Best Practices in Design of Mobile Health Behavior Interventions Based on Behavioral Theory

Numerous commercial applications are available to help people lose weight, gain fitness and improve health. More recently mobile health behavior interventions opened new possibilities in healthcare to improve healthcare delivery (McCurdie et al., 2012), to replace routine tasks (West, 2012) and to help empower patients (Skinstad & Farshchian, 2016). While one literature review in 2007 (Norman et al., 2007) concluded that eHealth applications are still in its infancy, the outlook towards eHealth and mobile health behavior interventions has changed. More recent reviews suggest that mobile health behavior interventions have increased their effectiveness and underline their potential (Payne, Lister, West, & Bernhardt, 2015; Pfaeffli Dale, Dobson, Whittaker & Maddison, 2016; McIntosh, Jay, Hadden, & Whittaker, 2017). Our work is situated in the context of mobile health behavior interventions with the PRE-LIFE project. The goal of this project is to develop a mobile coaching application for couples undergoing fertility treatment. The application will guide couples regarding physical activity, diet and mental wellbeing to improve the results of fertility treatment. Previous projects in the context of mobile health behavior interventions include b-SLIM and PICASSO-Tx. The aim of b-SLIM was to develop a digital coach that monitors eating habits, physical activity and motivation to help people lose weight; The aim of PICASSO-Tx was to coach organ transplant recipients with respect to taking medication, physical activity and diet. A theoretical framework for behavior change can help design and develop mobile health behavior interventions. It can provide guidelines for the design of interventions by targeting causes of behavior and it can help evaluate mobile health behavior interventions (Michie, Johnston, Francis, Hardeman, 2008; Riley, et al., 2011; Mohr, Schueller, Montague, Burns & Rashidi, 2014). Different behavioral theories have been proposed for behavior change. Self Determination Theory (SDT) states that for sustainable behavior change, autonomous motivation instead of controlled motivation is needed. Autonomous motivation is driven by internal rewards or external rewards with values that are partly integrated; Controlled motivation is driven by external rewards. To develop autonomous motivation, three psychological needs have to be satisfied: autonomy, competence, and relatedness (Ryan & Deci, 2000; Deci & Ryan, 2011). SDT can be used to help understand what motivates users. For the b-SLIM project, Jansen, Van Mechelen and Slegers (2017) used SDT to develop persona’s; They used SDT to guide data collection and data analysis to better understand the interaction between autonomy, competence and relatedness. Social Cognitive Theory (SCT) describes how self-efficacy influences people’s behavior: Unless people believe they can produce an outcome, they will not act. People develop self-efficacy through previous success, others’ successes, positive appraisal and somatic and emotional feedback in judging their own ability (Bandura, 1998). SCT can be used to understand motivation and it informs behavior change as it explicitly states how people develop self-efficacy. Features of mobile health behavior interventions such as accumulating previous achievements, likes of physical activities or examples of others’ physical activities are in line with SCT. The PICASSO-Tx project shows an example of this: One feature illustrates the cumulative steps with possible destinations reached by those steps. This feature was well received by the users as they reported they were proud to reach certain places or cities (Vandenberghe, Vanhoof, Dobbels, & Geerts, 2015). Finally, the Fogg Behavior Model (FBM) uses motivation, ability and triggers to explain behavior. Behavior is a trade-off between motivation and ability; A trigger is needed to start behavior (Fogg, 2009). The FBM can be useful to understand behavior because it not only takes into account internal factors (motivation and ability), but it also recognizes that in many cases an external trigger is needed to start behavior. As an example of this, Burner, Menchine, Kubicek, Robles and Arora (2014) developed a text message based intervention for patients with diabetes to help them manage their disease better. Messages that triggered patients to take their medication and reminded them of healthy living challenges were most effective. This work in progress aims to study how behavioral theories can be used to successfully develop mobile health behavior interventions. This will be done by reviewing the recent literature on mobile health behavior interventions and by evaluating these mobile health behavior interventions using behavioral theories. Based on this, we will define best practices for design that will provide implications for our current project and future developments of mobile health behavior interventions.status: accepte