Frontiers in Public Health (Oct 2015)
Mobile applications for chronic disease self-management : building a bridge for behavior change
Abstract
Background One of the biggest challenges in the future of healthcare is the rising prevalence of chronic, non-communicable diseases. In high-income countries seven out of ten leading risk factors of death are caused by the way people eat, drink or move. Health behavior patterns are considered to account for 40 % of early mortality. If nothing changes, from 2011 until 2030 the cost of chronic disease in the whole world may reach 47 trillion dollars. It is clear that chronic disease care needs to change. Today people with chronic disease spend less than 0,1 % of their time yearly in direct contact with healthcare and guidance. The rest of the time they are under the influence of family, colleagues, acquaintances, media and all the conflicting information from them. Digital elements are emerging in healthcare. Some of these digital elements emerging are mobile applications. Of all the people in Finland, 70 % own a smartphone. These devices are often in the proximity of their owner; in a pocket or a purse, making them easy and fast to use for various purposes. This is why they can also prove to be useful tools for personal healthcare and chronic disease self-management support, for example for recording diet and exercise related values as well as various disease specific values like blood glucose or blood pressure measurements. They also enable two-way interaction with healthcare professionals and patients in their everyday life. This requires well designed applications that affect the patient’s health behavior and are tempting to use. According to research, this is not always the case. Aim The aim of this thesis study was to find out how multipurpose mobile applications intended for chronic disease self-management implement known behavior change techniques in order to change behavior, and to find out how they utilize known gamification features in order to maintain the change. The purpose of this study was to create a new, multidisciplinary behavior change intervention tool for both healthcare professionals and mobile application developers to aid their development processes. Methods This study used mixed methods; quantified content analysis to gain more knowledge about the real life problem, as well as service design thinking to guide the creation of the final construct. First, currently available multipurpose mobile applications suitable for multiple chronic disease self-management were systematically investigated. Their current usefulness in how they aimed to change patient’s behavior and maintain it was measured using the Behavior Change Technique taxonomy by Michie et al. (2013) and the Gamification taxonomy by Robinson and Bellotti (2013). As the scope of this study was to describe what behavior change techniques and gamification features are used in mobile applications for chronic disease self-management, only simple descriptive statistics were calculated. Secondly, a new framework was created building upon existing information, experience and theory by the principles of constructive research approach using also features from autoethnographic approach. Results A total of 20 mobile applications suitable for tracking multiple chronic issues were found and analyzed. The mean amount of behavior change techniques found in these applications was 7,2. The variance was however very big, from 1 to 22 behavior change techniques out of possible 93. The same could be seen with gamification features, in which the mean amount of features was 5,85 out of possible 42. In general, less than 10 % of the possible behavior change techniques were used, and less than 15 % of the possible gamification features were used. The main approaches found to change behavior were “self-monitoring of behavioral outcome(s)” by 100 %, “self-monitoring of behavior” by 75 %, “behavioral practice” and “goal setting outcome(s)” by 45 %, “habit formation” and “prompts/cues” by 40 %, “biofeedback” by 35 %, “information about health consequences” and “instruction on how to perform behavior” by 30 %, “goal setting (behavior)” by 25 % and “social support (unspecified)” by 20 %. “Social reward”, “social comparison” and “action planning” were present in only 15 % of the applications. The most often used gamification features were “context” by 100 %, “records of achievements” by 80 %, “interaction modes” by 65 %, “perceptuality” by 45 %, “best records” by 35 %, “guidance” by 35 % and “internal objectives” by 30 %. The framework BC-TIP, “the Behavior Change Techniques Intervention Process”, was created using the constructive research approach which does not dictate certain methods for creating the new construct. Although the framework created in this study is not a service in the traditional sense, the idea of service design thinking guided the creation of it. Design thinking can be seen as a creative process focusing on the building of new solutions by synthesis and ideation. In addition to synthesis, some other methods used are visual communication and prototyping. All these methods were used in this part of the study. The co-creativeness appeared in the fact that these techniques are the result of many researchers approaching different sides of the same phenomenon, and the creation continued in this construction process. Sequencing and evidencing were pursued by bringing the timeline and the journey visible. Conclusions The results of this study imparted that the studied applications for chronic disease self-management did not utilize these taxonomies nearly as well as they could. This indicates the need for better designed applications that take these features into account. To help in this process, BC-TIP framework was developed. This framework provides visual and narrative guidance amongst the behavior change techniques making them easier to be used by professionals from various disciplines, like healthcare and mobile application design. It has the potential to help create better mobile applications for chronic disease management, proven by a weak market test. However, future testing of the usability of the BC-TIP framework in the creation of chronic disease self-management support interventions and commercial production of mobile applications will further provide stronger market testing, according to constructive research approach.
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