Don't judge a book or health app by its cover: User ratings and downloads are not linked to quality.

OBJECTIVE: To analyse the relationship between health app quality with user ratings and the number of downloads of corresponding health apps. MATERIALS AND METHODS: Utilising a dataset of 881 Android-based health apps, assessed via the 300-point objective Organisation for the Review of Care and Health Applications (ORCHA) assessment tool, we explored whether subjective user-level indicators of quality (user ratings and downloads) correlate with objective quality scores in the domains of user experience, data privacy and professional/clinical assurance. For this purpose, we applied spearman correlation and multiple linear regression models. RESULTS: For user experience, professional/clinical assurance and data privacy scores, all models had very low adjusted R squared values (< .02). Suggesting that there is no meaningful link between subjective user ratings or the number of health app downloads and objective quality measures. Spearman correlations suggested that prior downloads only had a very weak positive correlation with user experience scores (Spearman = .084, p = .012) and data privacy scores (Spearman = .088, p = .009). There was a very weak negative correlation between downloads and professional/clinical assurance score (Spearman = -.081, p = .016). Additionally, user ratings demonstrated a very weak correlation with no statistically significant correlations observed between user ratings and the scores (all p > 0.05). For ORCHA scores multiple linear regression had adjusted R-squared = -.002. CONCLUSION: This study highlights that widely available proxies which users may perceive to signify the quality of health apps, namely user ratings and downloads, are inaccurate predictors for estimating quality. This indicates the need for wider use of quality assurance methodologies which can accurately determine the quality, safety, and compliance of health apps. Findings suggest more should be done to enable users to recognise high-quality health apps, including digital health literacy training and the provision of nationally endorsed "libraries".

Association Between the Characteristics of mHealth Apps and User Input During Development and Testing: Secondary Analysis of App Assessment Data.

BACKGROUND: User involvement is increasingly acknowledged as a central part of health care innovation. However, meaningful user involvement during the development and testing of mobile health apps is often not fully realized. OBJECTIVE: This study aims to examine in which areas user input is most prevalent and whether there is an association between user inclusion and compliance with best practices for mobile health apps. METHODS: A secondary analysis was conducted on an assessment data set of 1595 health apps. The data set contained information on whether the apps had been developed or tested with user input and whether they followed best practices across several domains. Background information was also available regarding the apps' country of origin, targeted condition areas, subjective user ratings, download numbers, and risk (as per the National Institute for Health and Care Excellence Evidence Standards Framework [ESF]). Descriptive statistics, Mann-Whitney U tests, and Pearson chi-square analyses were applied to the data. RESULTS: User involvement was reported by 8.71% (139/1595) of apps for only the development phase, by 33.67% (537/1595) of apps for only the testing phase, by 21.88% (349/1595) of apps for both phases, and by 35.74% (570/1595) of apps for neither phase. The highest percentage of health apps with reported user input during development was observed in Denmark (19/24, 79%); in the condition areas of diabetes (38/79, 48%), cardiology (15/32, 47%), pain management (20/43, 47%), and oncology (25/54, 46%); and for high app risk (ESF tier 3a; 105/263, 39.9%). The highest percentage of health apps with reported user input during testing was observed in Belgium (10/11, 91%), Sweden (29/34, 85%), and France (13/16, 81%); in the condition areas of neurodiversity (42/52, 81%), respiratory health (58/76, 76%), cardiology (23/32, 72%), and diabetes (56/79, 71%); and for high app risk (ESF tier 3a; 176/263, 66.9%). Notably, apps that reported seeking user input during testing demonstrated significantly more downloads than those that did not (P=.008), and user inclusion was associated with better compliance with best practices in clinical assurance, data privacy, risk management, and user experience. CONCLUSIONS: The countries and condition areas in which the highest percentage of health apps with user involvement were observed tended to be those with higher digital maturity in health care and more funding availability, respectively. This suggests that there may be a trade-off between developers' willingness or ability to involve users and the need to meet challenges arising from infrastructure limitations and financial constraints. Moreover, the finding of a positive association between user inclusion and compliance with best practices indicates that, where no other guidance is available, users may benefit from prioritizing health apps developed with user input as the latter may be a proxy for broader app quality.

Quality of Digital Health Interventions Across Different Health Care Domains: Secondary Data Analysis Study.

BACKGROUND: There are more than 350,000 digital health interventions (DHIs) in the app stores. To ensure that they are effective and safe to use, they should be assessed for compliance with best practice standards. OBJECTIVE: The objective of this paper was to examine and compare the compliance of DHIs with best practice standards and adherence to user experience (UX), professional and clinical assurance (PCA), and data privacy (DP). METHODS: We collected assessment data from 1574 DHIs using the Organisation for the Review of Care and Health Apps Baseline Review (OBR) assessment tool. As part of the assessment, each DHI received a score out of 100 for each of the abovementioned areas (ie, UX, PCA, and DP). These 3 OBR scores are combined to make up the overall ORCHA score (a proxy for quality). Inferential statistics, probability distributions, Kruskal-Wallis, Wilcoxon rank sum test, Cliff delta, and Dunn tests were used to conduct the data analysis. RESULTS: We found that 57.3% (902/1574) of the DHIs had an Organisation for the Review of Care and Health Apps (ORCHA) score below the threshold of 65. The overall median OBR score (ORCHA score) for all DHIs was 61.5 (IQR 51.0-73.0) out of 100. A total of 46.2% (12/26) of DHI's health care domains had a median equal to or above the ORCHA threshold score of 65. For the 3 assessment areas (UX, DP, and PCA), DHIs scored the highest for the UX assessment 75.2 (IQR 70.0-79.6), followed by DP 65.1 (IQR 55.0-73.4) and PCA 49.6 (IQR 31.9-76.1). UX scores had the least variance (SD 13.9), while PCA scores had the most (SD 24.8). Respiratory and urology DHIs were consistently highly ranked in the National Institute for Health and Care Excellence Evidence Standards Framework tiers B and C based on their ORCHA score. CONCLUSIONS: There is a high level of variability in the ORCHA scores of DHIs across different health care domains. This suggests that there is an urgent need to improve compliance with best practices in some health care areas. Possible explanations for the observed differences might include varied market maturity and commercial interests within the different health care domains. More investment to support the development of higher-quality DHIs in areas such as ophthalmology, allergy, women's health, sexual health, and dental care may be needed.

Anhedonia in Relation to Reward and Effort Learning in Young People with Depression Symptoms.

Anhedonia, a central depression symptom, is associated with impairments in reward processing. However, it is not well understood which sub-components of reward processing (anticipation, motivation, consummation, and learning) are impaired in association with anhedonia in depression. In particular, it is unclear how learning about different rewards and the effort needed to obtain them might be associated with anhedonia and depression symptoms. Therefore, we examined learning in young people (N = 132, mean age 20, range 17-25 yrs.) with a range of depression and anhedonia symptoms using a probabilistic instrumental learning task. The task required participants to learn which options to choose to maximize their reward outcomes across three conditions (chocolate taste, puppy images, or money) and to minimize the physical effort required to obtain the rewards. Additionally, we collected questionnaire measures of anticipatory and consummatory anhedonia, as well as subjective reports of "liking", "wanting" and "willingness to exert effort" for the rewards used in the task. We found that as anticipatory anhedonia increased, subjective liking and wanting of rewards decreased. Moreover, higher anticipatory anhedonia was significantly associated with lower reward learning accuracy, and participants demonstrated significantly higher reward learning than effort learning accuracy. To our knowledge, this is the first study observing an association of anhedonia with reward liking, wanting, and learning when reward and effort learning are measured simultaneously. Our findings suggest an impaired ability to learn from rewarding outcomes could contribute to anhedonia in young people. Future longitudinal research is needed to confirm this and reveal the specific aspects of reward learning that predict anhedonia. These aspects could then be targeted by novel anhedonia interventions.

Social reinforcement learning as a predictor of real-life experiences in individuals with high and low depressive symptomatology.

BACKGROUND: Several studies have reported diminished learning from non-social outcomes in depressed individuals. However, it is not clear how depression impacts learning from social feedback. Notably, mood disorders are commonly associated with deficits in social functioning, which raises the possibility that potential impairments in social learning may negatively affect real-life social experiences in depressed subjects. METHODS: Ninety-two participants with high (HD; N = 40) and low (LD; N = 52) depression scores were recruited. Subjects performed a learning task, during which they received monetary outcomes or social feedback which they were told came from other people. Additionally, participants answered questions about their everyday social experiences. Computational models were fit to the data and model parameters were related to social experience measures. RESULTS: HD subjects reported a reduced quality and quantity of social experiences compared to LD controls, including an increase in the amount of time spent in negative social situations. Moreover, HD participants showed lower learning rates than LD subjects in the social condition of the task. Interestingly, across all participants, reduced social learning rates predicted higher amounts of time spent in negative social situations, even when depression scores were controlled for. CONCLUSION: These findings indicate that deficits in social learning may affect the quality of everyday social experiences. Specifically, the impaired ability to use social feedback to appropriately update future actions, which was observed in HD subjects, may lead to suboptimal interpersonal behavior in real life. This, in turn, may evoke negative feedback from others, thus bringing about more unpleasant social encounters.

Effects of serotonin and dopamine depletion on neural prediction computations during social learning.

We have previously shown that individuals with high depression scores demonstrate impaired behavioral and neural responses during social learning. Given that depression is associated with altered dopamine (DA) and serotonin (5-HT) functioning, the current study aimed to elucidate the role of these neurotransmitters in the social learning process using a dietary depletion manipulation. In a double-blind design, 70 healthy volunteers were randomly allocated to a 5-HT depletion (N = 24), DA depletion (N = 24), or placebo (N = 22) group. Participants performed a social learning task during fMRI scanning, as part of which they learned associations between name cues and rewarding (happy faces) or aversive (fearful faces) social outcomes. Behaviorally, 5-HT depleted subjects demonstrated impaired social reward learning compared to placebo controls, with a marginal effect in the same direction in the DA depletion group. On the neural level, computational modeling-based fMRI analyses revealed that 5-HT depletion altered social reward prediction signals in the insula, temporal lobe, and prefrontal cortex, while DA depletion affected social reward prediction encoding only in the prefrontal cortex. These results indicate that 5-HT depletion impairs learning from social rewards, on both the behavioral and the neural level, while DA depletion has a less extensive effect. Interestingly, the behavioral and neural responses observed after 5-HT depletion in the current study closely resemble our previous findings in individuals with high depression scores using the same task. It may thus be the case that decreased 5-HT levels contribute to social learning deficits in depression.

Impaired social learning predicts reduced real-life motivation in individuals with depression: A computational fMRI study.

BACKGROUND: Major depressive disorder is associated with altered social functioning and impaired learning, on both the behavioural and the neural level. These deficits are likely related, considering that successful social interactions require learning to predict other people's emotional responses. Yet, there is little research examining this relation. METHODS: Forty-three individuals with high (HD; N = 21) and low (LD; N = 22) depression scores answered questions regarding their real-life social experiences and performed a social learning task during fMRI scanning. As part of the task, subjects learned associations between name cues and rewarding (happy faces) or aversive (fearful faces) social outcomes. Using computational modelling, behavioural and neural correlates of social learning were examined and related to real-life social experiences. RESULTS: HD participants reported reduced motivation to engage in real-life social activities and demonstrated elevated uncertainty about social outcomes in the task. Moreover, HD subjects displayed altered encoding of social reward predictions in the insula, temporal lobe and parietal lobe. Interestingly, across all subjects, higher task uncertainty and reduced parietal prediction encoding were associated with decreased motivation to engage in real-life social activities. LIMITATIONS: The size of the included sample was relatively small. The results should thus be regarded as preliminary and replications in larger samples are called for. CONCLUSION: Taken together, our findings suggest that reduced learning from social outcomes may impair depressed individuals' ability to predict other people's responses in real life, which renders social situations uncertain. This uncertainty, in turn, may contribute to reduced social engagement (motivation) in depression.

Increased social anhedonia and reduced helping behaviour in young people with high depressive symptomatology.

BACKGROUND: Social anhedonia, the decreased enjoyment of pleasant social experiences, is associated with depression. However, whether social anhedonia in depression affects prosocial behaviours is unclear. The current study aimed to examine how high levels of depressive symptomatology in young people affect responses to usually rewarding social situations, including helping behaviour. METHODS: We recruited 46 females, 16 scoring high on the Beck Depression Inventory (BDI scores>20, Mage=19; HD) and 30 scoring low (BDI<10, Mage=20; LD). In a social emotion task (SET), participants were presented with social scenarios and asked to rate their expected emotional responses. Subsequently, participants' helping behaviour was measured by dropping a pile of papers near them and recording their responses. Lastly, participants completed the SET again. RESULTS: The SET at time 1 revealed that HD individuals reported significantly stronger negative (p<.001) and weaker positive (p<.05) emotional responses to social situations than LD subjects. Additionally, all participants showed a significant increase in positive responses (p<.05) on the SET between time 1 and time 2. Moreover, HD subjects were less likely to engage in actual helping behaviour than LD participants. LIMITATIONS: Limitations of the study are that only females were tested and that no psychiatric screening interview was conducted. CONCLUSIONS: Our results indicate that young females with high levels of depression symptoms expect to respond less positively to social situations and engage less in helping behaviour compared to those with low depressive symptomatology. Social anhedonia in depression may thus contribute to decreased engagement in rewarding social situations. This, in turn, may lead to social withdrawal and might maintain depression symptoms though a lack of exposure to positive social feedback.