Fifteen goals (5 short term, 5 long term, and 5 maintenance goals) from each of the 50 individuals were analyzed, for a total sample of 750 wellness goals.

Of the 750 wellness goals, 15 themes were identified. Table 1 displays the themes in more detail.

Based on the types of goals that participants selected, investigators identified three methods that were used to help participants and the nurse track progress toward achieving those goals.

Table 2 displays more detail about how goal theme was related to gender, goal type, and goal classification. Table 3 displays the themes of the fact-finding goals which identify the educational needs of our target population and determine what content is important for the educational module within iMHere.

Of the 750 total wellness goals, 669 (89%) were achieved; 81 (11%) were not achieved. Furthermore, 20 out of 50 participants (40%) achieved all of their goals, and 42 participants (84%) achieved at least 13 out of 15 goals (87%). Eight individuals accounted for 67% of the goals that were not achieved. There was a significant difference in achievement of goals based on sex (P=.02), as well as diagnosis, goal temporality, and goal type (P<.001 for each respective analysis). Those of male sex and with SCI diagnosis were more likely to achieve goals than females or those with SB. Table 2 indicates the number of times a theme was reported across sex, goal temporality, and goal type.

Shorter temporality of the goal coincided with a higher likelihood that the goal would be achieved. Almost all goals surrounding fact-finding were achieved. There was no significant difference in achievement based on goal theme (P=.75; See Table 4).

Participants chose gift cards as incentives for achieving goals. The most popular preference was for healthy dining or groceries at 41.2% of participants, followed by 27.7% opting for entertainment, 12.4% for general retail, and 11.3% for clothing or personal care. Only 4.5% of participants chose gift cards catering to home improvement, and 2.8% chose gift cards for gasoline.

Based on the cumulative results, a list of software requirements was developed:

A goal-setting module was created for iMHere, based on the PSFS (see Figure 1).

To our knowledge, this is the first study to examine patient goals in an effort to develop more robust mHealth tools that support goal achievement in self-management. We successfully developed a goal-setting module based on the PSFS. We also identified three functionalities that may possibly help users track and achieve goals when using mHealth systems.

About one-quarter of the goals required the functionality of a checklist. The checklist is a simple tool that has been shown to produce improved outcomes in a number of health-related and other disciplines [23]. This type of goal-setting feature is already available in the current version of iMHere. However, more complex functionality, such as the ability to add sub-items to lists, will be added to support complex tasks that require multiple steps.

Approximately half of the goals required ongoing tracking of progress toward meeting that goal. On the PSFS, patients are asked to rate on a scale how well they subjectively feel they are accomplishing their goal. However, within mHealth systems, it is now possible to collect, analyze, and display summary data back to the user as a way to “automate” the tracking of progress toward a goal. Data collected and displayed in this manner can be self-reported data or objectively gathered data. For example, in the current version of iMHere, users are able to report on a regular basis whether they have been taking each of their medications. In future versions of iMHere, data on self-reported compliance with medications will be displayed back to the users as a bar graph to indicate how often the users indicated they took medications over a period of a week or a month. Objectively gathered data can also be collected from peripheral devices. For example, activity monitors connected to future versions of iMHere will be used to show users how well they are meeting a physical activity goal.

The remaining goals involved recalling specific facts or finding information about health topics. Tracking achievement of a fact-finding mission can be accomplished with a checklist. Because almost all fact-finding goals were achieved, it is possible that participants chose fact-finding goals that were “easy” to achieve; therefore, more complex checklists or other functionalities may be needed if a patient would choose a more complex fact-finding goal that has multiple steps within it. Recall of specific information from materials accessed could be evaluated through a quiz. In the current version of iMHere, an educational module presents medical information relevant to a user’s health and also provides quizzes about that information. A future version of iMHere will link the educational quizzes to the goal-setting feature. A goal of our study was to identify the educational needs of our target population to determine what content is important for the educational module within iMHere. Based on the fact-finding goals set by participants, we will be building educational content to support themes identified in Table 3.

The data collected on themes of goals set by participants were useful in several ways. First, the data validated the importance of modules that have already been developed for iMHere (medication management, bowel management, bladder management, skin integrity, and mood). Second, the data generated development ideas for modules for other important health domains such as diet, exercise, weight management, appointment scheduling, tracking needs for items such as wheelchairs or adaptive driving, vocational and school activities, pain, and sleep. In this study, the theme with the largest representation of goals was diet. Therefore, it is not surprising that the gift cards participants selected for meeting those goals included options for healthy eating or purchasing groceries. Thus, a third concept that emerged was that specific incentives could be linked to types of goals achieved. Finally, data helped inform what types of goals could be included as “default” goals from which patients can select.

Achievement of goals was related to several factors. Individuals with SB and females achieved fewer goals than those with SCI and those of male sex. It may be that those with SB or females set goals that were lofty and therefore more difficult to achieve, they were less motivated to achieve their goals, or they had greater medical complexity, making goal achievement somewhat more difficult. More work is needed on larger samples to understand the factors that contributed to goal achievement. It was not surprising that short-term goals were achieved more often than long-term goals, since the participants tended to set more easily achievable activities as the short-term goals. Despite having some degree of impairments in executive function [16], individuals with SB did not seem to have difficulty conceptualizing or setting goals, an encouraging finding considering the majority of individuals with SB in this study had hydrocephalus.

Based on the variety of goals set and lessons learned from the clinical trial, we also identified other features that are important in creating goal-setting features in mHealth. First, a clear need exists for patients, clinicians, and even caregivers to be involved in the goal-setting process. Caregiver goals may be quite different from the goals of the persons they assist [24]. As a result, we plan to create a goal-setting module that can be viewed and edited through role-based access via both patient and caregiver apps, as well as a clinician portal. Additionally, we plan to provide “free text” options to allow for custom goals to be written, as well as “quick select” options for goals that are commonly set and which can be tracked with automated features within the app. Finally, it may also be useful to display “socially persuasive” data to users as a way to motivate them to achieve goals. For example, it may be possible to display a user’s compliance with taking medications in reference to the average compliance of peers. This technique has been found in other studies to increase the likelihood of achieving desired health outcomes [25].

The results of this study inform the software requirements for the graphical user interface of the iMHere goal-setting module. Several design changes will be made in order to meet these requirements. First, when entering a new goal, the patient will be able to: (1) select a goal functionality (checklist, data tracking, or fact-finding), which will determine how the app will track user progress toward achieving the goal, (2) choose one or more individuals (eg, user, clinician, caregiver) who will be responsible for independently determining whether the goal was achieved, and (3) choose supporters (eg, caregivers or peers) who are able to provide encouragement. Second, the goals will be marked as “in progress” by default until they are marked as “achieved” by a patient or his or her designee. Third, patients or designees will be able to enter a goal by typing as free text or choosing from a list of common “default” goals categorized by themes in Table 1. Fourth, each goal will contain an option to enter a deadline for the goal (selected from a calendar, or alternately, selected by designated time frame, such as one month) and options to receive prompts that query the patient whether he or she is on track to achieving the goal (eg, prompts appear on recurring schedule, or after a period of time, such as 75% of time has passed). Fifth, when first using the module or when accessing instructions, patients and designees will be reminded to create goals that are personally relevant to the patient, specific, measurable, and attainable [4,5].

A few limitations of this study deserve discussion. Our sample was limited to SB and SCI. External validity of this study is therefore limited to these populations. However, some findings may be relevant or translatable only to those particularly interested in engaging in health promotion activities. Our sample was also small; however, due to the large number of goals set by each participant, a large amount of goal-setting data was collected. One limitation of the parent study is that it lacked a control group. Because it was a clinical program, it was not possible or ethical to randomize participants into a group that did not receive these services. We therefore designed the parent study as a cohort trial and used intention to treat analysis, given the increasing popularity of integrated delivery systems and clinical utility of pragmatic research designs.

In future work, more complex functionalities could be added to the software, such as stakes (eg, consequences for not achieving the goal such as peers being notified), suggestions for brainstorming barriers (eg, option to contact clinician for help, extend deadline, or delete goal), and ability to opt into participating in socially persuasive group challenges, or pre-built goal modules that are designed around best practices (eg, workflow that guide the user how to conduct an evidence-based pressure ulcer prevention program). We plan to study the goal-setting module with patient, caregiver, and clinician users in future usability and feasibility trials.

In conclusion, lessons learned from analyzing wellness goals of participants with SB and SCI have been distilled into recommendations intended to help spearhead future development of iMHere. Goal-setting features in mHealth apps such as iMHere may be able to aid individuals in creating, pursuing, and achieving their wellness goals.