile mental wellness apps is not yet available, but the results have been promising and several large-scale randomized controlled trials are currently underway [
Several guidelines exist for designing technological apps that engage, motivate, and support behavior and attitude changes. Systems “designed to change people’s attitudes or behaviors” are called persuasive technologies [
The guidelines that are more closely related to mental wellness apps include Morris’ 7 guidelines for behavior change [
In this paper, we describe Oiva, a mobile app for stress management, and present results of a one-month field study that was performed to assess the feasibility of Oiva and validate its design choices. To the best of our knowledge, Oiva is the first ACT-based, stand-alone mobile intervention for self-administered preventative training of stress management skills. Most of the previous studies of mobile mental wellness apps have either focused on mood charting or combined mood charting with brief exercises that have been Web-based in some of the studies. Although mood charting appears to increase adherence and improve self-awareness among certain target groups, none of the studies so far have done a detailed analysis of how mental wellness exercises on a mobile platform should be designed to maximize adherence, user satisfaction and outcomes. To shed light specifically on this matter, the current study excluded the mood-charting component and focused on a structured training program with experiential exercises. The detailed objectives of this study were to: (1) investigate how the participants used the app, (2) study the effects of Oiva on the participants’ mental wellness, (3) explore the user experiences of Oiva and its functions, and (4) derive preliminary design implications for mobile mental wellness apps.
Oiva is a mobile mental wellness-training app targeted at working-age people who suffer from stress. Oiva is a stand-alone app for Android mobile phones and tablets, and it was designed in cooperation of experts in psychology, user needs and technology. The content and logic of Oiva were built upon ACT principles and methods, and the app delivers a complete ACT-based intervention program in bite-sized daily sessions.
Oiva contains 4 intervention modules or “paths” named Aware Mind, Wise Mind, Values, and Healthy Body. The first 3 paths teach the user the 6 core processes of ACT and the fourth path focuses on physical wellness, but with an ACT-based approach. The paths consist of altogether 46 text and audio exercises.
Each petal represents one of the paths, which are numbered according to their recommended order. Each path consists of 1–4 subsections (“steps”), which include 5–8 exercises (
Oiva gently steers the user through the intervention program without restricting free navigation. Paths, steps, and exercises are numbered in the recommended order and the next suggested item is dynamically highlighted (
Most of the exercises are short and take about 1-3 minutes to complete (
Progress in the program is presented in several ways. First, the number of completed exercises is displayed for each step. Second, the background color of steps and exercises changes once they are completed. Each completed exercise is rewarded by a virtual rose (
Screenshots of Oiva. (a) the main screen, (b) diary, (c) introduction video, (d) top menu of Aware Mind, (e) exercise introduction screen, (f) audio exercise, (g) text exercise, (h) exercise reflection screen.
Fifteen volunteer participants were recruited via email from the staff of the local technical university in Finland. Thirteen of the participants had not encountered Oiva and did not know the researchers prior to the study. Two of the participants had seen an earlier version of Oiva, because they had volunteered in a short usability test in a laboratory. There were no specific inclusion criteria, only that the participants needed to be interested in stress management and willing to use a prototype mobile app. The app was described as an acceptance-, value-, and mindfulness-based self-help program designed to help in, for example, stress management and relaxation, increasing physical activity, and practicing mindful eating.
The 15 participants (9 female) were university staff, including, for example, a human resources manager, a secretary, a researcher, and a laboratory engineer. Five participants were younger than 30 years old, 5 were between 31 and 40 years, and 5 were older than 40 years.
The participants signed an informed consent form prior to the study and were aware of their right to withdraw from the study at any time. Ethics committee approval was not acquired as the study was deemed to involve minimal risk and the focus was on studying mainly user experiences.
The participants filled in baseline questionnaires and attended a face-to-face group kick-off session, which consisted of two 10-minute presentations, one on ACT theory and one on Oiva. The aim and process of the study were explained. An Android smartphone with Oiva pre-installed was provided for each of the participants to be used for one month. The phone model was either ZTE Blade (7 participants) or Sony Ericsson Xperia ray (8 participants). A short user guide about Oiva was provided on paper. Active, preferably daily use was recommended, but finding personally appropriate ways of use was also encouraged. The study period was one month in May 2012. At the end of the study, each participant was given two movie tickets to compensate for the time spent in study procedures.
Data were collected from 3 sources: (1) online questionnaires completed at baseline, after one week’s use and after one month’s use, (2) interviews conducted after one month’s use, and (3) the usage log of Oiva app.
Background information (eg, age and previous experience in using mobile phones and wellness technologies) was collected at baseline. Wellness questionnaires were administered at baseline and after one month’s use. Psychological flexibility was assessed with a 7-item Acceptance and Action Questionnaire (AAQ-II, [
Qualitative data on user experiences, usage, and usefulness were gathered in individual, semi-structured, face-to-face interviews after one month’s use. The interviews were designed among the authors and a discussion guide outlining the themes of the interview was created. Some of the themes included were: the situations where Oiva was used in, whether using Oiva affected the participant’s wellness, the user experiences of different features of Oiva, Oiva’s ability to persuade and reward usage, and desired new features of Oiva. The first author, who has several years of experience in user experience studies, conducted the interviews. Each interview lasted about 45 minutes and was audio recorded.
The usage log files were collected from the phones after the interview. The usage log contained all user actions and their time stamps. The number of characters in diary entries was also logged, but not the content of the entries.
The log files of 14 participants were analyzed. One participant was excluded due to unreliable time stamps in her log file caused by a date change in her phone. Individual usage sessions were first detected and counted. Then, usage days were calculated as days containing a usage session. The durations of individual sessions were calculated based on the start and end times of each session, and the total duration of use by summing the durations of all sessions. As the app can be always “on” and running in the background, there were no specific log events that would flawlessly indicate the start of a usage session. Thus, two criteria were used to determine the start of a session. First, if an “app started” event was detected without any prior activity for the past 10 minutes, a new session was considered to have started. Second, if there was at least a 20-minute pause between consecutive log events, a new session was marked. The 20-minute requirement was chosen to avoid marking a new session while the user was listening to or otherwise performing an exercise.
Statistical analysis of the quantitative data from the wellness questionnaires and our custom rating scales for the experienced benefits was performed as follows. First, one female participant was excluded as she omitted some of the questionnaires. Coincidentally, she was the same participant who was also excluded from log file analyses. Then, change in participants’ ratings of wellness from before to after using Oiva was analyzed with paired comparisons using Wilcoxon signed rank tests. Finally, we tested if the median ratings of experienced benefits of Oiva (ie, improvement or maintenance of wellness, learning new things, and gaining new insights) were statistically significantly on the positive side (ie, above the mid-point of 4) using Wilcoxon signed rank tests.
The interview audio recordings were transcribed and analyzed with a qualitative content analysis method called thematic coding [
According to the baseline questionnaire, all except one of the participants used mobile phones daily, and all but one had used mobile phones for more than ten years. Eleven participants were currently using a smartphone. Of the participants, 67% (10/15) had already tried some mobile wellness apps (eg, for exercise tracking), and 73% (11/15) had tried wellness-related Web services (eg, for weight management). Eleven participants (73%) had some prior knowledge of ACT related topics (eg, mindfulness).
The average duration of the usage period from the first log event to the last was 34.0 (SD 5.3, range 26-46) days. The participants used Oiva, on average, on 11.5 (SD 5.8, range 4-20) days, and there were, on average, 16.8 (SD 9.0, range 5-36) usage sessions per participant during the study. The average duration of usage sessions was 12.3 (SD 5.2, range 4.4-24) minutes. The average total usage time per participant was 192 (SD 99, range 56-339) minutes.
Ratings of stress and scores in SWLS and AAQ-II questionnaires before and after using Oiva.
|
Before |
After |
|
Stress | 3.1 (0.2) | 2.5 (0.1) | .003 |
SWLS | 23.1 (1.3) | 25.9 (0.8) | .02 |
AAQ-II | 17.2 (1.5) | 17.2 (1.6) | .95 |
aSEM=standard error of mean
Mean post-study ratings (± SEM) of the effects attributed to Oiva.
The most common place to use Oiva, reported by 80% (12/15) of participants, was at home. Typical usage contexts at home included: in bed before falling asleep or after waking up (5/15, 33% of participants), in the backyard (2/15, 13% of participants), or in the middle of household routines (3/15, 20% of participants). One participant who used Oiva outdoors commented that the elements of nature (eg, birds singing or fresh air) strengthened the effects of the exercises. Only 27% (4/15) of participants had used Oiva at work. Forty percent (6/15) of the participants had tried performing exercises in mobile contexts, for example, when commuting, and 27% (4/15) of them reported liking this way of use. Mobile situations were often regarded as restless and not providing a possibility for proper concentration.
Despite little actual mobile use, the mobile device was regarded as a good platform for a stress management app. Ten participants (67%) brought up the ease of carrying a mobile phone along as the main benefit. Even at home, the mobile phone was taken along to different places, such as bed, hammock, or living room floor, where the usage of a computer would have been more difficult. Also, being able to open the app quickly and not requiring an extra device to carry were important benefits of the mobile phone for 27% (4/15) of participants (eg, compared to relaxation CDs or laptops). The mobile phone implementation was perceived especially suitable for short and easy exercises (6/15, 40% of participants) and for audio exercises (4/15, 27% of participants). Three participants specifically mentioned that some of the exercises, such as long exercises requiring concentration and tranquility, were less suitable for a mobile phone. However, not having Oiva installed in their personal phone affected use; 60% (9/15) of participants believed that, if Oiva had been installed in their own phone, they would have used it in a more versatile way and also in mobile contexts.
A typical barrier of use was being busy in everyday life (7/15, 47% of participants), which made it difficult to find suitable, peaceful moments for exercises. For example, concentrating on the exercises in the evening when already tired was perceived challenging (3/15, 20% of participants). Forty percent (6/15) of participants also mentioned that they forgot to use Oiva unless they consciously dedicated a time slot for it in their schedules.
The participants preferred short and simple exercises that were easy to integrate into their everyday life, could be done anywhere and were easy to perform even without Oiva after learning the techniques. Forty-seven percent (7/15) of participants said that these exercises gave them immediate benefits and that they intended to continue doing them also after the study.
The one-month usage period seemed too short to 73% (11/15) of the participants. They felt that establishing profound lifestyle changes and new routines takes longer than a month, and that they only had time to explore the exercises but not to apply the skills properly to their own life. The participants who had learned to apply the skills in their life and perform the exercises even without Oiva had been familiar with the techniques already prior to the study. The short breathing and relaxation exercises were an exception as the techniques were very easy to learn.
According to the interviews, the main benefit of Oiva was being able to take a break in the midst of daily hassles, whether at work or at home (eg, taking care of children or household chores). Especially the short breathing and relaxation exercises were found useful for this purpose. One participant described how differently her day began after doing an exercise compared to her routine mornings: “When I did an exercise in the morning before leaving for work, the day begun in a totally different way. Otherwise I would have just driven to work in a rush”
Four participants (27%) reported gaining more profound benefits, such as changes in their thoughts and attitudes. These included getting a new perspective on their life or starting to consider their values and actions. Two participants (13%) had also discussed their values with their spouses. One of them stated this would not have happened without Oiva. The other one had experienced value-based exercises beneficial in a new life situation, after becoming a parent for the first time. A third participant described that value exercises had helped her realize concretely that she has the power to decide how she spends her time and her life.
Four participants (27%) also reported gaining the ability to let go of their thoughts and feelings, and change their perspective to them. They reported that these skills had helped them deal with negative thoughts and feelings, distance themselves from stressful thoughts and accept setbacks. It had made them question whether some of their issues were as serious as they had thought.
Mindfulness was considered a good philosophy for Oiva. Seven participants (47%) commented that Oiva’s exercises concretely demonstrated how they could apply mindfulness in their everyday life. In general, the participants regarded the exercises as interesting, concrete, down-to-earth, and memorable. The stories and metaphors helped them understand the topics. In addition, as Oiva included versatile topics and exercises in a structured form, the participants were able to choose the most suitable exercises.
Audio exercises were preferred over text by 73% (11/15) of participants because they provided guidance through the exercise. They were also perceived to provide a “more personal feeling” and make it easier to concentrate and relax. An unexpected benefit, reported by one participant, was that audio exercises enabled performing them together with other people. However, text exercises were considered useful for recapitulation and therefore both formats were needed.
Eight participants (53%) performed exercises in the order recommended by Oiva. Guidance was perceived to facilitate use, as reflected in a comment: “It does not limit but provides the direction where to go, that works!” If the participants felt that the recommended exercise was not suitable for a specific situation, they skipped it at that moment. The recommended order was not taken by 47% (7/15) of participants, who chose exercises based on interesting topics, names of the exercises, or their own feelings. They did not feel that the guidance limited their freedom of choice. The app “told in a plain enough way, not with exclamation mark, where one is going and what is being suggested next”, as one participant articulated.
Although the participants liked the current guidance in Oiva, they wished for even more guidance. Six participants (40%) would have liked a scheduled program and 67% (10/15) would have liked to receive reminders to use Oiva. They felt that these features would bring order and motivation. However, they stated that scheduling should not be too restrictive. Skipping and choosing different exercises should still be possible.
Skepticism toward gamification was expressed by 60% (9/15) of participants. They thought that collecting points, rewards, and achievements would not sit well with a mental wellness app or fit the philosophy of mindfulness. They felt that the motivation to use Oiva rises from its content and wellness effects and that the real achievements and rewards come from learning and self-improvement. Instead, they wanted to see their progress in the skills they had learned and the positive changes they had accomplished.
Nine participants (60%) made entries to Oiva’s diary. The interviews revealed that the entries mainly dealt with thoughts, feelings, and insights raised by the exercises, and answers to the questions in the reflection screen. According to the participants, one of the main benefits of the diary was that it enabled the follow-up of thoughts when the same exercise was repeated. Two participants used a paper diary, because they wanted to be able to write and draw freely. Three participants wished to have more structured and guided questionnaires with pre-defined response options, as they found it difficult to know what to write. They also felt that a structured diary would enable easier follow-up and comparison of entries. In general, the touch screen text input was regarded as cumbersome, which may have caused some of the problems encountered with the diary.
At the time of the study, Oiva did not offer anything extra when the user had completed all the exercises, which 80% (12/15) of the participants saw as an inadequate end for the program. Nine participants (60%) mentioned that they would have wanted a follow-up program to remind them to continue to do the exercises, preferably focusing on the exercises that were the most beneficial for them or where there still was room for improvement. The follow-up program could also provide new content and exercises. The participants felt that the usage of Oiva should not end after completing the exercises once, but that the exercises should be repeated whenever needed. The skills learned should be integrated to one’s life and Oiva could help by guiding in that.
The 4 main goals of this study were: (1) to find out how the participants used the app, (2) to study whether using Oiva improved the participants’ mental wellness, (3) to explore how Oiva and its functions were experienced, and (4) to derive preliminary design guidelines for mobile stress management apps.
Oiva was used actively by the participants, on average, every third day. The sessions were relatively long for mobile use, on average 12 minutes. This result is similar to the one reported by Doherty et al [
Statistically significant improvements in stress and life satisfaction were achieved during the study. The positive mean ratings on the subjective scales of improvement or maintenance of wellness, learning new things, and gaining new insights suggest that the participants explicitly attributed these positive effects to Oiva, although other factors (eg, changes in common stressors for the university staff) cannot be excluded in this study. Furthermore, as the study sample was small, these results should be considered preliminary and indicative.
The interview data implied that the participants had taken the first steps towards learning the skills related to ACT. Most participants reported increased mindfulness, but also learning other skills, such as skills related to acceptance, cognitive defusion, values, and committed actions. However, we did not observe significant changes in psychological flexibility, which would have been in line with such changes. One of the reasons may be that most of the sample already had some prior knowledge of ACT. Moreover, psychological flexibility has been described as a fundamental basic aspect of health [
It is assumed that mobile devices are well-suited for wellness apps because they enable interventions in mobile contexts. In our study, we found that most of the use occurred, not in mobile situations, but in situations that were peaceful and provided an opportunity for proper concentration. The short breathing and relaxation exercises formed an exception—they were found easy to integrate into everyday life and in some cases even mobile situations. However, the strengths of the mobile platform became evident because the mobile phone was easy to carry along anywhere enabling more freedom in choosing the locations of use. Also, being fast to open for a quick session was an important benefit.
Participants appreciated guidance in both navigation and performing the exercises. They liked to hand over the responsibility of deciding the order of exercises to the app. Thus, guidance may have helped in creating a sense of therapeutic alliance between Oiva and the participants [
Based on our findings, we propose the following set of preliminary design implications for mobile mental wellness training apps.
Most, if not all, participants understood that the purpose of Oiva was to learn skills and techniques that improve wellness, and to integrate these skills to everyday life as a process of mental self-development. The main benefit for most participants was the possibility to do exercises to calm down quickly. The short breathing and relaxation exercises were used to take a break, a “moment for me”. Such exercises were well-suited to the relatively short one-month study period, since they were quick to absorb, easy to integrate into one’s daily habits and everyday life, and did not require much thought or preparation.
The participants perceived some of Oiva’s exercises as more challenging, especially the exercises that were longer or related to more challenging skills (eg, values or acceptance). They required more concentration and effort, and therefore had a high threshold to get started with. However, the challenging exercises would probably have stronger effects on psychological flexibility and thus it is essential to lower the threshold for the users to engage in them. One way to approach this could be to utilize context-awareness on mobile platforms to identify appropriate moments to engage the user [
Interestingly, the majority of the participants did not wish for extra rewards or game-like elements in Oiva. An achievement-oriented approach is often utilized in the apps for physical activity [
In general, the preference for guidance as “giving direction but not limiting” was expressed frequently. Oiva’s way of gently recommending an exercise while still leaving the user the freedom of choice was appreciated. The participants also liked having audio narration to guide them through exercises. In self-help apps, active guidance is a way to foster a sense of alliance [
Many participants used the diary as a self-reflection tool, as they wrote down feelings and thoughts related to exercises, as well as responded to the questions that were asked at the end of the exercises. The participants emphasized the importance of raising emotional awareness through self-reflection [
This study was an uncontrolled field trial involving a small number of volunteer participants, which must be taken into account in interpreting the results. Many of the participants were already somewhat familiar with ACT-based methods, which may have facilitated the adoption of the app and learning the skills. Due to the lack of a control group, common confounding factors affecting the wellness of university staff at the time of the study cannot be assessed. Also the usage patterns observed in the study may not fully reflect realistic usage patterns, as the participants were not able to use Oiva in their own mobile phones.
The study participants were not the direct target group of the app. For ethical reasons, we did not want to present a prototype app to people suffering from severe stress, and thus chose a healthy group of participants for this feasibility study. This choice limits the generalizability of the results.
This article presented Oiva, a mobile stress management app based on acceptance and commitment therapy methods. We studied the usage, impact, and user experiences of Oiva in a one-month field study with 15 participants. The active usage, observed positive effects on wellness, and the generally positive user experiences of Oiva suggest that it is possible to develop engaging mobile apps that are experienced as beneficial for personal mental wellness. Our present results establish Oiva as a good starting point for continuing research on mobile support for mental wellness. We believe that the insights gained from our in-depth interviews with the participants may help future researchers to create effective and engaging mental wellness apps.
Oiva is currently being studied in a randomized controlled trial with working-age subjects suffering from stress and features of metabolic syndrome. In the study, Oiva is compared to an ACT-based face-to-face intervention with similar content, delivered as 6 group meetings during an 8-week period, and a control group. Each study condition will involve about 80 subjects. The impact of interventions will be measured by psychological, physical, and anthropometric questionnaires and measurements at baseline, after the intervention, and at 6 months after the intervention.
In future versions of Oiva, we aim to enable easier tailoring of programs to different target groups as well as individual needs and explore the possibilities of context-sensitivity in supporting better integration into the daily life. We will also study the opportunities of adding social features to the app [
acceptance and action questionnaire
acceptance and commitment therapy
cognitive behavioral therapy
standard error of mean
satisfaction with life scale
The study was supported by the SalWe Research Program for Mind and Body (Tekes-the Finnish Funding Agency for Technology and Innovation grant 1104/10).
Conflicts of Interest: None declared.